Pleurectomy with lung decortication

Pleurectomy: access and sac mobilization

In the surgical treatment of chronic pleural empyema, the main procedure is pleurectomy. The lateral approach is considered optimal. Because prolonged chronic inflammation significantly narrows the intercostal spaces, surgeons frequently have to resort to resection of the fifth or sixth rib.

Mobilization of the empyema sac begins with blunt dissection of the thickened parietal pleura, after which retractors are placed into the wound. If total empyema is diagnosed, the sac must be dissected along its entire length: from the pleural dome to the diaphragm, as well as dorsally up to the spine and ventrally to the lung root. To ensure meticulous hemostasis during this extensive stage, electrocautery and tight packing with sponges soaked in warm saline are used.

Pulmonary decortication and completion of the surgery

After complete mobilization of the empyema sac, its opening is initiated. The parietal wall is incised, gradually transitioning to the visceral pleura until the lung tissue appears in the wound. Decortication itself consists of the careful separation of the sac from the pulmonary surface using a gauze sponge (tupther/peanut dissector).

• If very dense adhesions are encountered, they are carefully divided with scissors.
• At this stage, it is critical not to damage the lung tissue itself to avoid air leaks.
• The sac is removed entirely along with all purulent contents.

Finally, final decortication is performed—the meticulous removal of remaining fibrous deposits. This is necessary for complete lung expansion. The pleural cavity is drained by two tubes with multiple side holes.

Complications and alternative procedures

Pleurectomy does not always end successfully. If during manipulation the lung tissue begins to tear or the lung fails to expand due to deep fibrous changes, further decortication is strictly contraindicated. In such situations, surgeons are forced to switch to alternative methods. These include C-shaped thoracoplasty or complete pleuropneumonectomy—the radical removal of the empyema sac en bloc along with the non-functioning lung.

Opening of the residual pleural cavity (thoracostomy)

Open drainage is also indicated for chronic pleural empyema. The surgery is performed under endotracheal anesthesia. A critically important point: if a large bronchopleural fistula opens into the cavity, separate bronchial intubation (or intubation of the opposite healthy lung) is required to protect the airways from pus aspiration.

The surgical access site is chosen based on radiography data, guided by the localization of the residual cavity. Most often, a 12–15 cm skin incision is made along the ribs in the subscapular or axillary region. In the axillary region, the incision often has a "hockey stick" shape—vertical with a turn of the lower end toward the nipple. Following subperiosteal rib resection, a trial puncture with a thick needle is performed. The needle must pass through the posterior leaf of the periosteum, the endothoracic fascia, and the thick parietal pleura. Having obtained the contents (pus, air, or fluid), the cavity is opened with a scalpel and explored with a finger.

Creation of a thoracostomy and wound management

To create a wide "window" measuring approximately 10 by 8 cm, the surgeon identifies the floor of the purulent cavity and additionally resects segments of one or two more ribs. It is important that the lowest resected rib strictly corresponds to the floor of the cavity.

The intercostal muscles and altered pleura are excised, followed by a thorough toilet of the wound. The edges of the skin incision are inverted inward and securely sutured to the thickened parietal pleura with thick interrupted catgut sutures. Such fixation creates optimal conditions for regular packing and open wound treatment. Subsequently, after complete cleansing and sanitation of the cavity, it is closed using thoracoplasty and transferred muscle flaps.

Class and exam questions

What else to study on this topic

• Technique of C-shaped thoracoplasty
• Features of pleuropneumonectomy
• Topographic anatomy of the intercostal spaces
• Plastic closure of the pleural cavity with muscle flaps
• Management of patients with bronchopleural fistulas

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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