الفهرس 
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Abstract
VATS in our study was compared with open thoracotomy approach in third stage empyema and we tried to limit the study to this stage only and not mixed with other stages empyema that was a problem in previous studies done in this point. Our cut point in diagnosis was failure lung expansion despite functioning chest tube with restrictive visceral pleura.
VATS showed promising results regarding pain, operative time, blood loss and early return to daily activities but was with no significant difference than open approach regarding the hospital stay, operative and post-operative complications, and the total outcome of the procedure regarding lung expansion and infection resolution. Some studies show better results than ours in VATS due to the learning curve and the availability of the instruments used in minimally invasive technique, the previous factors indeed may affect the VATS technique results in the future in our center.
The conversion of the VATS procedure to open thoracotomy was (6.7%) in our study which should not be consider a failure of the procedure, but we should accurately investigate cases and factors that may end in conversion from the minimally invasive to the open technique and have more selective criteria to the patients who undergoing VATS with the best outcome. And we should not hesitate at any point of the procedure to convert the technique to reach the main goal of lung expansion or manage the complications.
So, we recommend the minimally invasive video assisted thoracoscopic surgery as management of the third stage empyema as it
Summary and Recommendations
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had been proved to be similar in the outcome as open technique but with more advantages than it.
For validation of our study data and refining of its results, it should be assessed in a larger sample also, we recommend globally selected criteria of VATS patients to decrease the rate of conversion.