Pleurectomy

Full name of procedure:

Video-assisted thoracoscopic apical bullectomy (blebectomy), apical pleurectomy, basal pleural abrasion

Short name:

(VATS) Pleurectomy

Reason for procedure:

The commoner reasons for performing the procedure are:

•to prevent further pneumothoraces (collapsed lung) occurring

•to seal a persistent air leak from the lung or

•to allow a trapped lung to re-expand

A pneumothorax is a potentially life-threatening condition, particularly if there is a build-up of air under pressure, known as a tension pneumothorax. This impairs the function of the other lung and the heart and is particularly distressing. It is a particular threat if it occurs when flying or scuba diving.

Description of procedure:

The procedure is performed under general anaesthetic. The lung being operated on is collapsed by the anaesthetist to allow the surgeon access to the lung and the pleural cavity (the body compartment where the lung is located).

The procedure is performed using video-assisted thoracoscopy (keyhole surgery). Three incisions, each an inch long, are made between the ribs. A camera is placed through one, while instruments are placed through the other two. The operation has three components:

1. Bullectomy: In this procedure any abnormal blisters (blebs) or emphysematous air spaces (bullae) are stapled, sewn over or excised from the lung - usually the apex (top of the lung). It is these blebs and bullae which can rupture, letting air escape from the lung into the pleural cavity (between the ribs and the lung), allowing the lung to collapse and causing a pneumothorax.

As new bullae can develop over time, two procedures are performed to create adhesions between the lung and the chest wall. If there is a further leak of air, the adhesions keep it trapped in a small pocket and prevent the lung collapsing.

2. Apical pleurectomy is the stripping of the pleura (the lining of the lung and ribcage) from the inside of the ribs. This produces dense adhesions between the apex of the lung, the commonest place for bullae, and the ribcage.

3. Basal pleural abrasion: To preserve some its function the basal pleura is not stripped. To produce adhesions it is abraded (roughened using a cloth towel) to produce bleeding and inflammation.

The blood produced by the pleurectomy and the abrasion becomes a glue which forms the adhesions between the lung and the ribcage. In time these mature into scar tissue forming permanent adhesions.

Benefits of the procedure:

•Pleurectomy reduces the chance of symptomatic recurrence of spontaneous pneumothorax, on that side, to approximately 2-5%. (Without the operation the risk of a second pneumothorax is 30%: after a second pneumothorax, the risk of a third is 60%).

•While air leaks may occur in the future, the adhesions will prevent the lung collapsing.

•Activities such as flying and scuba diving should have a reduced risk of tension pneumothorax.

Risks of the procedure:

Anaesthetic complications: As with all procedures performed under general anaesthesia reactions to the anaesthetic can occur. While these are uncommon, the more severe reactions can affect the heart (heart attack or abnormal heart beat), the lungs (asthmatic attack or pneumonia) or the brain (stroke or fit).

Complications of the operation: Any procedure performed by a surgeon has risks of injury, complication or death. Complications specific to pleurectomy are:

•Bleeding - the operation works by producing bleeding; the blood clots form adhesions which then fuse the lung to the chest wall. There will therefore be some bleeding after the surgery. A basal chest drain will be inserted to drain excess blood.

•Air leak - where the lung has been stapled, sewn, cut or where adhesions have been divided there is the potential for leakage of some air from the lung. An apical drain will be placed to drain air and keep the lung expanded.

•Prolonged air leak - if the lung is slow to heal or if the lung is slow to fully re-inflate the air leak may persist for a number of weeks. Where this is the case a portable flutter bag drain will be applied and you will be allowed home with district nurse supervision and weekly medical review.

•Conversion to thoracotomy - sometimes the presence of existing adhesions, the inability to collapse the lung or for other technical reasons, it may not be possible to perform the procedure adequately using a fully thoracoscopic approach. In such cases, one of the incision, usually the one at the back, will be extended to allow a hand to be introduced to complete the procedure fully. This occurs in 10-20% of cases.

•Postoperative pain: There will be pain from the thoracoscopy port sites, especially those through which a drain will be left after the operation. Local anaesthetic will be injected around the incisions to tide you through the first 12 - 24 hours. You will have a patient controlled analgesia system (PCAS). Using this you will be able to give yourself a shot of painkilling medication as you require it. You will be encouraged by the physiotherapists to use enough medication to allow you to move around your bed, breath deeply and cough as required. The requirement for pain killers decreases quickly over a few days, especially after the drains are removed. You will be started on painkilling tablets at that stage. You will be able to take these home when you are discharged from hospital.

•Long-term discomfort: While the pain settles in about two weeks, there may be vague discomfort in the chest even a number years after the surgery. The operation works by the creation of adhesions between the lung and the ribs. Adhesions can cause pain. Incisions can also be painful and the intercostal nerves, which run under each rib, can be irritated by instruments. It is still possible for there to be air leaks from new blebs. The adhesions confine such air leaks in pockets called loculations and prevent a major pneumothorax. However, such small air leaks can cause discomfort.

•Recurrence - 2-5% of patients will experience a recurrence, Most of these will require minimal intervention such as a chest drain or the insertion of talc to create more adhesions. However, a small number will require a more extensive repeat procedure through a full chest incision.

Female Patients Only

There is an uncommon condition called catamenial pneumothorax (recurrent pneumothoraces occurring at the time of the menstrual period). This can be associated with small holes in the diaphragm or associated with a pelvic condition known as endometriosis. Some of these pneumothoraces can be treated using the contraceptive pill to control menstruation. Others need surgery including closure of the holes in the diaphragm. This can usually be done at the same time as pleurectomy.

Warning:

If you are taking any drug which thins the blood, this may increase the risk of bleeding. An alternative may need to be prescribed up to two weeks before the procedure and you may need to be admitted earlier than planned. Please advise your surgeon (or contact his secretary) if you are taking any of the following drugs:

•Warfarin

•Aspirin

•Plavix (Clopidogrel)

•Drugs for treating arthritis such as :

oVoltarol (diclofenac),

oIndocid (indomethacin),

oBrufen (ibuprofen),

oKetoralac,

oMobic (meloxicam),

oCelebrex (celecoxib),

oVioxx (rofecoxib),

oAdvil,