Surgical management of parapneumonic empyema

Empyema carries a poor prognosis if not treated early and aggressively from the time of diagnosis. The ultimate goal of the surgical management of parapneumonic effusion is to achieve full evacuation of pleural exudates and full lung expansion through chest tube insertion, intrapleural fibrinolytic treatment, and open vs. video-assisted thoracoscopic surgery (VATS) decortication. Proper peri-operative assessment and postoperative care are needed to be successful and avoid major complications. Open decortication has classically been the standard of care for patients with advanced empyema, overall, in obese patients or patients with comorbidities, although VATS decortication can be safely performed decreasing, significantly, both the ICU and hospital length of stay, postoperative pain, complications and mortality rate and also improving the cosmetic results eventually. Uniportal VATS decortication requires strong surgical skills, experience, and adequate technology to be successful. Despite that, it is gaining popularity due to some technical advantages over multiportal VATS, in addition to the less inflammatory response and less immunosuppression that it causes. The perimammary uniportal VATS decortication is a novel approach for female patients which provides a wide visualization of the chest, less pain, fast recovery, and better cosmetic results due to a less-visible scar eventually. Robotic-assisted thoracoscopic decortication is promising but is currently performed in very few centres worldwide. Further studies will prove the benefits of these novel approaches for minimally invasive decortication.