The Ultimate Thoracic Salvage: OWT-VATS, Intrapleural VAC, and Laparoscopic Transdiaphragmatic Omentoplasty for Post-Lobectomy Empyema

Managing chronic, multidrug-resistant post-lobectomy empyema with a trapped lung and an active air leak represents a formidable surgical challenge. For patients who are unfit for formal open decortication or extensive thoracomyoplasty, innovative, minimally invasive salvage strategies are required.

Case Presentation

A 42-year-old male presented with a hostile thorax four months after undergoing a right lower lobectomy. A two-stage, minimally invasive approach was employed.

Phase One

The first phase consisted of sterilization and space reduction using sequential trans-thoracostomy video-assisted thoracoscopic surgery (OWT-VATS) debridement and continuous intrapleural vacuum-assisted closure (VAC) at -100 mmHg. Over a five-week protocol, six serial VAC exchanges were performed under deep sedation utilizing topical lidocaine analgesia.

This targeted negative-pressure therapy successfully sealed the parenchymal air leak, eradicated secondary pathogens, and reduced the residual pleural cavity volume from 700 cc to 150 cc while promoting healthy macroscopic granulation.

Phase Two

The second phase involved definitive space obliteration via a laparoscopic transdiaphragmatic omentoplasty. The greater omentum was harvested laparoscopically and transposed into the chest through a right phrenotomy, guided by bimanual tactile feedback. The omental flap was anchored over the sealed fistula site.

To ensure the viability of the reconstruction, intravenous indocyanine green (ICG) was administered. Near-infrared fluorescence imaging visualized directly through the thoracostomy window objectively confirmed robust microvascular perfusion of the distal omental flap inside the pleural cavity.

Outcome

The patient experienced an uneventful recovery and was discharged on postoperative day 12. At the six-month outpatient follow-up, the patient remained asymptomatic, and all wounds had healed completely.

The sequential integration of OWT-VATS, intrapleural VAC therapy, and laparoscopic ICG-guided omentoplasty provides a safe, highly effective, and definitive salvage strategy for refractory hostile thoraces, minimizing the physiological burden associated with traditional open techniques.

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References

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