Perioperative management - Uniportal wedge resection and pleurectomy

High individual risk of recurrence and patient preference

• By performing operative pleurodesis and wedge resection of the lung apex, a recurrence rate of less than 5% can be achieved.

Persistent air fistula or insufficient thoracic drainage

• If there is a persistent air fistula after thoracic drainage placement or incomplete re-expansion of the lung, surgical intervention is recommended.

• Lack of cardiopulmonary reserve for lung ventilation
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic plan regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

In primary spontaneous pneumothorax, specific preoperative diagnostics are not necessarily required. However, in predominantly very young patients, performing a low-dose computed tomography may be considered to avoid missing potential pathologies intraoperatively.

• Shaving of the chest wall, if necessary
• SingleShot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Injury to adjacent structures, particularly the trachea and main bronchi, major vessels, and the esophagus, necessitating corresponding extension of the procedure
• Damage to the phrenic nerve with diaphragmatic elevation on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paralysis on the affected side
• Postoperative air fistula after wedge resection
• Postoperative lymph fistula with chylothorax
• Postoperative hemorrhage with potentially necessary re-operation
• Cardiac arrhythmias
• Positioning injuries

Treatment alternative: Talc pleurodesis, conservative therapy

Intubation anesthesia with one-lung ventilation of the opposite side.

For standard positioning (depicted here for right-sided operations) in minimally invasive thoracic surgical procedures, the hyperextended lateral position is recommended.

• Bending of the operating table at the level of the scapula tip
• Horizontal alignment of the thoracic wall using a slight anti-Trendelenburg position
• Stabilization of the position using padded side supports in the area of the abdomen and lumbar spine, as well as a U-shaped pillow between the legs. It may occasionally be helpful to use an additional shoulder support.

Finally, it is important to pad pressure-sensitive areas and place the head on a gel ring to avoid excessive bending of the cervical spine. The arm on the operating side is positioned laterally using an arm holder and should be placed below shoulder level to avoid any potential obstruction during the subsequent operation.

The arrangement (the image shows a right-sided operation) of the surgeon and assistants ventrally and opposite the OR nurse was described by the Copenhagen working group led by Hendrik Hansen. Especially in uniportal VATS, but also in 3-port VATS, optimal work can be performed here through the anterolaterally located minithoracotomy.

• Wound protection ring foil (wound retractor)
• Standard VATS instrumentation with curved instruments
  • Argon beamer for hemostasis and pleurodesis recommended
• Endoscopic stapling device
  • For emphysematous lung tissue, reinforcement of the staple line before parenchyma transection is advisable.
• Titanium clip applicator

• Postoperative Analgesia

Due to the pain caused by the thoracic drainage, a combination analgesia of a non-opioid analgesic (e.g., metamizole) in combination with a low-dose opioid (e.g., tilidine) is advisable. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Management of acute perioperative and post-traumatic pain.

• Medical Follow-up
  • X-ray control on the operating table
  • Thoracic drainage with suction 20mmHg for about 2 days postoperatively, removal after X-ray control if secretion volume is under 250ml/24h and no air fistula is detected
• Thrombosis Prophylaxis

In the often young patients without significant comorbidities, postoperative thrombosis prophylaxis may possibly be omitted or the duration of therapy shortened. There are currently no clear recommendations. The standard thrombosis prophylaxis after thoracic surgical procedures includes therapy for 14 days with low molecular weight heparin subcutaneously, considering comorbidities, renal function, and laboratory control to exclude HIT. Link to the current guideline: Prophylaxis of venous thromboembolism (VTE)

• Mobilization

Full mobilization possible from the 1st postoperative day

• Physical Therapy

Mobilization, breathing exercises, and secretion mobilization

• Diet Progression

Regular diet

• Bowel Regulation

Accompanying opioid analgesia

• Work Incapacity

Approximately 14 days, considering the type of work and patient situation