In organized stage 3 pleural effusions, the thickened visceral pleural layer entraps and collapses the lung resulting in lung volume loss with crowding of the intercostal spaces. The patient is a 56-year-old male previously treated for pulmonary tuberculosis with a left pleural effusion. A 4 cm single incision for thoracoscopy through the 4th intercostals space in the anterior axillary line was performed with removal of the segment of the rib along the wound to provide adequate space for surgery. The single incision technique with rib segment excision minimizes intercostal nerve injury in the crowded rib space compared with use of multiple ports. After gaining access to the pleural cavity, the fibrinous debris in the pleural space is evacuated to provide adequate space for dissection and good view of the thick visceral pleura trapping the lung. Identification of the correct plane between the organized pleura and lung parenchyma is key to the safe conduct of thoracoscopic decortication. Decortication is done using blunt end of suction tip, a swab, and a peanut mounted on curved ring forceps. Once the lung is completely mobilized, the thickened organized pleura is excised and hemostasis along the chest wall is attained. At the end of the procedure, warm saline lavage of the pleural cavity is done along with manual bagging of the lung to check for lung expansion and air leak. Two chest drains are placed, directed anteriorly and posteriorly, with the drains exiting from edges of the skin incision. The patient was discharged in the morning of the 5th postoperative day with the chest x-ray showing well expanded lung.
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Single Incision Thoracoscopic Decortications for Stage 3 Organized Pleural Effusion
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Very nice video. Well done. whenever I try this I never get a tissue plain like that ! I always seem to get loads of air leaks as the cortex seems stuck to it like concrete. Perhaps I should be more careful !
in deed nice video, in usual empyemas isn’t quite easy to find the pleural visceral plain; this is an ancient tuberculosis empyema how much time as passed between the diagnosis and the surgery?
Nice … getting such a plane between the lung and the fibrous peel is always nice . thanks for sharing
Thank you all for the comments, Indeed getting the correct plane is the key to performing thoracoscopic decortication. A few basics i follow are- Exposure of the fibrous tissue layer as much as possible along with evacuation of debris, asking our anesthetist colleague to keep the lung well collapsed by evacuating trapped air with suction, incising the pleura just along the utility incision if one fails to get the plane and once the plane is entered asking our anesthetist colleague to gradually inflate the lung intermittently, and lastly patience till we get the correct plane.
The patient had Surgery 6 months after the CT image in view of dyspnoe on exertion.
Well done and congratulations on this meticulous work
I always do such cases through a mini-thoracotomy (about 6 cm) incision.I usually need 1-1&1/2 hour to do the case and most patients leave hospital on day 4 after operation.Post op pain is not bad.
Could you please tell us about the average duration of operation and about the hospital stay and post op pain in your cases
Very decent outcome, but begs the question: Q: when is a thoracotomy NOT a thoracotomy? A: When you put a scope through it. [Credit to Walter G Wolfe, Duke University]. A more precise title for this operation would be: “Thoracotomy, rib resection for stage 2-3 empyema, as recorded by videothoracoscope.” Parenthetically, this was not a tuberculous empyema.