Empyema and Pneumothorax Surgery by VATS

Empyema surgery, pneumothorax surgery and most other operations for benign pleural and lung disease can now be done by video-assisted thoracoscopic surgery (VATS), with conversion to open surgery the exception. Dr. Shaiwal Khandelwal, Director - Thoracic Surgery, Max Hospital, Gurugram, India, performs VATS decortication for empyema in about 1.5 to 2 hours, usually without a blood transfusion, and most patients go home drain-free by day four or five.

This article covers the pleural and benign lung work in his practice, including bronchopleural fistula, bronchiectasis, fungal and hydatid disease and lung volume reduction. The overview of the full specialty sits in the complete guide to thoracic surgery from basics to robotics, and lung cancer and mediastinal surgery are covered in lung cancer and mediastinal surgery by VATS and robotics.

Empyema surgery: VATS decortication instead of open surgery

Empyema is pus in the pleural space, the thin cavity between the lung and the chest wall. Left untreated, it organises into a thick fibrous layer (the "peel") that encases the lung and stops it expanding. In Dr. Khandelwal's practice the most common cause is tuberculosis, alongside pyogenic (bacterial) empyema, and multiloculated pleural effusions, where the fluid is partitioned into many separate pockets, are a very common presentation.

His standard operation is VATS decortication, the removal of this peel through keyhole ports so that the lung can re-expand. Only very rarely does he need an open window procedure (a pleurocutaneous window) or a thoracoplasty, the older operations that collapse or permanently open the chest wall to obliterate an infected space. He offers decortication for stage two and stage three empyema, including patients with fibrothorax, in whom the scarred pleura has already pulled the ribs together.

What the operation involves

Working through a camera, the surgeon:

1. Breaks down the walls between the loculated pockets and drains the whole empyema.
2. Removes all the pleural debris and debrides the pleural cavity completely.
3. Mobilises the lung through a full 360 degrees: the anterior hilum, the apex, the surface over the diaphragm, the inferior pulmonary ligament and the posterior hilum are all released, and the diaphragm itself is mobilised.
4. Opens the fissures between the lobes.
5. Peels both the visceral layer (on the lung) and the parietal layer (on the chest wall), exposing the healthy lung underneath.

At the end the lung re-expands to fill the chest, with all three lobes visible on the right side. A chest X-ray six months after one of his operations showed so little residual change that it was hard to tell the patient had ever had an empyema on that side.

Recovery and outcomes

The operation usually takes 1.5 to 2 hours, and most patients do not need a blood transfusion. Looking back at his own data, Dr. Khandelwal is able to remove the chest drains after two to three days in most cases, and patients are discharged without a drain by the end of the fourth or fifth day. Conversion to open surgery is very rare, and when it does happen it is particularly in tuberculous empyema.

Adhesions after decortication

Adhesions are unavoidable. In young patients he performs both a visceral and a parietal decortication, and he is explicit that dense adhesions will form afterwards. The purpose of empyema surgery is not to prevent adhesions but to free the lung and prevent fibrothorax, the permanent trapping of the lung inside a rigid fibrous shell.

Chylothorax surgery: finding the thoracic duct with ICG fluorescence

Chylothorax is a leak of chyle, the milky lymphatic fluid absorbed from the gut, into the pleural space. The definitive surgical treatment is ligation of the thoracic duct, which Dr. Khandelwal performs on the right side just above the diaphragm.

The difficulty is finding the duct. It is only a few millimetres thick, and in an inflamed chest it can be invisible. One case illustrates his solution. A woman had a tuberculous empyema on one side and a chylothorax on the other. Before surgery she was given a fatty meal to increase chyle flow, and indocyanine green (ICG), a fluorescent dye, was injected into the inguinal lymph nodes. Under the robotic camera the paraspinal area was dissected first; in the dense inflammatory tissue the duct could not be seen. When the infrared light was switched on, the duct lit up green, was localised and was ligated.

This was followed by a routine VATS decortication for the empyema. She had no recurrence of the chylothorax and was discharged after four days.

Pneumothorax surgery: when it is indicated

Pneumothorax, air in the pleural space that collapses the lung, is a very common disease in India, according to Dr. Khandelwal. He offers surgery in three situations:

• High-risk individuals, even at the first episode.
• A persistent air leak: a patient whose chest drain continues to leak air for more than three to five days.
• A second or recurrent episode, where surgery is a definite indication.

He operates through a single port. The source of the leak, usually a bulla (an air-filled blister) at the lung apex or in the apical segment of the lower lobe, is controlled by stapling. Recurrence is then prevented by mechanical pleurodesis, abrading the pleura so that the lung surface adheres to the chest wall. In his experience he has not had a recurrence of pneumothorax after this procedure, and patients are usually discharged after 48 hours without a drain.

Bronchopleural fistula surgery: ending months of chest drainage

A bronchopleural fistula is a persistent communication between an airway and the pleural space. Patients with one suffer a great deal: some have a chest drain that keeps bubbling for months without anyone being able to remove it.

One of his patients had developed the problem after a COVID-19 infection and had lived with a bubbling drain for around a month before referral. During surgery the team filled the pleural cavity with saline and asked the anaesthetist to inflate the lung, which showed exactly where the air was escaping, from the right lower lobe. The pleural debris was removed, the lung was mobilised off the diaphragm and both fissures were opened. The leaking area was stapled off, the air leak was checked again and had stopped, and a mechanical pleurodesis completed the operation. He was discharged after three days. Intercostal nerve blocks are used for pain control.

Bronchiectasis surgery and the destroyed lung

Bronchiectasis, permanent widening and scarring of the airways, is a very common problem in Indian practice and, Dr. Khandelwal believes, in African countries too. It may be congenital or follow tuberculosis.

Surgery is curative when the disease is localised, and palliative when the most diseased areas are removed even though not everything can be. Its benefits are a reduction in mucus production and a reduction in the systemic shunt, the abnormal blood flow through the enlarged bronchial arteries that supply diseased lung.

Who is a candidate for bronchiectasis surgery

• The disease is localised.
• The patient has adequate pulmonary reserve.
• The bronchiectatic process is irreversible.
• The patient has significant symptoms: cough, haemoptysis (coughing blood), recurrent pneumonia or symptoms suggesting shunting of blood.

The operations range from wedge resection and segmentectomy to lobectomy, and at times pneumonectomy (removal of a whole lung), both for bronchiectasis and for a lung destroyed by tuberculosis.

Aspergilloma and mucormycosis surgery

Aspergilloma, a fungal ball growing in an old lung cavity, was very common in the COVID-19 era, and in that period Dr. Khandelwal also treated many patients with mucormycosis, an aggressive fungal infection, who needed lobectomy and sometimes pneumonectomy.

Most of these operations are possible by VATS, although some still need open surgery. Even then, VATS is used first to divide the peripheral adhesions, so the thoracotomy (the open incision between the ribs) is significantly smaller. It is a small, muscle-sparing incision with an excellent recovery.

Congenital and parasitic lung disease

Pulmonary sequestration

A pulmonary sequestration is a segment of non-functioning lung with an abnormal blood supply arising directly from the aorta. In the VATS resection he showed, the arterial feeder from the aorta was stapled, the vein was isolated and divided with a stapler, the abnormal lung was resected with staplers and the specimen was delivered through the VATS port.

Hydatid cyst of the lung: VATS removal

Hydatid disease, caused by the larval stage of the Echinococcus tapeworm, is very common in his practice, and he routinely operates on it by VATS. Spillage of cyst contents during surgery can seed new cysts, so before excising the cyst he fills the cavity with a scolicidal solution, povidone-iodine mixed with hydrogen peroxide, so that any parasites (scolices) released by a spill are killed.

Once the cyst is excised, the whole lung is mobilised, with as much lung as possible preserved. The bronchial communications that open into the cavity are identified and sutured, and the cavity is closed by capitonnage, folding and suturing its walls together.

Interstitial lung disease: VATS lung biopsy

For undiagnosed interstitial lung disease, VATS lung biopsy is the gold standard. In Dr. Khandelwal's experience, a VATS biopsy always provides the diagnosis in these patients.

Lung volume reduction surgery for emphysema

Lung volume reduction surgery (LVRS) removes the most damaged, over-inflated parts of an emphysematous lung so that the healthier lung and the diaphragm work better. Outcomes depend chiefly on patient selection: in the National Emphysema Treatment Trial, open and VATS operations gave similar mortality and function, with faster recovery after VATS. VATS is fairly well tolerated, and Dr. Khandelwal describes the outcomes now as excellent.

Who is a good candidate for LVRS

The criteria he uses:

• Age under 75 years.
• Smoking cessation for more than three months, which is essential.
• Prednisolone at a low dose, less than 10 mg per day.
• No significant comorbidity such as pulmonary hypertension, heart failure, coronary artery disease or renal disease.
• Motivation to undergo surgery and good nutritional status.
• Imaging that shows hyperinflation on the chest X-ray, a flattened diaphragm and heterogeneous disease.

Patients do best when the emphysema is heterogeneous with upper-lobe predominance. On lung function, his thresholds are a total lung capacity above 120% of predicted, a residual volume above 150% of predicted, a diffusing capacity (DLCO) above 20% of predicted and a six-minute walk of more than 140 metres. The forced expiratory volume in one second (FEV1) is typically between 20% and 45% of predicted, the range used in the National Emphysema Treatment Trial.

Before surgery these patients undergo extensive pulmonary rehabilitation. Once they are prepared, LVRS is performed, and they do really well afterwards.

Wedge resection for atypical lung lesions

VATS wedge resection is also used for atypical lung lesions, which are commonly seen after transplantation and in other immunosuppressed states.

What connects these VATS operations

Across these conditions, Dr. Khandelwal's approach rests on three principles: operate through ports wherever possible, mobilise and preserve as much lung as possible, and control pain with intercostal blocks so that drains come out early and patients go home within days. The robotic and lung-preserving techniques he applies to cancer, and the referral pathway for patients abroad, are described in the complete guide, and the wider specialty is on the thoracic surgery hub. His answers to doctors' questions on adhesions and transplantation after tuberculosis are on the Live Discussion page.