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VATS pleurodesis is done to cause pleural symphysis. It is most commonly done to prevent the reaccumulation of symptomatic pleural effusions, malignant or benign, in a patient with otherwise good performance status (Figure 1). In addition, it can be used to treat spontaneous or secondary pneumothoraces and manage thoracic duct leak, in conjunction with ligation of the thoracic duct.
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PREOPERATIVE PREPARATION
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A CT scan of the chest is performed to evaluate the anatomy of the pleural space. Loculations and adhesions are noted. Chest CTs or chest radiographs performed after thoracentesis are reviewed to evaluate the ability of the lung to expand and touch the chest wall—visceral to parietal pleural apposition. Without visceral to parietal pleural apposition, pleurodesis will not be effective.
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General anesthesia with single-lung ventilation is required. Epidural analgesia is avoided, as it may cause profound hypotension following talc pleurodesis. Intercostal nerve blocks are performed at the end of the procedure. Prior to positioning, bronchoscopy is performed to rule out obstructive lesions in the airway that could prevent reexpansion of the lung. Obstructing lesions that can be removed, reestablishing distal aeration, do not prevent an effective pleurodesis. If an obstructing lesion cannot be removed and would prevent reexpansion of the lung on the involved side, pleurodesis is not performed and a long- or intermediate-term tunneled indwelling pleural catheter is placed to manage the effusion.
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The patient is placed in the appropriate lateral decubitus position slightly rolled forward (Figure 2). The surgeon stands in front of the patient, with the assistant standing to the surgeon’s left or behind the patient. The anesthesiologist stands at the head of the patient. The surgical nurse stands opposite the side of the surgical assistant. Monitors are positioned at the head of the bed and on either side of the patient.
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INCISION AND EXPOSURE
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A single 1.5-cm incision is made in the 8th intercostal space along the midaxillary line and thoracic access is obtained as in Chapter 3. The ipsilateral lung is then dropped by isolating ventilation to the contralateral lung.
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A Yankauer suction catheter is used to drain the effusion through this access point, and the 10-mm thoracoscope introduced. If the lung is trapped and cannot expand to touch the chest wall, a 19-French Blake drain or tunneled indwelling catheter can be placed and the incision closed, as pleurodesis will be ineffective. If the lung is able to completely expand to meet the chest wall after draining the effusion, pleurodesis can be performed.