What are the differences between open thoracotomy decortication and Video-Assisted Thoracoscopic Surgery (VATS) decortication?

From the Guidelines

VATS decortication is the preferred surgical approach over open thoracotomy decortication due to its association with less postoperative pain, shorter hospital stays, and fewer complications, as evidenced by a recent study published in 2023 1. The main difference between open thoracotomy decortication and VATS (Video-Assisted Thoracoscopic Surgery) decortication is the surgical approach used to remove the fibrous tissue (cortex) that restricts lung expansion in conditions like empyema or hemothorax.

• Open thoracotomy decortication involves a large incision between the ribs to gain direct access to the pleural space, allowing surgeons to manually separate and remove the restrictive tissue under direct visualization.
• In contrast, VATS decortication uses several small incisions through which a camera and specialized instruments are inserted to perform the same procedure with video guidance. Key benefits of VATS decortication include:
• Shorter hospital stays, with a mean reduction of 2.3 days compared to open thoracotomy 1
• Less postoperative pain, as reported in the meta-analysis 1
• Fewer complications, with 152 complications per 1000 patients compared to 197 per 1000 patients for open thoracotomy 1
• Slightly lower mortality rates, with 35 deaths per 1000 patients compared to 47 per 1000 patients for open thoracotomy 1 However, open thoracotomy may be preferred for complex cases with dense adhesions, chronic organized empyema, or when the lung tissue is severely compromised. The decision between these approaches depends on the stage of disease, patient factors, and surgeon expertise. Both procedures aim to achieve the same goal of restoring lung expansion and function, but VATS offers a minimally invasive alternative when technically feasible, as supported by the recent guideline published in the British Thoracic Society guideline for pleural disease 1.

From the Research

Differences between Open Thoracotomy Decortication and VATS Decortication

• The main differences between open thoracotomy decortication and Video-Assisted Thoracoscopic Surgery (VATS) decortication lie in their approach, outcomes, and complications 2, 3, 4, 5, 6.
• VATS decortication is a minimally invasive procedure that utilizes a thoracoscope to visualize the pleural space, allowing for decortication and drainage of empyema 2, 3, 4, 5, 6.
• Open thoracotomy decortication, on the other hand, involves a traditional open-chest surgery approach, which can result in higher morbidity and longer hospital stays 3, 4, 5.

Outcomes and Complications

• Studies have shown that VATS decortication is associated with:
  • Shorter operative times 3, 5
  • Reduced postoperative complications, such as atelectasis, prolonged air leak, and sepsis 3, 4, 5
  • Lower morbidity rates 2, 3, 4, 5
  • Shorter hospital stays 2, 3, 4, 5, 6
• In contrast, open thoracotomy decortication is often associated with higher conversion rates, longer hospital stays, and increased morbidity 3, 4, 5.

Specific Patient Populations

• In pediatric patients with stage 3 or 4 empyema, VATS decortication has been shown to be a safe and effective treatment option, with a morbidity rate of 16% and no deaths 2.
• In adults with primary empyema, VATS decortication has been found to have superior outcomes compared to open decortication, with reduced postoperative morbidity, complications, and length of hospital stay 4.
• In patients with early stage multiloculated empyema, VATS deloculation and debridement has been shown to be superior to tube thoracostomy alone and fibrinolytic therapy, with a higher success rate and reduced drainage time and hospital stay 6.