Pleurectomy 

Updated: Apr 18, 2019
Author: Fahad Aziz, MD; Chief Editor: Dale K Mueller, MD 

Overview

Background

Pleurectomy is a type of surgery in which part of the pleura is removed. This procedure helps to prevent fluid from collecting in the affected area and is used for the treatment of mesothelioma, a pleural mesothelial cancer.[1] Pleurectomy provides symptomatic relief but does not appear to benefit survival rates.

Malignant pleural effusions generally result from metastatic spread of disease to the pleura and are commonly seen in the course of many tumors. Less frequently, effusions are associated with primary tumors of lung, pleura, or mediastinum.

Many nonsurgical methods have been proposed to control effusion and to improve respiratory function. Nonetheless, many studies have demonstrated the benefits of pleurectomy in patients with malignant effusions secondary to various cancers.[2]

Pleurectomy reduces the risk of symptomatic pleural effusions and recurrence of spontaneous pneumothorax.[3]

Indications

Pleurectomy is most commonly indicated for mesothelioma. However, other less common indications include the following:

  • Primary pneumothorax

  • Pneumothorax secondary to chronic obstructive pulmonary disease (COPD)

  • Traumatic pneumothorax

  • Malignant pleural effusions

Outcomes

Pleurectomy can be safely performed and effectively controls the symptoms of pleural effusion that develops with malignant pleural mesothelioma. The addition of postoperative phototherapy or intrapleural chemotherapy does not improve long-term survival, but pleurectomy does result in symptom palliation.[4]

 

Periprocedural Care

Monitoring & Follow-up

Postoperative management requires good pain management with epidural catheters, intravenous patient-controlled analgesia, local pain pumps, intercostal rib blocks, or a combination of these maneuvers.[5]

Aggressive chest physiotherapy with early ambulation, incentive spirometry, and other methods of sputum mobilization are used to prevent atelectasis and pneumonia.[5]

Chest tubes are placed to evacuate both fluid and air. Sclerosing maneuvers (ie, talc, doxycycline) may be necessary to seal persistent air leaks.[5]

 

Technique

Pleurectomy for Mesothelioma

Pleurectomy has gained importance in the management of the mesothelioma.[6] The procedure includes the complete decortication of the lung (resection of visceral pleura) and the parietal pleura.[5, 7, 8, 9, 10]

The technique is as follows:

  1. The patient is placed in a full lateral position after placement of a double-lumen endotracheal tube.[5]

  2. A posterolateral thoracotomy incision is made, completely dividing the latissimus muscle, and the chest is entered through either the fourth or fifth intercostal space. Usually, the serratus muscle can be spared but occasionally must also be divided to allow adequate access.[5]

  3. An additional eighth or ninth interspace thoracotomy within the same skin incision may be necessary for adequate exposure of the inferior thorax.[5]

  4. Pleurectomy involves complete resection of both visceral and parietal pleura and can include both pericardial and diaphragmatic resection, as well as resection of additional lung nodules.[5]

  5. The parietal pleura is first dissected off the chest wall and then the mediastinum.[5]

  6. The pleura is then opened and the visceral pleura removed.[5]

  7. Although the procedure can allow extensive debulking, it is not generally possible to attain complete macroscopic debulking of tumor with this procedure.[5]

Pleurectomy for Pneumothorax

Pleurectomy in the setting of pneumothorax is performed using video-assisted thoracoscopy.[11] Three incisions, each 1 inch long, are made between the ribs. The operation has 3 components: bullectomy, apical pleurectomy, and basal pleural abrasion, discussed below.

Bullectomy

In this procedure, any bullae are stapled, sewn over, or excised from the lung, usually the apex (top of the lung). These bullae can rupture at any time to cause spontaneous pneumothorax.[3] Pleurectomy is performed to create adhesions between the lung and the chest wall, preventing further air leak. Even if the bullae rupture, the air will be trapped in a small pocket and prevent lung collapse.

Apical pleurectomy

Apical pleurectomy is the stripping of the pleura from the inside. This produces dense adhesions between the apex of the lung, the most common location of bullae, and the ribcage.[3]

Basal pleural abrasion

To preserve its function the, basal pleura is not stripped. To produce adhesions, it is abraded to produce an inflammatory reaction.[3]

The blood produced by the pleurectomy and the abrasion causes adhesions between the lung and the ribcage. Over time, these mature into scar tissue, forming permanent adhesions.

Complication

Potential complications of pleurectomy include the following:

  • Bleeding

  • Prolonged air leak

  • Conversion to thoracotomy

  • Postoperative pain

  • Recurrence