Patient information for thoracosocopic
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 25%. (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.
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 :
o Voltarol (diclofenac),
o Indocid (indomethacin),
o Brufen (ibuprofen),
o Ketoralac,
o Mobic (meloxicam),
o Celebrex (celecoxib),
o Vioxx (rofecoxib),
o Advil,
o Neurofen,
o Feldene.
Contact numbers:
 Royal Victoria Hospital Thoracic Surgical Ward 4a: 028 90632016
 Belfast City Hospital Thoracic Surgical Ward 5 South: 028 90263649
 Royal Victoria Hospital Thoracic Secretaries: 028 9063 3730/2027
 Belfast City Hospital Thoracic Secretaries: 028 90263749
Keywords to search the internet
Thoracoscopy
Pleurectomy
Bullectomy
Pneumothorax
Useful websites
http://en.wikipedia.org/wiki/Pneumothorax
http://www.nlm.nih.gov/medlineplus/ency/article/000087.htm
http://www.pneumothorax.org/