Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 9 Supp. 2 2023 08 21 549 552 Roopali Phulli Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India. Habib Karim Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India. Mahesh Kurwe Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India.Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India. Manu Kesavankutty Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India. Klein Dantis Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences-Raipur, India. 2022 08 25 2022 09 10 Surgical resection is frequently the intervention required for post-tuberculous empyema or other sequels. However, pneumonectomy may not be feasible in some situations, and video-assisted thoracoscopic surgery (VATS) plays a role in such a scenario. Whether a patient undergoes open resection of VATS, isolation of infected lung is integral to one-lung ventilation and better access to the surgical field, and a double-lumen tube (DLT) remains the preferred choice. Difficulties in DLT placement after pneumonectomy are reported; however, failure to isolate a lung by appropriately placed DLT is scarce or absent. A 28-year cachectic gentleman with poor preoperative lung function was suffering from endobronchial tuberculosis. He also had one episode of tuberculosis twelve-year back. At presentation, he had a massive pneumothorax and stage-III empyema as a sequel, including a rare finding of plastered mediastinum mimicking vanishing lung syndrome. He underwent uniportal-VATS under general anesthesia using one-lung ventilation. Complete lung destruction from active tuberculosis and its sequel leading to the plastered mediastinum and deformed airway pose a significant lung isolation challenge. U-VATS can be considered for therapeutic purpose where standard thoracotomy and pneumonectomy is contra-indicated. However, lung isolation in such patients is tricky and poses a risk. The present case highlights the challenges faced with lung isolation using a DLT and discusses the probable remedy to these problems. https://aacc.tums.ac.ir/index.php/aacc/article/view/630