Video-Assisted Thoracoscopic Surgery (VATS) pleurodesis addresses recurrent fluid or air accumulation in the chest cavity. This procedure combines the minimally invasive VATS technique with pleurodesis. Pleurodesis involves intentionally fusing the two layers of the pleura, which are the membranes lining the lung and the inside of the chest wall. The goal of this fusion is to eliminate the pleural space where air or fluid can collect, providing a long-term solution to prevent recurrence.
Conditions Requiring VATS Pleurodesis
VATS pleurodesis is required to manage conditions causing the space between the lung and chest wall to repeatedly fill with fluid or air. One common non-cancer indication is Recurrent Spontaneous Pneumothorax (RSP), a repeated collapse of the lung due to air leakage. Since the recurrence rate can be as high as 60% to 80%, a permanent fix is often necessary.
For patients with recurrent air leaks, simpler treatments like chest tube drainage alone are often inadequate. VATS pleurodesis is also a widely used approach for Malignant Pleural Effusion (MPE), where fluid buildup is caused by cancer, such as metastatic disease. In these oncological cases, the procedure is performed for palliative care to reduce symptoms like breathlessness and improve quality of life.
Less common indications include:
- Persistent pleural fluid leaks.
- Chylothorax (lymphatic fluid in the chest).
- Refractory effusions related to conditions like heart failure.
The procedure is only performed when the lung is capable of fully expanding, as a “trapped lung” cannot adhere to the chest wall, making pleurodesis ineffective.
The Minimally Invasive Procedure
The VATS approach uses small incisions, typically two or three ports, on the side of the chest. The patient is placed under general anesthesia, and a specialized breathing tube may temporarily deflate the lung on the affected side to provide the surgeon with an operating field. Through one port, a thoracoscope (a small camera) is inserted to provide a magnified view of the pleural space on a monitor.
The surgeon first drains any existing air or fluid from the pleural space to ensure the lung is fully expanded against the chest wall. Once the space is clear, the pleurodesis action is performed, which involves intentionally irritating the pleural surfaces to trigger a healing response that leads to adhesion. The method chosen depends on the patient’s underlying condition.
Mechanical pleurodesis is often preferred for recurrent pneumothorax, especially in younger patients. It involves the surgeon physically abrading or “scratching” the parietal pleura using a dry gauze or similar instrument. This abrasive action creates inflammation and scarring that forces the lung’s lining to stick to the chest wall. In cases of pneumothorax, the surgeon may also use VATS to identify and resect any small air-filled sacs, called blebs or bullae, that were the source of the air leak.
Chemical pleurodesis, often used for malignant effusions, involves the application of a sclerosing agent, most commonly sterile talc powder. The talc is sprayed or “poudraged” onto the pleural surfaces, inducing a robust inflammatory reaction that leads to adhesion between the two pleural layers. At the end of the procedure, a chest tube is placed through one of the incisions to drain any remaining fluid, air, or blood before the small incisions are closed.
Post-Operative Management and Recovery Timeline
Immediate post-operative care focuses on managing pain, which is common due to the incisions. Effective pain control often utilizes nerve blocks or epidurals to manage discomfort associated with the chest incisions and the presence of the chest tube. Patients are encouraged to begin walking shortly after surgery and to use an incentive spirometer to help fully re-expand the lung and prevent complications like pneumonia.
The chest tube remains in place to ensure the lung stays fully expanded and to drain any ongoing air or fluid. It is usually removed only when drainage is minimal (typically less than 100 milliliters over 24 hours) and when a chest X-ray confirms the lung is fully inflated with no persistent air leak. The average hospital stay typically ranges from three to seven days, depending on the time required for chest tube removal.
Once discharged, recovery at home continues. Patients are advised to avoid strenuous activity, including heavy lifting, for approximately four to six weeks. Patients should also avoid driving if they are still taking narcotic pain medication. Most people gradually return to their normal activity levels and exercise routine within this four-to-six-week period.
Long-Term Effectiveness and Potential Complications
VATS pleurodesis is highly effective in preventing the recurrence of air or fluid accumulation. Studies show that surgical pleurodesis, particularly with talc poudrage for malignant effusions, has a long-term success rate exceeding 90%. For recurrent pneumothorax, the long-term recurrence rate after VATS pleurodesis combined with bleb resection is low, often falling in the range of 2% to 6%.
While the procedure is minimally invasive, it carries risks and complications. These include:
- Chronic pain, sometimes referred to as post-thoracotomy pain syndrome, which can persist along the incision sites or rib cage.
- Bleeding.
- Infection (empyema).
- Fever or inflammation following the application of chemical agents like talc.
The fusion of the pleural layers preserves long-term lung function, making it a safe option for most patients. However, the pleurodesis procedure permanently alters the anatomy. The resulting dense scar tissue makes any future thoracic surgery on that lung significantly more difficult. This permanent adhesion is the trade-off for the high success rate in preventing recurrent episodes.