Decortication of the lung is a surgical procedure designed to remove a thick, restrictive layer of tissue that forms around the lung and the inside of the chest cavity. This layer, often called a “peel” or “rind,” is composed of fibrin and fibrous scar tissue covering the pleura (the lining of the lung and chest wall). The primary purpose of the surgery is to free the lung from this constricting sheath, allowing it to fully re-expand and restore normal breathing function. This operation is a definitive treatment used when simpler methods of draining fluid or infection have failed, alleviating severe symptoms like shortness of breath and chest pain.
The Conditions That Require Decortication
The need for decortication typically arises from chronic inflammation or infection within the pleural space. The most frequent indication is an advanced, organized infection called empyema, a collection of pus that has thickened and solidified over time. This complication often follows severe bacterial pneumonia, where initial fluid buildup progresses into a fibrous, non-draining mass. The buildup of inflammatory products promotes the growth of fibroblasts, which lay down the restrictive collagen-rich peel.
Another common cause is a chronic hemothorax, the accumulation of blood in the chest cavity, usually due to trauma. If this blood is not completely cleared, the resulting inflammatory cascade leads to the formation of a dense, constricting peel. When this fibrous layer encases the lung, the condition is referred to as fibrothorax or a “trapped lung,” preventing the lung tissue from fully inflating. Decortication mechanically removes the peel, which is necessary when the lung’s capacity is impaired and treatments like antibiotics or simple drainage are no longer effective.
Understanding the Surgical Procedure
Decortication is performed under general anesthesia, and the patient is typically positioned on their side to allow the surgeon access to the affected lung. The procedure’s objective is the meticulous separation and removal of the fibrous membrane from both the parietal pleura (chest wall) and the visceral pleura (lung surface). This process requires careful dissection to peel away the rind while avoiding injury to the underlying, often fragile, lung tissue.
Surgeons utilize two main approaches: open thoracotomy or Video-Assisted Thoracoscopic Surgery (VATS). An open thoracotomy involves a larger incision, often 8 to 10 inches, between the ribs to provide direct visual and manual access to the pleural space, which remains the standard for complex or long-standing cases with dense adhesions. VATS, a minimally invasive technique, uses several small incisions to insert a camera and specialized instruments, allowing the surgeon to perform the peeling process with video guidance. VATS is generally associated with less post-operative pain and a quicker recovery, and it is often the preferred initial approach for less organized disease.
Once the restrictive peel is completely removed, the anesthesiologist is asked to fully inflate the lung to confirm its re-expansion and to identify any resulting air leaks. Any significant air leaks are then formally closed with sutures to prevent complications. Before closing the chest, one or more chest tubes are strategically placed to drain any residual fluid or air from the pleural space. These tubes are an essential part of the procedure, ensuring the lung remains fully expanded during the initial recovery phase.
Post-Operative Care and Recovery
Following the surgery, patients are closely monitored, often in a recovery unit, for the immediate post-operative period. A primary focus of care is aggressive pain management, which may involve a combination of epidural catheters, nerve blocks, and patient-controlled analgesia to control the significant discomfort associated with major chest surgery. Effective pain relief is crucial because it allows the patient to participate in the necessary respiratory therapy.
Chest tubes remain in place for drainage and to monitor for air leaks or fluid output. The tubes are typically removed once the drainage is minimal and the lung is confirmed to be fully expanded without a persistent air leak, a process that usually takes several days. The average hospital stay for decortication varies, but patients undergoing VATS may be discharged within 48 to 72 hours, while those who had an open thoracotomy may stay for three to seven days.
A major component of recovery involves pulmonary rehabilitation, including the frequent use of an incentive spirometer and deep breathing exercises. These activities are vital to encourage the newly freed lung to fully expand and to prevent post-operative collapse. While a return to normal daily activities can begin soon after discharge, patients are advised to avoid heavy lifting and vigorous exercise for four to eight weeks, depending on the surgical approach, to allow the chest wall to heal completely.
Potential Risks and Expected Outcomes
As with any major chest operation, decortication carries general surgical risks, including the potential for bleeding and infection. Specific to this procedure is the risk of a prolonged air leak, where air continues to escape from the lung surface into the chest tube for an extended period, sometimes requiring prolonged chest tube use or a second intervention. Another concern is injury to the underlying lung tissue or adjacent vital structures like the diaphragm or major blood vessels during the intricate peeling process.
The overall prognosis for patients undergoing decortication is favorable when the procedure is performed for the appropriate indications. The primary expected outcome is a significant improvement in lung function and a reduction in shortness of breath, as the lung is no longer physically restricted. Most patients experience good results, with the lung expanding fully and working more efficiently post-surgery. This restoration of lung function translates to an improved quality of life and better exercise tolerance.