540811

research-article2014
SRIXXX10.1177/1553350614540811Surgical InnovationHofmann et al

Original Article
Surgical Innovation

Minimally Invasive Vacuum-Assisted

1­–5
© The Author(s) 2014
Reprints and permissions:
Closure Therapy With Instillation sagepub.com/journalsPermissions.nav
DOI: 10.1177/1553350614540811

(Mini-VAC-Instill) for Pleural sri.sagepub.com

Empyema

Hans-Stefan Hofmann, MD1,2, Reiner Neu, MD2, Tobias Potzger, MD2,

Rudolf Schemm, MD1, Christian Grosser1, Tamas Szöke, MD1,
and Zsolt Sziklavari, MD1

Abstract
Enthusiasm for minimally invasive thoracic surgery is increasing. Thoracoscopy plays a significant therapeutic role in
the fibrinopurulent stage (stage II) of empyema, in which loculated fluid cannot often be adequately drained by chest
tube alone. For some debilitated and septic patients, further procedures such as open-window thoracostomy (OWT)
with daily wound care or vacuum-assisted closure (VAC) therapy are necessary. In the present article, we propose
a new option of minimally invasive VAC therapy including a topical solution of the empyema without open-window
thoracostomy (Mini-VAC-instill). Three patients who underwent surgery using this technique are also presented. The
discussion is focused on the advantages and disadvantages of the approach.

Keywords
pleural empyema, VAC-instill, minimally invasive thoracic surgery

Introduction Technique
Despite significant advances in the treatment of thoracic Under general anaesthesia, a 5- to 6-cm long incision
infections, pleural empyema remains a problem in mod- centred over the area of the greatest pleural fluid collec-
ern thoracic surgery. If the patient is medically unstable, tion was made (Figure 1A). The intercostal muscle was
the evacuation of pus and debridement can be managed divided, and the empyemal cavity was opened. After the
by open-window thoracostomy (OWT).1,2 Vacuum- intercostal aspiration of all pus and necrotic debris, the
assisted closure (VAC) therapy supports the treatment of cavity was flushed with a polyhexanide solution
acute or chronic wound infections both in general and in (Lavanid 0.02%, Serag-Wiessner KG, Naila, Germany).
thoracic surgery. These benefits include the removal of Then, the VAC sponge (Instill Dressings, KCI Medical,
accumulating fluid, increased oxygen tension in the Wiesbaden, Germany; 400-600 µm) was introduced in
wound, increased blood flow, and increased granulation the pleural cavity over a flexible polymer membrane
tissue proliferation. The combination of OWT and VAC (Alexis, Applied Medical, Rancho Santa Margarita, CA)
therapy should be discussed as soon as possible, espe- retractor (technique described earlier4; Figure 1B and
cially for complicated pleural empyema and in patients C). On the top of the VAC sponge, the VAC instill pad,
with an increased risk for impaired wound healing.3 The including the tubing, was positioned (Figure 1D). The
Mini-VAC procedure offers a minimally invasive
approach with the abdication of an OWT.4 1
Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
In cases of highly infected/bacterial colonised pleural 2
University Regensburg, Regensburg, Germany
empyemas, flushing by a chest tube or the OWT is often
necessary. In this report, we demonstrate that the Mini- Corresponding Author:
Hans-Stefan Hofmann, Department of Thoracic Surgery, Hospital
VAC treatment concept can also be used for the intermit- Barmherzige Brüder Regensburg, Prüfeningerstraße 86, 93049
tent instillation of the pleural cavity through the VAC Regensburg, Germany.
sponge (Mini-VAC-instill). Email: hans-stefan.hofmann@barmherzige-regensburg.de

Downloaded from sri.sagepub.com at UNIVERSIDAD DE SEVILLA on January 13, 2015

2 Surgical Innovation 

Figure 1.  Technique of Mini-VAC-instill procedure: 5-cm incision over the pleural empyema (A), introduction of VAC sponge
over ALEXIS retractor (B, C), and VAC-instill pad (D). VAC, vacuum-assisted closure.

wound volume determines the amount of fluid instilled. Case Reports

The vacuum device coupled with automated, controlled
antiseptic fluid delivery regulates the instilled fluid vol- The demographic, clinical, and treatment characteristics
ume. The volume of the pleural space was tested and of the patients are given in Table 1.
determined (approximately 150 mL). The level of suc-
tion was set to −100 mm Hg from the start. The flushing
Case 1
of the pleural cavity was performed with a predeter-
mined amount of 0.02% polyhexanide solution A 56-year-old man was diagnosed with pleural empyema
(Lavanid) in an automated topical solution delivery after a third course of palliative chemotherapy for gastric
modus (30 minutes every 8 hours). The patients were cancer stage IV. The pleural space was highly colonized
treated in parallel with wide spectrum antibiotics. Based with Escherichia coli and Bacillus cereus. The decision
on the microbiological results, the spectrum was occa- for quick and complete eradication was made. Because of
sionally modified. The Mini-VAC-instill system was the poor general condition of the patient (Karnofsky
changed every 3 to 4 days. Only a small amount of index 50%), we rejected an extensive surgical procedure
debridement was required at each sponge change. The (decortication). Considering the high bacterial coloniza-
remaining pleural space was, in all cases after the Mini- tion, the Mini-VAC-instill system was implemented.
VAC-instill therapy, very small and only filled with an After eleven days of treatment, the pleural cavity was
aminoglycoside antibiotic gentamicin sponge (Genta- visually determined to be clean, and the patient had 2
Coll resorb, Resorba GmbH, Nürnberg, Germany). negative quantitative cultures. On the 12th postoperative

Downloaded from sri.sagepub.com at UNIVERSIDAD DE SEVILLA on January 13, 2015

Hofmann et al 3

Table 1.  Demographic, Clinical, and Treatment Characteristics.

Characteristic Patient 1 Patient 2 Patient 3

Age (years)/gender 75/male 57/male 87/female
Karnofsky index 50 50 40
Multimorbiditya Yes No No
Immunosuppression No Yes (chemotherapy) No
Etiology Primary Primary Secondary
Empyema Stage II Stage II Stage II
Primary intervention Chest tube Chest tube Chest tube
Microbiology Escherichia coli Escherichia coli, Bacillus cereus Staphylococcus aureus
Mini-VAC-instill therapy (days) 5 12 10
VAC-changes 1 3 1
Microbiology after Mini-VAC-instill Sterile Sterile Sterile
Discharge after Mini-VAC-instill 5th day 4th day 7th day
a
More than or equal to 4 chronic diseases.

day, the remaining pleural space was filled with a haemo- cachexia of the patient, and auscultation and percussion of
styptic collagen sponge containing the aminoglycoside the lungs revealed fluid in the left hemithorax. Her arterial
antibiotic gentamicin (Genta-Coll resorb). The wound oxygen saturation at rest while breathing room air was
was closed with single stitches and healed per primam. 90%, and her C-reactive protein level was increased by
The chemotherapeutic treatment of the gastric tumor was more than 100-fold. The CT scan of the thorax showed a
continued after 2 weeks. fracture of thoracic vertebra 8 and both an intraspinal and
stage II pleural empyema (Figure 2A). Antibiotic therapy
with piperacillin/sulbactam was started. The microbiologi-
Case 2
cal diagnosis was Staphylococcus aureus. After a chest
A 75-year-old male patient with a Karnofsky index of 50% tube thoracostomy, thoracic vertebra 8 was dorsally stabi-
presented to our department with recurrent fever that lized by the neurosurgeons. Pus was demonstrated in the
reached as high as 38°C and chills that had lasted for 1 chest tube and in the intraspinal region. The chest tube was
month. He also reported cough, dyspnea, and expectora- flushed with betaisodona 10% thrice per day. Because this
tion. He was an active smoker with a 40-pack-year history treatment failed clinically and on the CT scan control, the
of smoking. Routine laboratory testing showed inflamma- decision to use the Mini-VAC-Instill was made 14 days
tion. The chest X-ray showed a pleural effusion, and the after the neurosurgical operation. The Mini-VAC-instill
chest computed tomography (CT) raised the suspicion of therapy was performed with 150 mL of 0.02% poly-
pleural empyema stage II. The patient underwent a tube hexanide solution, and the VAC sponge was only changed
thoracostomy. Escherichia coli and anaerobic species were once. The pleural cavity was sterile and could be primarily
isolated. The primary drainage treatment failed despite closed on the seventh day after the first installation of the
daily solution changes. The decision to use the Mini-VAC- Mini-VAC. She was discharged from the hospital 5 days
instill was made. The VAC sponge was changed only once. after primary chest closure. After the follow-up at 1 month,
After 5 days of the Mini-VAC-instill treatment with 0.02% no pleural empyema had recurred (Figure 2B).
polyhexanide, the pleural cavity was sterile and could be
primarily closed. The patient was discharged from the hos-
pital on the fifth postoperative day. At the 1-month follow-
Discussion
up, no pleural empyema had recurred. The VAC-instill therapy differs from the standard VAC
treatment in that topical solutions are cyclically flushed
into the foam dressing and held for a user-selected period
Case 3 before removal under negative pressure. Studies have
A 87-year-old woman presented with left inspiratory chest reported on the effectiveness of VAC-instill in wounds
pain in the emergency room. The medical history revealed with high levels of exudate and pus and in acute traumatic
a left thoracotomy for a kyphoplasty of thoracic vertebra wounds or wounds acutely debrided due to infected soft
12 and decompression of the spinal canal three months ear- tissue.5,6
lier. In the past 6 weeks, she suffered with a fever and sig- The bacteriology of pleural empyemas is often poly-
nificant worsening. The physical examination demonstrated microbial and mixed, containing multiple species of both

Downloaded from sri.sagepub.com at UNIVERSIDAD DE SEVILLA on January 13, 2015

4 Surgical Innovation 

intended for topical use include topical cleansers, antibi-

otics, antifungals, and antiseptics. Intervals in pleural
flushing (the ebb-and-flow technique) are better than
continuous pleural flushing with standard intervals.9 In
practice, these cycles of flushing are repeated from 4 to
12 times hourly.10,11 According to the present state of
knowledge, polyhexanide is the first-choice antiseptic
solution when using instillation for acutely or chronically
infected wounds (after debridement).12 However, the key
aspect of this therapy is the delivery method of the topical
solution, not the type of solution.
The system should only be exchanged every 3 to 4
days. Thus, daily time-consuming doctor and caregiver
wound intervention is not necessary. The sponge changes
are facile and fast because the Mini-Vac-instill therapy
also enables minimization of intraoperative manual activ-
ities (eg, debridement) by fast cleaning.
The wound should be assessed at every dressing change,
and the decision to continue the Mini-VAC-instill should be
made during this time. We recommend Mini-VAC-instill
therapy only for hospital use because patients are often sep-
tic and infected by multiple species of bacteria. After clean-
ing of the pleural space, conversion to simple Mini-VAC
therapy to bridge to the ambulant sector, with the aim of
further reduction of the pleural cavity, is possible.

Conclusions
Figure 2.  Chest CT scan of pleural empyema before (A) and
Standard pleural VAC therapy offers rapid treatment for
after (B) Mini-VAC-instill therapy. CT, computed tomography;
VAC, vacuum-assisted closure. complex pleural empyema. In septic patients with highly
infected/bacterially colonized pleural empyema, we rec-
ommend Mini-VAC-instill therapy. This procedure pro-
aerobic and anaerobic bacteria, with the latter found in up vides intermittent topical solution delivery and removal
to 75% of the cases.7 The diffusion of antibiotics into the from the wound site. Wound cleaning, the removal of
pleural fluid is good, but certain agents may be inacti- infectious material and wound healing are supported by
vated in the presence of pus, low pH, and beta-lactamase this system. The procedure is minimally invasive and
enzymes. In addition to a surgical intervention, flushing highly compatible, especially in patients in poor general
of the pleural cavity by a chest tube is often necessary to condition.
clean the empyemal cavity. If the patient is also medically
unstable, the evacuation of pus and debridement can be Declaration of Conflict Interests
managed traditionally by OWT and daily open wound
treatment, including flushing of the pleural space. The author(s) declared no conflicts of interest with respect to
research, authorship, and/or publication of this article.
The present Mini-VAC-instill therapy (an upgrade of
Mini-VAC) guarantees the advantage of an open treat-
ment, including flushing without OWT. Rib resection for Funding
OWT is associated with more postoperative pain and a The author(s) received no financial support for the research,
muscle flap closure in most cases. authorship, and/or publication of this article.
The decision not to proceed with classical decortica-
tion of the lung appears not to be a disadvantage because References
similar lung reexpansion was achieved by debridement 1. Eloesser L. An operation for tuberculous empyema. Chest.
alone without decortication in patients presenting with 1935;1(8):8-9, 23.
empyema.8 2. Clagett OT, Geraci JE. A procedure for the management of
The Mini-VAC-instill allows pleural cleaning, irriga- postpneumonectomy empyema. J Thorac Cardiovasc Surg.
tion and removal of infectious materials. Solutions 1963;45:141-145.

Downloaded from sri.sagepub.com at UNIVERSIDAD DE SEVILLA on January 13, 2015

Hofmann et al 5

3. Sziklavari Z, Grosser C, Neu R, et al. Complex pleural 8. Kho P, Karunanantham J, Leung M, Lim E. Debridement
empyema can be safely treated with vacuum-assisted clo- alone without decortication can achieve lung re-expansion
sure. J Cardiothorac Surg. 2011;6:130. in patients with empyema: an observational study. Interact
4. Hofmann HS, Schemm R, Grosser C, Szöke T, Sziklavari Cardiovasc Thorac Surg. 2011;12:724-727.
Z. Vacuum-assisted closure of pleural empyema without 9. Engelmann C. Septische Thoraxchirurgie. Berlin,
classic open-window thoracostomy. Ann Thorac Surg. Germany: Pabst Science; 1998.
2012;93:1741-1742. 10. Rosenfeldt FL, McGibney D, Braimbridge MV, Watson
5. Gabriel A, Shores J, Heinrich C, et al. Negative pressure DA. Comparison between irrigation and conventional
wound therapy with instillation: a pilot study describing treatment for empyema and pneumonectomy space infec-
a new method for treating infected wounds. Int Wound J. tion. Thorax. 1981;36:272-277.
2008;5:399-413. 11. Conlan AA, Abramor E, Delikaris P, Hurwitz SS. Taurolidine
6. Gabriel A, Shores J, Bernstein B, et al. A clinical review instillation as therapy for empyema thoracis. A prospective
of infected wound treatment with vacuum assisted closure study of 50 patients. S Afr Med J. 1983;64:653-655.
(V.A.C.) therapy: experience and case series. Int Wound J. 12. Kramer A, Assadian O, Below H, Willy C. Wound anti-
2009;6(suppl 2):1-25. septics today—an overwiew. In: Willy C, ed. Antiseptics
7. Hughes CE, Van Scoy RE. Antibiotic therapy of pleural in Surgery—Update 2013. Berlin, Germany: Lindqvist
empyema. Semin Respir Infect. 1991;6:94-102. Books; 2013:83-110.

Downloaded from sri.sagepub.com at UNIVERSIDAD DE SEVILLA on January 13, 2015