Step 1
Surgical Anatomy
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A thorough understanding of normal pulmonary hilar and mediastinal anatomy from the thoracic inlet to the diaphragm, which may be significantly altered in the presence of empyema, is essential for effective, safe surgical management.
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Pulmonary volume loss with elevation of the hemidiaphragm and mediastinal shift often occurs and should be considered when any intervention is planned.
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The phrenic and vagus nerves and esophagus should be identified and protected because they can be tethered and retracted with a fibrothorax.
Step 2
Preoperative Considerations
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A simple exudative parapneumonic effusion can progress to a complicated effusion with loculation and empyema thoracis. The stage of progression or chronicity is important to determine because it often influences treatment decisions.
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A thorough history and physical examination and a chest computed tomography (CT) scan are usually sufficient for treatment planning. Any history of antibiotic use, blood and pleural fluid cultures, and other pleural fluid characteristics can be useful if available. Characteristic symptoms include fever, chills, dyspnea, and pleuritic chest pain.
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The CT scan can be helpful in characterizing the parapneumonic effusion (e.g., pleural thickening, loculation, fluid complexity, pulmonary consolidation) and identifying concomitant chest pathology (e.g., adenopathy, pulmonary lesions, and esophageal pathology).
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Purulent pleural fluid should be managed initially with a large-bore chest tube. Intrapleural fibrinolytic agents such as tissue plasminogen activator can be used to enhance the effectiveness of tube drainage and avoid the need for surgery, with some reports demonstrating benefit.
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If the lung fails to fully reexpand or clinical signs and symptoms of infection persist, then operative intervention is warranted, with the primary goal to establish more complete drainage of infection and complete lung expansion (decortication).
Step 3
Operative Steps
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General anesthesia is used with provision for single-lung ventilation; the patient is placed in a full lateral decubitus position.
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One or two 5-mm thoracoports should be placed initially within the free pleural space, preferably within the effusion or empyema cavity. The free fluid is evacuated to allow inspection of the space with the 5-mm, 30-degree thoracoscope.
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Thoracoscopic assessment of the empyema cavity and the surrounding free or loculated pleural space will determine whether any of the drainage and decortication can be done effectively using a video-assisted thoracic surgery (VATS) technique and, if open thoracotomy is required, to select the best location for the thoracotomy incision ( Fig. 15-1 ).
