Pleurectomy: Everything You Need to Know

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 pneumothorax (collapse), or for treatment of pleural mesothelioma, a type of cancer that affects the pleura.

What Is a Pleurectomy?

A pleurectomy is a procedure that's done for treatment of certain 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 (a fluid-filled space between the layers).

There are different pleurectomy methods, depending on the condition being treated.

Pleurectomy techniques include:

• 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 thoracoscope (thin fiberoptic scope) access the chest cavity through small incisions between the ribs
• Pleurectomy with decortication (PD): Mechanical or chemical induction of scarring between the pleural layers in order to prevent the accumulation of fluid
• 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

Conditions in which pleurectomy is generally avoided include:

• If your health can't tolerate major surgery
• If you have a lung condition that prevents your lungs from fully reinflating

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

• Multiple tumors affecting the entire lung
• Multiple areas of cancer on the chest wall
• Cancer on the lung opposite to the primary tumor
• A severe heart or respiratory disease that's causing 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

Post-operative pain and difficulty breathing can occur if blood clots cause lung tissues to stick to the chest wall, forming adhesions. Removal of existing adhesions can cause complications of bleeding and air leakage.

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

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 when it is sometimes used in first-line treatment if the cancer can be fully removed.

The four common indications for a pleurectomy are:

• Recurrent pneumothorax: Lung collapse is 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 by people who require the surgery, even children. For 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, your healthcare provider will order tests to help characterize the severity of your illness and select the most appropriate surgical procedure for you.

In addition, your healthcare provider will need to ensure that you are fit for surgery based on your age, overall health, and the type of surgery you are undergoing.

Pre-operative tests used for thoracic (chest) surgery may include:

• A physical exam, including a review of breathing sounds, blood pressure, and respiratory rate
• A review of your medical history, including tobacco use and any history of COPD, congestive heart failure, sleep apnea, or angina
• Blood tests, including a complete blood count, arterial blood gases, fasting glucose, and liver function tests
• Spirometry, used to measure lung function
• Electrocardiogram, used to measure heart rhythm

If the presurgical tests indicate that you could benefit from surgery, you will meet with your surgeon to review the recommendation, ask questions, and schedule your 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.

Location

A pleurectomy is performed in a hospital operating room. 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

During your surgery, you will be asked to change into a hospital gown, so what you wear to the procedure does not matter.

Food and Drink

No solid foods or drinks are allowed after midnight the night before your surgery.

Medications

Your healthcare provider may advise you 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:

• Anticoagulants (blood thinners) like Coumadin (warfarin) and Plavix (clopidogrel)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil (ibuprofen), Celebrex (celecoxib), and Mobic (meloxicam)

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

What to Bring

You will need to bring your government ID and your health 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 valuables, such as jewelry, at home.

Also, bring any medications you regularly take, ideally in their original bottle with the prescription label.

Pre-Op Lifestyle Changes

Irrespective of the condition being treated, healthcare providers generally recommend that you quit smoking prior to a pleurectomy. Smoking complicates lung diseases and can slow recovery after surgery. Most healthcare providers 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 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 is a major surgery requiring general anesthesia. Depending on the aim of the surgery, the procedure generally takes between two and four hours.

Your surgical team will be led by a thoracic surgeon accompanied by an anesthesiologist, an operating room nurse, an anesthesia nurse, and a circulating nurse. 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.)

Your 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, your anesthesiologist will visit to double-check your drug allergies and review any adverse reactions to anesthesia you may have had in the past.

During the Surgery

Once your anesthesia medication puts you to sleep, an endotracheal tube is placed in your throat to deliver oxygen and anesthesia.

You will be positioned on your side to provide easier access to the surgical site.

Depending on the method of your surgery, you will have either a long incision on your 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, your surgeon carefully peels away and removes one or more of the pleural layers. 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 blood or fluid discharge from your 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 monitored until you awaken from the anesthesia. In most cases, you will then be taken to a surgical floor with monitoring, and rarely to the intensive care unit (ICU).

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

The morning after surgery or sooner you will begin moving around to prevent the formation of clots and adhesions. You will start deep breathing exercises to help your lungs expand, usually with the aid of an incentive spirometer. Pain medications are prescribed to help manage post-operative pain.

In most cases, the chest tube will be removed while you are in hospital. The length of your stay and degree of post-operative monitoring is guided by the aim and extent of the surgery.

Recovery

Recovery from a pleurectomy can vary depending on your general health prior to surgery and the extent of the operation. 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 be guided by a physical therapist trained in pulmonary diseases.

In the days immediately following your discharge, you will need to keep your surgical wound clean and dry, changing the dressing as often as your healthcare provider or nurse instructs you.

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

Coping With Recovering

Managing post-operative pain is one of the greatest immediate challenges following a pleurectomy, and healthcare providers 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, healthcare providers 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 your 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 check for postoperative complications.

You may also perform pulmonary function tests so your healthcare provider can monitor your post-operative lung function.

Depending on your 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

The most important lifestyle adjustment you have to make after pleurectomy is to stop smoking because smoking 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 healthcare provider 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

A pleurectomy is a major surgery that can have a major impact on your quality of life. Most people who undergo a pleurectomy will recover fully. It is important that you take the steps necessary to prepare and recover so that you can maximize the benefits of this procedure.