Single Incision Thoracoscopic Decortications for Stage 3 Organized Pleural Effusion

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.