Lung decortication is a specialized thoracic surgery designed to restore full function to a restricted lung. The procedure involves the surgical removal of a thick, restrictive layer of fibrous tissue, often referred to as a “peel” or “cortex,” that forms on the outside surface of the lung. This peel develops in the pleural space, which is the area between the lung and the chest wall, and prevents the lung from expanding completely when a person inhales. The primary goal of decortication is to “un-trap” the lung, allowing it to re-inflate and function normally, thereby improving the patient’s breathing and overall respiratory health.
Medical Situations That Require the Surgery
The formation of the restrictive fibrous peel, known medically as fibrothorax, is typically a complication of a previous inflammatory process within the chest cavity. This inflammation causes fluid or blood to accumulate in the pleural space. If this material is not completely reabsorbed or drained, it can organize and solidify into a tough, inelastic membrane. This thickened tissue acts like a stiff casing, physically preventing the lung from expanding and hindering gas exchange.
The two main conditions necessitating this surgery are chronic empyema and chronic hemothorax. Empyema is a severe infection where pus builds up in the pleural space, often as a progression of pneumonia. If the pus cannot be cleared, the body’s inflammatory response creates the fibrous peel to wall off the infection.
Chronic hemothorax involves old, clotted blood in the pleural space, typically following severe chest trauma. Like pus, this clotted blood organizes into a dense, restrictive peel that traps the lung. Decortication becomes necessary once the peel is well-established (usually after four to six weeks) and the patient experiences disabling symptoms.
How the Procedure is Performed
The objective of the surgery is the careful dissection and removal of the fibrotic tissue from the lung’s surface while preserving the delicate underlying lung tissue. Surgeons employ two main approaches to remove the restrictive peel, chosen based on the case complexity and the patient’s health. Both methods require general anesthesia.
Video-Assisted Thoracoscopic Surgery (VATS)
Video-Assisted Thoracoscopic Surgery (VATS) is the less invasive approach, utilizing several small incisions to insert a tiny camera and specialized instruments. This technique is often preferred for earlier, less organized peels, as it is associated with less post-operative pain and a quicker recovery. The surgeon uses video guidance to meticulously peel the cortex off the lung.
Open Thoracotomy
In contrast, an open thoracotomy involves a larger incision, typically between the ribs, to gain direct access to the chest cavity. This approach is reserved for more complex, chronic cases where the fibrous peel is exceptionally dense, heavily calcified, or involves significant scarring and adhesion to the chest wall. The open technique allows the surgeon better visualization and manual control to ensure the complete removal of the thick layer, which is paramount for successful lung re-expansion.
What to Expect During Recovery
Recovery begins immediately post-surgery with monitoring in a recovery unit, where a breathing tube inserted during general anesthesia is removed. Patients will have one or more chest tubes placed in the surgical area to drain fluid, blood, and air from the chest cavity, ensuring the newly freed lung remains fully expanded. These drainage tubes are kept in place until the drainage decreases and any air leaks have resolved, which can take several days.
Pain management is a significant focus, particularly after an open thoracotomy, involving a combination of oral medications, intravenous pain relievers, or regional techniques like nerve blocks. The typical hospital stay ranges from a few days for a VATS procedure to nearly a week for an open thoracotomy. Early mobilization, such as walking, is encouraged within the first day or two to aid lung function and prevent complications.
Potential complications include prolonged air leaks from the lung tissue, bleeding, or infection. A persistent air leak, where air continues to escape from the lung into the chest tube, is a common post-operative challenge. Long-term recovery at home can take several weeks to months, depending on the surgical approach. Patients are advised to limit heavy lifting and strenuous activities and will often be enrolled in pulmonary rehabilitation to restore lung capacity.