Overview
Definition:
Uniportal video-assisted thoracoscopic surgery (VATS) decortication is a minimally invasive surgical procedure performed through a single incision to remove the fibrous peel (peel) that encases the lung, often due to chronic infection (empyema) or inflammation
It aims to re-expand the lung and improve respiratory function.
Epidemiology:
Empyema, the primary indication for decortication, occurs in approximately 0.2% to 1.3% of community-acquired pneumonias and is more common in patients with underlying comorbidities, immunocompromise, or after thoracic interventions
Uniportal VATS is gaining popularity for its reduced invasiveness.
Clinical Significance:
Effective decortication is crucial for managing chronic empyema and fibrothorax, restoring lung function, resolving sepsis, and improving patient quality of life
Uniportal VATS offers advantages in pain reduction, cosmesis, and potentially shorter hospital stays compared to traditional thoracotomy.
Indications
Primary Indications:
Chronic, organizing empyema
Loculated pleural effusions unresponsive to drainage
Fibrothorax with restrictive lung physiology
Malignant pleural disease requiring pleurodesis or tumor debulking.
Secondary Indications:
Hemothorax requiring clot evacuation
Tuberculous empyema
Post-pneumonectomy empyema
Pleural sarcomas.
Contraindications:
Severe comorbidities precluding general anesthesia or VATS
Uncontrolled coagulopathy
Extensive adhesions making lung mobilization impossible via VATS
Active sepsis requiring open pleural washout.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination
Assessment of respiratory function (spirometry, ABGs)
Evaluation of comorbidities (cardiac, renal, hepatic)
Nutritional status assessment.
Imaging:
Chest X-ray (PA and lateral)
Contrast-enhanced CT scan of the thorax to delineate the extent of loculations, pleural thickening, and lung involvement
Consider MRI for complex cases or suspected tumors.
Laboratory Tests:
Complete blood count (CBC), renal function tests (RFTs), liver function tests (LFTs), coagulation profile, blood type and crossmatch
Sputum for AFB and culture if tuberculosis is suspected
Pleural fluid analysis if recent drainage occurred.
Anesthesia And Postop Planning:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation
Epidural or intercostal nerve block for postoperative analgesia
Plan for chest tube management and physiotherapy.
Procedure Steps Uniportal Vats
Patient Positioning And Incision:
Patient in lateral decubitus position
A single incision, typically 3-5 cm, is made in the thoracics triangle (e.g., 5th intercostal space, posterior axillary line).
Instrumentation And Access:
A rigid or flexible thoracoscope is inserted, providing visualization
Specialized articulating instruments (graspers, dissectors, suction irrigators) are used through the same port.
Pleural Access And Drainage:
Careful dissection through intercostal muscles and pleura
Insertion of a drain port or drainage catheter
Lavage and evacuation of purulent material or organized clot.
Decortication Technique:
The plane between the visceral pleura and the peel is identified and dissected using blunt and sharp dissection, electrocautery, or ultrasonic devices
The peel is meticulously removed from the lung surface, starting from the hilum and working outwards
Care is taken to avoid injuring the lung parenchyma.
Lung Reexpansion And Drainage:
Once decortication is complete, positive pressure ventilation helps the lung to fully re-expand
One or two chest tubes are placed for drainage and to ensure complete lung expansion
The single incision is closed in layers.
Postoperative Care
Pain Management:
Aggressive multimodal analgesia including epidural anesthesia, IV opioids, NSAIDs, and oral analgesics
Early mobilization is encouraged.
Chest Tube Management:
Chest tubes are typically connected to an underwater seal drainage system with or without suction
Monitoring for air leak, fluid output, and tube patency
Chest X-ray to assess lung re-expansion.
Respiratory Physiotherapy:
Early ambulation, incentive spirometry, deep breathing exercises, and assisted coughing to prevent atelectasis and pneumonia.
Antibiotic Therapy:
Intravenous antibiotics tailored to the culture and sensitivity of the empyema fluid, typically continued for 7-14 days or longer based on clinical response.
Complications
Early Complications:
Persistent air leak
Hemorrhage requiring reoperation
Injury to lung parenchyma or intercostal neurovascular bundle
Postoperative pneumonia
Atelectasis
Residual pleural space infection.
Late Complications:
Chronic empyema
Bronchopleural fistula
Chronic pain
Rib fractures
Development of fibrothorax
Recurrence of effusion.
Prevention Strategies:
Meticulous surgical technique to avoid parenchyma injury
Adequate chest tube drainage and monitoring
Aggressive pain control and early mobilization
Prompt management of air leaks and infections
Careful selection of surgical candidates.
Prognosis
Factors Affecting Prognosis:
Stage of empyema at surgery (e.g., fibrinopurulent vs
organizing/chronic)
Presence of comorbidities
Promptness of surgical intervention
Adequacy of decortication and lung re-expansion
Development of complications.
Outcomes:
Successful decortication generally leads to significant improvement in lung function and resolution of symptoms
However, complete functional recovery may be limited by pre-existing lung disease or severe fibrothorax
Mortality rates for VATS decortication for empyema are generally low (<5%).
Follow Up:
Regular follow-up with chest X-rays and clinical assessment to monitor for recurrence or complications
Pulmonary function tests may be performed to assess recovery of lung volumes and capacities.
Key Points
Exam Focus:
Uniportal VATS decortication emphasizes minimally invasive access, specialized instruments, and careful peel dissection
Key indications are chronic empyema and fibrothorax
Complications include persistent air leak and re-infection.
Clinical Pearls:
Achieving a plane between the peel and the lung is crucial
Use of articulating instruments enhances dexterity in the single port
Aggressive physiotherapy and pain management are vital for early recovery.
Common Mistakes:
Inadequate dissection leading to incomplete peel removal
Injury to lung parenchyma during dissection
Insufficient pain control leading to poor mobilization
Delayed recognition and management of air leaks.