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