Fig. 2

A part of the second through fourth ribs that formed the ceiling of the pleural empyema cavity was removed to create space for the skin and thickened parietal pleura (TPP) to fill the cavity. The costal cartilage obtained from the rib resection was trimmed and harvested to fit into the diameter of the bronchopleural fistula. The free costal cartilage (arrow) was sutured and fixed with five stitches with 3-0 PDS (A). A sealing test verified the absence of air leaks. The TPP and skin were used to tightly cover the visceral pleura, with 3-0 PDS fixing it airtight. To maintain a tight seal, a Blake® silicone drain was inserted between the visceral pleura and the thickened parietal pleura, and a suction reservoir was utilized to sustain negative pressure (B and C)