Case Report: Dual port thoracoscopy for decortication, part II

case report on dual port thoracoscopy

This case study was prepared with assistance from Dr. Carlos Ochoa. Since we have been discussing the relevance of case reports and providing tips on case report writing for new academic writers – we have written the following case report in the style advocated by McCarthy & Reilley (2000) using their case report worksheet to demonstrate the ease of doing so in this style.

Since the previous presentation of dual-port thoracoscopy for decortication was missing essential materials, we are presenting a second case report.

Authors: K. Eckland, ACNP-BC, MSN, RN & Carlos Ochoa, MD

Case Report: Dual port thoracoscopy for decortication of a parapneumonic effusion

Abstract:  The use of increasingly minimally invasive techniques for the treatment of thoracic disease is becoming more widespread. Dual and even single port thoracoscopy is becoming more frequent in the treatment of parapneumonic effusions and empyema.

Clinical question/problem: the effectiveness and utility of dual port thoracoscopy for parapneumonic effusions.

Analysis of literature review: Despite the increasing frequency of dual and single port thoracoscopic techniques, there remains a dearth of literature or case reports on this topic.  Pubmed and related searches reveal only a scattering of reports.

Summary: As the case report suggests, dual port thoracoscopy is a feasible and reasonable option for the treatment of parapneumonic effusion.

Case history:  50-year-old patient with a three-week history of pneumonia, with complaints of right-sided chest pain, cough and increased phlegm production.  Additional past medical history is significant for poorly controlled diabetes, hypertension, and obesity with central adiposity.  Medications included glyburide and lisinopril.

After being seen and evaluated by an internal medicine physician, the patient was started on oral antibiotics.  After three weeks, when his symptoms failed to improve, he was referred by internal medicine to thoracic surgery for out-patient evaluation.

On exam: middle-aged obese diabetic gentleman in no immediate distress, resting comfortable in the exam room.  Face appeared moderately flushed, but skin cool and dry to the touch, no evidence of fever.

On auscultation, he had diminished breath sounds over the right lower lobe with egophony over the same area.  The remainder of the exam was essentially normal.

Lab studies showed a mildly elevated WBC of 11.6, decreased Hgb of 10.4 / HCT 32.5.   Hemoglobin A1c 10.6, Fasting glucose 228, HDL mildly low at 40.

EKG showed slight axis deviation, with slightly prolonged QRS complex (.16) with no evidence of loss of R, St elevation or other abnormalities.  He was cleared by internal medicine for surgery.

Radiographic data:

Chest x-ray showing right-sided loculated effusion
CT slices, tissue window

After risks, benefits and alternatives to VATS decortication were explained to the patient – the patient consented to proceed with surgical decortication.  After scheduling surgery, the patient was seen by anesthesia in preparation for the procedure.

Surgical procedure:  Dual-port thoracoscopy with decortication of parapneumonic effusion.

Dual port thoracoscopy

After being prepped and drapped in sterile fashion and confirmation of dual lumen endotracheal tube placement, a small 2 cm incision was made for insertion of a 10mm port.  Following entry into the chest with the thoracoscope, the right lung was deflated for optimal inspection and decortication of loculations.  After completing the majority of the procedure, a second access port was created for better visualization and to ensure that a thorough decortication was completed.  The lung and pleural were separated from the chest wall, and diaphragm, and demonstrated good re-expansion with lung re-inflation prior to completion of the procedure.

chest tubes at conclusion of case

At the conclusion of the procedure, two 28 french chest tubes were placed in the existing incisions.  These were sutured into place, and connected to a pleurovac drainage system before applying a sterile gauze dressing.  The patient remained hemodynamically stable throughout the case, with no episodes of hypoxia or desaturation.  Following surgery, the patient was transferred to the PACU in stable condition.

Post-operative course was uncomplicated.  Chest tubes were water-sealed on POD#3 and chest tubes were removed POD#4, with the patient being subsequently discharged after chest x-ray.

close up view of dual port thoracoscopy

Literature Review

A literature review was performed on PubMed using “dual port thoracoscopy”, “dual port VATS”, “2 port” as well as minimally invasive thoracoscopic surgery “

Results of search:  A limited number of case studies (3) described thoracoscopic surgery with a single port.  There was one case found describing cases conducted with two ports, and the majority of reports involved three or more access ports.

Discussion/ Conclusion

While convention medical wisdom dictates a trial and error treatment approach with initial trial of antibiotic therapy followed by chest tube placement (Light, 1995), surgeons have long argued that this delay in definitive treatment places the patient at increased risk of significant morbidity and mortality (Richardson, 1891). Multiple recent reviews of the literature and research comparisons continue to demonstrate optimal outcomes with surgery based approaches versus antibiotics alone, TPA and tube thoracostomy.  The ability to perform these procedures in the least invasive fashion (VATS versus thoracotomy approaches) defies the arguments against surgical intervention as advanced by interventionalists (radiologists and pulmonologists.)  Successful decortication with the use of dual port thoracoscopy is another example of how technology is advancing to better serve the patient and provide optimal outcomes, and offers a minimally invasive option when single port surgery may not be feasible.

During the case above, visibility and access to the thoracic cavity was excellent.  However, in cases requiring additional access, reversion to the standard VATS configuration can be done easily enough with significant delays or additional risks to the patient.

References/ Resources

Foroulis CN, Anastasiadis K, Charokopos N, Antonitsis P, Halvatzoulis HV, Karapanagiotidis GT, Grosomanidis V, Papakonstantinou C. (2012). A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study.  Surg Endosc. 2012 Mar;26(3):607-14. [free full text not available.]

Gonzalez – Rivas, D., Fernandez, R., De la Torre, M., & Martin – Ucar, A. E. (2012).  Thoracoscopic lobectomy through a single incision.  Multimedia manual cardio-thoracic surgery, Volume 2012This is an excellent article which gives a detailed description, and overview of the techniques used in single incision surgery.  Contains illustrations, full color photos and videos of the procedure.

Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C. (2012).  Single-incision video-assisted thoracoscopic lobectomy: initial results.  J Thorac Cardiovasc Surg. 2012 Mar;143(3):745-7.

Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. (2011).  Single-port video-assisted thoracoscopic left upper lobectomyInteract Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41.

VATS decortication: Empyema

an in-depth look at video-assisted thoracoscopy for decortication of advanced empyema.

In a previous series of posts discussing a recent paper presented by a group of Australian pulmonologists, we debated the use of VATS for decortication of advanced empyemas versus medical treatments.  Today, I would like to talk more about the VATS decortication procedure itself.  This procedure is performed to remove infected material (pus) from the thoracic cavity so the lung can re-expand.

when fully encapsulated as seen in this ct scan may be difficult to distinguish from lung abscess – but note the compressed lung, which is a characteristic of empyema.

In advanced empyema, a tough, fibrous layer (or peel) forms around the lung and prevents full re-expansion. (This peel has the appearance and texture of rubbery chicken skin.)

thick pleural removed during decortication

In these cases, decortication (or peel removal) is necessary for full recovery.

VATS decortication of a loculated empyema

If the peel isn’t removed, the lung will remain compressed and infection can easily recur.  In VATS surgery, several ports are used (small 2cm incisions) versus a larger thoracotomy incision.  This isn’t always possible; if the infection is severe, or surgeons are unable to free the lung through the smaller incisions.  Sometimes surgeons have to convert to open surgery intra-operatively.  However, VATS is preferable for patients, (if possible).  Smaller incisions mean less injury, less pain leading to fasting healing, and a shorter hospital stay.

empyema, advanced with extensive purulence
advanced empyema requiring open thoracotomy for decortication

Click here to see a video showing a standard thoracotomy incision (with retractors holding it open).

For a related case study on VATS decortication.

As we mentioned in a previous post – empyema is a serious, potentially fatal infection* – in fact – one out of three patients with this condition will die from it.

What’s the difference between empyema and a parapneumonic effusion?  Answer: Pus.

*while this case report features a patient from Uganda, similar cases have been encountered in my practice here in the USA.


Prilozi. 2010 Dec;31(2):61-70.  Indications for VATS or open decortication in the surgical treatment of fibrino-purulent stage of parapneumonic pleural empyema.  Colanceski R, Spirovski Z, Kondov G, Jovev S, Antevski B, Cvetanovski M V.  Article linked in text above, recommending early surgical treatment for better patient outcomes.  However, this study did not compare surgical treatments to medical therapies.

Asian Cardiovasc Thorac Ann 2010;18:337–43. Thoracic empyema in high-risk patients: conservative management or surgery?   Bar I, Stav D, Fink G, Peer A, Lazarovitch T, Papiashvilli M.  Limited study of 119 patients showing benefit in both groups of patients with surgery used as primary management strategy in clinically unstable patients.  (Increased mortality in this limited study of surgical interventions versus medical management can be attributed to the fact that surgery was used as a last resort in the sicker, more debilitated patients by the authors descriptions).

Metin M, Yeginsu A, Sayar A, Alzafer S, Solak O, Ozgul A, Erkorkmaz U, Gürses A.  Treatment of multiloculated empyema thoracis. Singapore Med J. 2010, Mar 51(3): 242-6.  Comparison of VATS, open surgery and conventional treatment for empyema.  Authors recommend VATS for first line treatment.

older references on VATS decortication:

J Thorac Cardiovasc Surg 1999;117:234-8. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome.  Cassina PC et al.  Authors discuss the results of VATS decortication in 45 patients after failed medical treatment and attempted thoracostomy drainage.  Several patients required open thoracotomy due to late organized infectious process.

Ann Thorac Surg 2006;81:309-313.  Video-Assisted Thoracic Surgery for Pleural Empyema.  Wurnig, S. S.,Wittmer, V., Pridun, N., & Hollaus, P. H. (2006).  Linked in text above. Austrian study of 130 patients

Ann Thorac Surg 2003;76:225-30. Minimally invasive surgery in the treatment of empyema: intraoperative decision-making. Roberts, J. R