Robert E. Merritt
Indications for Decortication
The most common benign condition involving the pleura is an infection involving the pleural space or empyema. Patients who present with pneumonias often have associated pleural effusions, which can be either parapneumonic effusions or an empyema. The pleural fluid should be sampled with thoracentesis to determine the distinction between paraneumonic effusion and empyema. If the fluid gram stain or culture is positive for a pathogen or the fluid pH is less than 7.1, then an empyema is typically diagnosed. The classification of empyema is based on the temporal evolution of the pleural space infection and dictates the optimal management. The three phases of empyema consist of:
1. Exudative Phase: This initial phase of empyema is characterized by free-flowing purulent fluid through the thorax and associated inflamed parietal pleura. Simple drainage with chest tube thoracostomy and intravenous antibiotics are usually sufficient to manage the pleural effusion.
2. Fibropurulent Phase: This phase is characterized by loculated pleural fluid and fibrinous exudative deposits on the visceral pleural surfaces. Empyemas in this phase often require a VATS or thoracotomy to lyse adhesions, break up loculations, and drained purulent pleural fluid.
3. Fibrous Phase: This phase is characterized by the formation of a thick, fibrous rind on the visceral pleural surface of the lung. A thoracotomy is usually required to achieve a complete decortication.
An early decortication with a VATS approach during the fibropurulent phase is highly effective and can significantly decrease morbidity associated with empyema. VATS offers a decided advantage over simple chest tube thoracostomy because of multiple factors.
1. Loculated purulent fluid can be completely drained because adhesions can be directly visualized and lysed during VATS.
2. Atelectatic lung can be re-expanded under direct vision.
3. Chest tubes can be placed in the appropriate position for optimal drainage in the postoperative period.
The definitive drainage of purulent fluid associated with empyema with VATS can significantly improve patient outcomes and prevent progression to a fibrothorax, which often requires an open thoracotomy. Other indications for decortication include chronic hemothorax and recurrent pleural effusion.
Contraindications for Decortication
Malignant pleural disease
Endobronchial tumor with bronchial obstruction
Chronic respiratory failure and ventilation dependence
Chronically trapped lung with limited pulmonary dysfunction
PREOPERATIVE PLANNING
Patients with empyema should have a preoperative CT scan of the thorax to identify loculated fluid cavities that need to be drained. The location of loculated fluid pockets will assist with the placement of VATS ports. Broad-spectrum antibiotics should be initiated to treat active pneumonia. The antibiotic coverage can be modified after the culture and sensitivities are completed. Large pockets of purulent fluid can be drained with a chest tube thoracostomy prior to a planned VATS decortication. Chest tube drainage is particularly important for patients who present with an empyema and associated signs of sepsis, such as fever, tachycardia, leukocytosis, and hypotension.
SURGERY
Positioning for VATS Decortication
I routinely perform a fiberoptic flexible bronchoscopy before a VATS decortication procedure to assess the airway anatomy and to obtain endobronchial cultures. Also, an endobronchial tumor causing airway obstruction and postobstructive pneumonia can be identified and treated. After the fiberoptic flexible bronchoscopy is completed with a single-lumen endotracheal tube, the patients are reintubated with a double-lumen endotracheal tube for selective lung ventilation. Patients are then positioned in the right or left lateral decubitus position. All pressure points should be padded with gel pads to prevent nerve compression and skin necrosis. A padded beanbag is used to hold the patient in position. The operating room table is flexed with the patient’s anterior-superior iliac crest below the break in the bed. The flexion opens up the rib spaces to allow placement of VATS ports. The video monitors are placed at the head of the table and the surgeon stands in front of the patient.
Incisions
Three standard VATS incisions are used to perform a VATS decortication (Fig. 21.1). The first incision is placed in the eighth intercostal space in the posterior axillary line. A 5-mm trocar is placed through the incision and 5-mm thoracoscope inserted in the left chest. The 5-mm thoracoscope is lower profile and less likely place torque on the intercostal nerve. A 10-mm incision is placed three to four fingerbreadths below the tip of scapula. A 10-mm incision is also placed anteriorly at the level of the inframammary crease. I use low profile lung clamps and vascular clamps, which easily pass through the VATS incisions without placing pressure on the intercostal nerve.
Figure 21.1 The standard placement of the incisions for a VATS decortication.
VATS Decortication Technique for Fibropurulent Phase of Empyema
Once the VATS ports are placed, the 5-mm thoracoscope is placed into the chest cavity for inspection of the free pleural space. A 10-mL syringe can be used to aspirate fluid to ensure the VATS incision is located at a level where there is a free pleural space. The first VATS port should be placed in a pocket of free fluid to avoid injury to the lung parenchyma. Free fluid is aspirated with a 5-mm suction catheter and sent for gram stain and culture. Complete mobilization of the lung should be performed by lysing adhesions between the visceral pleura and the chest wall. The lysis of adhesions can be performed with sponge on clamp with blunt dissection (Fig. 21.2). The blunt dissection should be carried to the hilum circumferentially. The lung apex and the lung base should be fully mobilized as well. Dense adhesions between the lung base and the diaphragm can be divided with the bovie electrocautery or a Ligasure device. Injury to mediastinal structures, such as the esophagus, the trachea, aorta, and superior vena cava should be avoided. The phrenic nerves should be identified and persevered as well. The lung is then re-expanded by the anesthesia team to identify areas of trapped lung that may need further decortication. I typically place a right-angle chest tube in the costophrenic sulcus and a straight chest tube toward the apex for postoperative drainage.
Figure 21.2 The sponge stick is used to bluntly dissect the plane between the visceral pleura and rind.
Figure 21.3 The pleural rind is being mobilized bluntly.
Open Decortication Technique for Organized Phase of Empyema
Patients who developed a thick fibrous rind on the visceral surface of the lung usually require a standard posterior-lateral thoracotomy for effective decortication. The lung should be ventilated during the decortication. The initial plane between the visceral pleural rind and the lung is established with sharp dissection. The lung surface is then retracted with a sponge stick and the plane is dissected bluntly (Fig. 21.3). Dense adhesions should be lysed with cautery or a Metzenbaum scissor (Fig. 21.4). The lung should be completely mobilized from the surface of the diaphragm. In some cases, the visceral pleural rind cannot be completely removed due to dense adhesions or fibrosis. These areas can be managed with an excision of the visceral pleura or by creating cross hatches on the visceral pleural rind with a scalpel (Fig. 21.5). When there is residual trapped lung, a space may be present in the pleural cavity. The residual pleural space can be filled with a rotational muscle flap or omentum for long-term management.
Figure 21.4 Sharp dissection is used for dense adhesions between the rind and the visceral pleura.
Figure 21.5 Cross hatchings are created with a scalpel when the pleural rind is too adherent to remove.
After the parietal rind has been dissected from the chest wall, the empyema cavity should be opened and drained. The fibrinous debris should be debrided and the parietal pleural rind should be excised. The pleural cavity is then irrigated with a copious amount of saline solution. Usually, two large-bore chest tubes are placed for postoperative drainage. The chest tubes are maintained on suction for 48 hours.
POSTOPERATIVE MANAGEMENT
Patients are usually extubated in the operating room; however, some patients are maintained on mechanical ventilation for 24 to 48 hours if they cannot be immediately extubated in the operating room. The chest tubes are maintained on suction for 48 hours. The chest tubes are removed when the drainage is less than 200 mL per 24 hours and the air leaks are resolved. Patients who develop prolonged air leaks can be managed with a Heimlich valve and return to outpatient clinic for chest tube removal. Postoperative x-rays are obtained daily to monitor lung re-expansion and identify recurrent effusions.
COMPLICATIONS
The common postoperative complications after decortication included:
Prolonged air leak
Hemorrhage
Respiratory failure
Recurrent empyema
Subcutaneous emphysema
Sepsis/bacteremia
Phrenic nerve palsy
Diaphragm injury
Esophageal injury
RESULTS
In modern case series, VATS decortication has been proven to be effective in the management of empyema. The complication rate ranges from 3% to 35% and the mortality rate ranges from 0% to 6%. The rate of successful treatment ranges from 72% to 100%. The majority of the VATS decortications were performed in the exudative or fibropurulent phase of empyema. Patients with organized empyema usually require conversion to thoracotomy due to the dense fibrosis and adherent visceral pleural rinds.
CONCLUSIONS
VATS decortication can be performed in patients with acute empyema in the exudative or fibropurulent phase with effective outcomes. The morbidity and mortality is relatively low. Patients who present in the organized phase of empyema typically have a thick, fibrous pleural rind encasing the lung. These patients require a posterior-lateral thoracotomy to achieve effective re-expansion of the lung.
Recommended References and Readings
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Landreneau RJ, Keenan RJ, Hazelrigg SR, et al. Thoracoscopy for empyema and hemothorax. Chest. 1996;109(1):18–24.
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Solaini L, Prusciano F, Bagioni P. Video-assisted thoracic surgery in the treatment of pleural empyema. Surg Endosc. 2007;21(2):280–284.
Wurnig PN, Wittmer V, Pridun NS, et al. Video-assisted thoracic surgery for pleural empyema. Ann Thor Surg. 2006;81(1):309–313.