Management of Parapneumonic Effusions

Annotation for Point G

Multiloculated empyemas with an established pleural peel evident on CT scanning (Fig. 2) should undergo prompt VATS.⁶ Although ‘‘medical’’ VATS using local anesthesia has been reported,⁶⁰ the standard procedure is lateral decubitus positioning with dual lung ventilation to facilitate comprehensive evaluation of the involved pleural cavity and systematic decortication.⁶¹ A key maneuver is to enter the pleural space without injuring the underlying lung because of extensive pleural adhesions. An initial incision in the upper thorax, where the empyema is least developed, is usually the safest strategy. In most cases, we have used the existing chest tube site to free the lung for placement of the initial port (Fig. 3). With the thorascope in position and the lung at least partially deflated, additional working ports are added under direct vision (Fig. 4). The sites for these ports are chosen to match the chest wall entrance of the chest tubes after VATS (Fig. 5). The objectives of VATS are to unroof all loculated collections, including those in the fissures, and to free the lung of the visceral pleural fibrous encasement. Usually, the decortication is initiated in the upper lobe, where the process is more limited, and ultimately, the fibrous debris is removed as much as possible from the lung surface to enable reexpansion. Dissection must be done carefully on the mediastinal side to avoid injury to the phrenic nerve and pulmonary vasculature. Similarly, clearing the diaphragm must be done cautiously to avoid perforation. In fact, the diaphragm does not need to be systematically debrided as long as the lower lobe is freed. After extensive decortication, the thorax is usually drained with three relatively large chest tubes (28F) to facilitate removal of debris and blood associated with the procedure (Fig. 5). The most inferior tube is usually an angled tube positioned in the posterior dependent recess of the chest.