What are the steps for converting a chest tube thoracostomy?

Conversion from Chest Tube Thoracostomy to Open Thoracotomy

When technical difficulties arise during video-assisted thoracoscopic surgery (VATS) or when the lung cannot be fully expanded despite adequate drainage, conversion to open thoracotomy should be performed immediately to ensure complete treatment and prevent complications. 1

Indications for Conversion

Primary Indications

• Inability to achieve complete lung expansion despite adequate chest tube drainage and decortication attempts via VATS 1
• Technical difficulties related to inflammation encountered during thoracoscopic procedures, particularly in cases of ruptured cavities or extensive pleural contamination 1
• Massive pleural contamination where resection of pathologic tissue is not technically possible through minimally invasive approaches 1
• Uncontrolled hemorrhage requiring open surgical control (haemothorax management) 1

Timing Classifications

Conversion should be classified by timing 1:

• Intraprocedural conversion: During the index procedure when technical limitations are encountered
• Periprocedural conversion: Within 30 days after the index procedure due to complications
• Delayed conversion: Beyond 30 days after the index procedure

Technical Approach to Conversion

Pre-Conversion Assessment

• Verify that multiple chest tubes are in place if dealing with complex effusions or empyema, as these are often needed for chronic drainage 1
• Ensure adequate anesthesia transition from conscious sedation to general anesthesia with single-lung ventilation capability 1
• Assess the extent of pleural disease to determine whether lobectomy versus wedge resection will be required 1

Surgical Technique

The conversion should proceed through standard posterolateral thoracotomy to provide optimal exposure for:

• Extensive decortication to allow maximal reexpansion of remaining lung tissue 1
• Resection of diseased tissue when inflammation makes VATS technically impossible 1
• Control of air leaks from necrotic tumor nodules or visceral pleural defects 1

Post-Conversion Management

• Insert 24-32F chest tubes following open procedures for adequate drainage 1
• Apply graded and progressive suction maintained until drainage is less than 100 ml per day 1
• Monitor for persistent air leaks beyond 4 days, which may require additional surgical intervention 2

Common Pitfalls and Caveats

Critical Safety Considerations

• Never clamp a bubbling chest tube during or after conversion, as this creates risk of tension pneumothorax 2
• Recognize that thick surrounding lung tissue often appears less extensive on imaging than encountered intraoperatively, particularly with ruptured cavities 1
• Anticipate satellite nodules and hilar scarring that may necessitate lobectomy rather than limited resection 1

Decision-Making Algorithm

Start with VATS approach when feasible, but maintain a low threshold for conversion when:

1. Lung fails to expand despite adequate tube drainage
2. Dense adhesions prevent safe dissection
3. Bleeding cannot be controlled thoracoscopically
4. Visualization is inadequate due to inflammation

The surgeon should be prepared to convert at any point during the procedure, as attempting to persist with VATS in the face of technical difficulties increases morbidity 1

Post-Operative Monitoring

• Maintain chest tubes on -20 cm H₂O suction after conversion 1
• Remove tubes when 24-hour drainage is 100-150 ml and no air leak is present 1
• Obtain chest radiograph 5-12 hours after last evidence of air leak before tube removal 1
• Ensure patients are managed on specialized wards by staff trained in chest tube management 2