Review Note

• Thoracoscopy and thoracotomy for: 

• Procedure Stripping of parietal pleura from inside of chest wall (pleurectomy). Production of adhesions between parietal and visceral pleura either chemically (talc, tetracycline) or by physical abrasion (pleurodesis) 
• Physical pleurodesis more effective at preventing reccurance than chemically, chemically ~50% effective 

• Pre-OP:
• Two groups:
• FIt and young with spontaneous/recurrent PTX (check for asthma)
• Old and co-morbid with COPD/recurrent pleural effusions
• Time Pleurectomy 1–2h; pleurodesis 20–40min
• If large pleural effusion (more than 2/3rds of hemithorax on CXR or >2000ml) should be tapped or partially drained at least 12 hrs before surgery - rapid intraoperative reexpansion can precipitate unilateral post-op ‘re-expansion’ pulmonary oedema
• Intra-op:
• Keep airway pressures low with patients with previous PTX, if current PTX should have chest drain as will worsen with IPPV (and avoid nitrous)
• Pain +++/++++
• Position Lateral decubitus for VATS or open thoracotomy
• Blood loss Can bleed from the stripped pleura; G&S
• Practical techniques: IPPV and OLV (DLT) advised for open/VATS procedures
• Patients with extensive effusions can have cardiovascular collapse when positioned ‘effusion side up’ for surgery, mechanism probably due to mediastinal shift and high intrathoracic pressure from IPPV -> reduced VR and CO. If this occurs, return supine and drain effusion prior to proceeding.
• Post-op:
• Extubate at end of case, sit patient upright
• CXR post-op to check for full lung expansion
• Analgesia:
• Pleural inflammation causes severe pain
• Multimodal but avoid NSAIDs (may make pleurodesis less effective)