Pleurectomy: Everything You Need to Know

In This Article

A pleurectomy is a surgery used to remove part of the pleura, the two thin layers of tissue surrounding the lungs. A pleurectomy is most commonly used to prevent pleural effusion (fluid collecting in the space between the pleural membranes), to help the lungs reinflate after collapse (pneumothorax), or to treat a type of cancer affecting the pleura called pleural mesothelioma.

What Is a Pleurectomy?

A pleurectomy is a surgery used both in adults and children to treat conditions that damage the pleura and affect the lungs. The pleura is comprised of the parietal pleura (closest to the chest wall), the visceral pleura (closest to the lungs), and the pleural cavity (between the layers which contains a small amount of lubricating fluid).

There are different ways that pleurectomy is performed, the choice of which can vary based on the condition being treated. These include techniques such as:

  • Thoracotomy: An open surgery in which an incision is made between the ribs to access the lungs
  • Video-assisted thoracoscopic surgery (VATS): A minimally invasive surgery in which narrow surgical instruments and a thin fiberoptic scope (thoracoscope) access the chest cavity through small incisions between the ribs
  • Pleurectomy with decortication (PD): A technique used in people with pleural mesothelioma to remove damaged pleural membrane and any tumors in the chest cavity
  • Total parietal pleurectomy: The complete removal of the parietal pleura to treat recurrent pneumothorax, including those caused by chronic obstructive pulmonary disease (COPD), cystic fibrosis, tuberculosis, or lung cancer
  • Pulmonary wedge resection with parietal pleurectomy (WRPP): A two-step surgery also used to treat recurrent pneumothorax in which the tip of the lung is removed, followed by the complete removal of the parietal pleura

Contraindications

Pleurectomy is only performed when absolutely needed, and there are few absolute contraindications to surgery in people with benign (non-cancerous) conditions.

Conditions in which pleurectomy is generally avoided include:

  • Being unfit for major surgery
  • Having a lung condition that prevents the lungs from fully reinflating (if used for pneumothorax)

If pleurectomy is used to treat a malignant (cancerous) condition, possible contraindications include:

  • Having multiple tumors affecting the entire lung
  • Having multiple areas of cancer on the chest wall
  • Having cancer on the lung opposite to the primary tumor
  • Having a severe heart or respiratory disease in people with poor performance status

Potential Risks

All surgeries carry risks of injury and complications. The most common associated with pleurectomy include:

  • Difficulty breathing
  • Bleeding
  • Air leakage from the lung
  • Chest infection
  • Pneumonia

Many of these complications, like post-operative pain and difficulty breathing, are caused when blood clots cause lung tissues to stick to the chest wall, forming adhesions. On the other hand, the removal of existing adhesions can cause bleeding and air leakage.

Some of these risks can be reduced by using minimally invasive VATS surgery, when appropriate.

When used to treat pneumothorax, between 2% and 5% of people undergoing pleurectomy will experience recurrence, usually within six months.

Purpose of a Pleurectomy

In most cases, a pleurectomy is recommended when other less invasive procedures fail. The only exception is with early-stage mesothelioma in which it is sometimes used in first-line treatment if all of the cancer can be removed.

The four common indications for a pleurectomy are:

  • Recurrent pneumothorax: The collapse of the lung classified as either primary spontaneous pneumothorax (occurring in the absence of lung disease) or secondary spontaneous pneumothorax (occurring in the presence of lung disease)
  • Benign pleural effusion: Abnormal accumulation of fluid in the pleural cavity that is not caused by cancer (such as can occur with congestive heart failure, severe lung infections, and advanced cirrhosis)
  • Malignant pleural effusion: The abnormal accumulation of fluid caused by cancer, most commonly lung cancer, breast cancer, or lymphoma
  • Pleural mesothelioma: A type of cancer that specifically affects the pleura and that is most commonly linked to the inhalation of asbestos

A pleurectomy is generally well-tolerated in people who require the surgery, even children. In people with a benign condition, a pleurectomy may be all that is needed to resolve the problem completely.

In individuals with mesothelioma, a pleurectomy can sometimes cure early-stage disease. Even if a cure is not possible, the surgery can extend survival and improve the quality of life as part of palliative care.

Selecting a Surgical Approach

Depending on the condition being treated, the doctor will order tests to help characterize the severity of the illness and select the most appropriate surgical procedure.

Condition Recommended Tests
Pneumothorax Chest X-ray
Computed tomography (CT) scan
Benign pleural effusion Chest X-ray
Computed tomography (CT) scan
Ultrasound of the chest
Thoracentesis
Pleural fluid analysis
Malignant pleural effusion •Chest X-ray
•Computed tomography (CT) scan
•Ultrasound of the chest
•Thoracentesis
•Pleural fluid analysis
Thoracoscopic biopsy
Pleural mesothelioma •Computed tomography (CT) scan
Magnetic resonance imaging (MRI)

Positron emission tomography (PET)
Bronchoscopy

Needle biopsy
Thoracoscopic biopsy

In addition, the doctor will need to ensure that you are fit for surgery based on your age, overall health, and the type of surgery you are undergoing. The pre-operative tests used for thoracic (chest) surgery may include:

Once you are declared fit for surgery, you will meet with the surgeon to review the recommendation, ask questions, and schedule the procedure.

How to Prepare

A pleurectomy is an inpatient procedure requiring a hospital stay. The preparations can vary based on the type of surgery performed and the condition being treated.

If you are uncertain why a certain surgical procedure was chosen, such as thoracotomy versus VATS, do not hesitate to ask the surgeon why.

Location

A pleurectomy is performed in the operating room of a hospital. The room will be equipped with an electrocardiogram (ECG) machine, anesthesia machine, respiratory ventilator, and, for VATS surgery, a fiber-optic thoracoscope with a video monitor.

What to Wear

As an inpatient procedure, you will be admitted to the hospital and asked to change into a hospital gown, so what you wear to the procedure does not matter. It is best to leave jewelry at home.

Food and Drink

No solid foods are allowed after midnight the night before your surgery. You can drink clear liquids up until four hours in advance of the surgery. Within four hours, no food or drink is allowed, including gum or hard candy.

Medications

You will need to stop taking certain drugs that can promote bleeding. Some will need to be stopped or substituted as early as two weeks before surgery. These include:

Always advise your doctor about any and all drugs you are taking, whether they are prescription, over-the-counter, nutritional, herbal, or recreational.

What to Bring

For hospital admission, you will need to bring your driver's license (or some other photographic form of government ID) along with your insurance card.

Bring only what you need for your stay, which may include toiletries, your cell phone and charger, extra underwear, a comfortable robe and slippers, and an outfit to go home in. Leave any valuables at home.

Also, bring any chronic medications you take, ideally in their original bottle with the prescription label. Nursing staff will typically take them from you upon admission and dispense them along with any other painkillers or drugs you are prescribed during your stay. This also prevents unexpected drug interactions.

You will also need to arrange for someone to take you home when you are discharged. Even minimally invasive VATS surgery can cause movement restriction and impair your ability to drive.

Pre-Op Lifestyle Changes

Irrespective of the condition being treated, doctors generally recommend that you quit smoking prior to a pleurectomy. Smoking not only complicates all lung diseases but can slow recovery by impairing the flow of blood through the body. Most doctors recommend that you quit smoking two to four weeks before thoracic surgery. Smoking cessation aids can be prescribed if needed.

For people with mesothelioma or malignant pleural effusion, quitting cigarettes improves response rates to cancer therapy and can even positively influence survival times.

To aid with recovery, preoperative pulmonary rehabilitation may be recommended. This generally involves walking two to three miles a day, if possible, and using an incentive spirometer that forces you to take slow, deep breaths to help strengthen the lungs.

What to Expect on the Day of Surgery

Pleuroscopy, no matter the technique used, is considered major surgery requiring general anesthesia. Depending on the aim of the surgery, a pleurectomy generally takes between two and four hours to perform.

The surgical team will be led by a thoracic surgeon (also known as a cardiothoracic surgeon) accompanied by an anesthesiologist, an operating room nurse, an anesthesia nurse, and a circulating nurse and/or theater technician. A surgical oncologist specializing in cancer surgery is also qualified to perform a pleurectomy.

Before the Surgery

On the day of your surgery, you will need to bathe with a surgical disinfectant and avoid any fragrances, creams, deodorants, or makeup. Even if you are not particularly hairy, the surgical site will likely need to be shaved. (Do not do this yourself; a nurse will be assigned to the task.)

The nurse will also perform a number of pre-operative procedures and make certain preparations. These include:

  • Taking your vital signs (temperature, heart rate, and blood pressure)
  • Drawing blood for blood tests, including a complete blood count and blood chemistry
  • Placing a pulse oximetry device onto your finger to monitor blood oxygen during surgery
  • Attaching electrodes to your chest for ECG monitoring
  • Inserting a catheter into a vein in your arm to deliver drugs and fluids via intravenous drip

Prior to surgery, the anesthesiologist will visit to double-check about any drug allergies you have or any adverse reactions to anesthesia you may have had in the past. In most cases, you won't see the surgeon until you are wheeled into the operating room.

During the Surgery

A pleurectomy is typically performed under general anesthesia. Once you are asleep, an endotracheal tube is placed in the throat to keep the airways open and deliver oxygen and anesthesia. You are then positioned on your side to provide easier access to the surgical site.

Depending on the surgery used, either a long incision will be made on the chest to spread the ribs open (thoracotomy) or smaller "keyhole" incisions will be made between the ribs without spreading them (VATS).

After gaining access into the chest, the surgeon carefully peels away and removes one or more of the pleural layers. Any excess fluid can be drained with a suctioning vacuum. Additional tissues or tumors can be removed if mesothelioma is involved.

Before the incision is closed, drainage tubes are placed to help drain any blood or fluid discharge from the chest cavity. The incision is then closed, often with dissolving sutures that don't need to be physically removed.

After the Surgery

After surgery, you are wheeled into the post-anesthesia care unit (PACU) where you will be constantly monitored until you awaken from the anesthesia. In most cases, you are then taken to the intensive care unit (ICU) until your vital signs are stabilized.

Blood transfusions are often needed, particularly if thoracotomy was performed.

Once you are fully stabilized, you are returned to the surgical ward to recover and start pulmonary rehabilitation. The length of your stay and degree of post-operative monitoring is guided by the aim and extent of the surgery.

Physical activity is started, often the morning after surgery or sooner, to prevent the formation of clots and adhesions. Deep breathing exercises are also performed, usually with the aid of an incentive spirometer, to help your lungs fully expand. Pain medications are prescribed to help manage post-operative pain.

In most cases, the chest tube will be removed while you are in hospital. This involves simply snipping the anchor stitch and closing the wound with surgical tape.

Barring any complications, most people can leave the hospital within a week of undergoing a pleurectomy. Some people may be discharged earlier, while those with serious disease may require longer stays.

Recovery

Recovery from a pleurectomy can differ depending on your general health prior to surgery and the extent of the operation itself. This period, which usually lasts around four weeks, will likely involve a structured rehabilitation program and follow-up visits with your surgeon.

Some people, particularly those who have undergone VATS surgery, may be able to return to work (albeit in a limited capacity) within a couple of weeks or even less.

Healing

Once you are discharged from the hospital, you will be prescribed a pulmonary rehabilitation program to restore your lung function and general health. This may involve a physical therapist trained in pulmonary diseases.

In the days immediately following your discharge, you will need to keep the surgical wound clean and dry, changing the dressing as often as the doctor or nurse instructs you. With proper care, post-operative infections can be avoided.

You will also need to avoid strenuous physical activity or lifting anything heavier than five to 10 pounds until your doctor tells you otherwise.

When to Call a Doctor

Call your surgeon immediately if you experience any of the following after a pleurectomy:

  • High fever (over 101.5 F)
  • Difficulty breathing or shortness of breath
  • Increased pain, redness, or swelling at the incision site
  • A foul-smelling, pus-like discharge from the wound
  • Coughing up blood or greenish-yellow mucus

Coping With Recovering

Managing post-operative pain is one of the greatest immediate challenges following a pleurectomy, and doctors are taking greater care than ever to avoid the overuse of opioid drugs, which are addictive.

In most cases, Tylenol (acetaminophen) is recommended at doses of between 500 and 1,000 milligrams (mg) every six hours as needed. NSAIDs like aspirin and ibuprofen can also be used at low doses in combination with (or alternating with) Tylenol. (Higher NSAID doses are avoided as they may promote bleeding.)

People who have undergone extensive surgery may require stronger, short-acting opioid drugs like hydrocodone (5 to 10 mg every six hours) or oxycodone (5 mg every four hours). Even so, doctors are reluctant to prescribe these drugs for longer than three days due to the risk of dependence.

Pain can also be managed with non-drug therapies such as meditation, cold therapy, and progressive muscle relaxation.

Follow-Up Care

After a few days at home, you will see the surgeon for a follow-up visit. A chest X-ray or other imaging studies will typically be ordered beforehand to determine how effective the surgery was and to ensure that there are no post-operative complications. Pulmonary function tests may also be performed to measure and monitor your post-operative lung function.

Depending on the condition, additional visits may be scheduled with a pulmonologist who specializes in lung diseases or a medical oncologist who specializes in the treatment of cancer. If a pleurectomy was used to treat mesothelioma, the surgery is often followed up with a course of chemotherapy and/or radiation therapy.

Lifestyle Adjustments

Most people who undergo a pleurectomy will recover fully, but that doesn't mean that lifestyle adjustments aren't needed. This is especially true with respect to cigarette smoking, which increases the risk of cancer recurrence, pneumothorax recurrence, and pleural effusion recurrence.

Under the Affordable Care Act, there are numerous smoking cessation aids classified as Essential Health Benefits (EHBs) that are fully covered by insurance—even for multiple quit attempts. By working with a doctor or therapist and/or joining a support group, your chances of quitting can improve.

It is important to embrace other healthy lifestyles, including reduced alcohol intake and weight loss if you are obese. Both of these things can contribute to recurrent pleural effusion and pneumothorax.

A Word From Verywell

It is important to remember a pleurectomy is major surgery and something that requires in-depth communication between you and your surgeon to make an informed choice. If you are not getting the answers you need, do not hesitate to seek a second opinion from a pulmonologist or oncologist specializing in your condition.

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