1. First cleaning steps by tube, irrigation, etc. Dealing with bronchial stump in case of bronchopleural fistula
2. Débridement
3. Open window
4. Vacuum-assisted closure (VAC)
5. Space filling
(a) Liquids, the so-called antibiotic plombage
(b) Soft tissue
I. Muscle (better myocutaneous flaps)
II. Greater omentum
6. Thoracoplasty
7. Combination of 6 and 5b
There are only a few cases in which one would go from step 2 directly to 6/7:
1. A mismatch between a large infected cavity and limited muscle mass
2. A transected latissimus dorsi and absence of omentum after major abdominal surgery
3. A high risk of infection or empyema after bilobectomy (rarely)
Surgical Technique
Figure 44.1
Schede thoracoplasty. In 1890, Schede introduced the extended full–costal plane demolition thoracoplasty (EFDT), in which the entire costal/intercostal plane is removed in a wide range. This procedure results not only in marked deformity, but also a loss of sensation in the involved hemithorax. The extended procedure means a high degree of burden for patients; therefore, Braun modified the operation into a three- to four-step procedure, resulting in lower morbidity and mortality, but with the same deformities and neurologic deficiencies. By 1935, Heller, Semb, and Holst developed a limited partial–costal plane demolition thoracoplasty. In contrast to the EFDT, this procedure preserves the intercostal muscle layer and parietal pleura. It not only causes less deformity and neurologic deficiencies, it also preserves viable backfill for the cavity and therefore requires a less extensive rib resection
Figure 44.2
(a, b) Thoracoplasty before and after. The method presented and described here is a personal modification, a combination based on the work of Friedrich (1907), Heller’s “jalousie” plasty (1929), and elements from Semb and Holst (1935) as well as others, such as Maurer (1952). It has been performed successfully for the past 30 years
