and Malcolm Wills2
(1)
Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
(2)
Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, UK
Abstract
The incidence of postpneumonic empyema has been increasing in recent years in most Western countries. The place of surgery in its management is debatable, with many centers advocating initial pleural drainage and instillation of fibrinolytics, reserving surgery for those who fail to respond to these measures. Some, however, suggest that primary surgery leads to a more rapid recovery and a shorter hospital stay. There is little evidence to convincingly show which is the best approach. The aim of surgery is clearance of debris from the pleural space, with reestablishment of a “single” pleural cavity free of loculations and full reexpansion of the lung. Postoperatively, early mobilization and physiotherapy are key. Thoracoscopy has the advantage of excellent visualization of the whole pleural space and minimal postoperative pain, allowing physiotherapy and mobilization to begin almost immediately.
Keywords
EmpyemaThoracoscopyPleural infection3.1 General Information
The incidence of postpneumonic empyema has been increasing in recent years in most Western countries. The place of surgery in its management is debatable, with many centers advocating initial pleural drainage and instillation of fibrinolytics, reserving surgery for those who fail to respond to these measures. Some, however, suggest that primary surgery leads to a more rapid recovery and a shorter hospital stay. There is little evidence to convincingly show which is the best approach. The aim of surgery is clearance of debris from the pleural space, with reestablishment of a “single” pleural cavity free of loculations and full reexpansion of the lung. Postoperatively, early mobilization and physiotherapy are key. Thoracoscopy has the advantage of excellent visualization of the whole pleural space and minimal postoperative pain, allowing physiotherapy and mobilization to begin almost immediately.
3.2 Working Instruments
5-mm Camera port
Two 5-mm accessory ports
5-mm 30-degree Telescope
Two blunt atraumatic graspers with long jaw, e.g., a Johan grasper
Sucker/irrigator
3.3 Positioning, Port Siting, and Ergonomic Considerations
The patient is positioned in the lateral position with the affected side uppermost, as for a thoracotomy. Placing a roll under the chest may be helpful in opening the rib spaces a little. One lung ventilation is not normally required, with a low pressure pneumothorax usually giving an adequate view. The patient should be firmly secured to the table so that the lateral roll can be used. It is helpful to have two screens positioned anterior and posterior to the chest as well as access to both sides of the patient, allowing optimum ergonomics while clearing the anterior and posterior parts of the pleural cavity.
If a chest drain is already in place, then the tract can act as the site for placement of the primary port. If not, then this should be placed where the empyema has been shown to be deepest on ultrasound images. Most commonly this is just below the tip of the scapula in the fourth or fifth interspace in mid-axilla. Further port placement will be dictated by the location of the empyema, but for the most common posterobasal empyema, one or two additional ports one or two rib spaces lower and in anterior and posterior axillary lines allow easy access to all areas of the pleural cavity.
3.4 Procedure
Figure 3.1a shows the pleural space in one patient, a loculated pleural space with strands of thin fibrous bands within the pus. On entering the pleural space, infected and loculated exudate and pus are seen (Fig. 3.1b). Initially the scope may be within the fibrinous debris, but by blunt dissection space can be created for insertion of further ports under direct vision.
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