What is decortication?
Decortication is a surgical procedure that removes the restrictive layer of fibrous tissue overlying an organ. It is mostly performed to remove the fibrous layer over the lung, chest wall, and diaphragm.
Pleura is a thin membrane that lines the outer surface of the lungs (visceral pleura) and the inner surface of the chest wall (parietal pleura). The space between these is called the pleural space. The pleural space is less than 1 mm thick and is filled with fluid.
When this space is affected by pathologic disorders, it can lead to medical consequences. One of the complications is fibrothorax, which is an abnormal accumulation of fibrous tissues (scar tissue) over visceral pleura.
Deposits of fibrous tissues over the lung can be so intense that the layers of the pleural space fuse, preventing the lung from expanding adequately. Over time, the lung becomes entrapped and breathing becomes difficult.
Decortication surgery aims to remove this fibrous layer and allow the lung to expand, decrease breathing problems and other lung symptoms. When the peel is removed, the elasticity of the chest wall returns, and the lung can expand and deflate.
Why is decortication performed?
The primary indication for decortication is fibrothorax leading to symptoms of lung restriction. Patients with fibrothorax present with difficulty in breathing which aggravates with the following:
- activity,
- decreased chest wall movement,
- reduced breath sounds,
- chest discomfort,
- chest pain, especially during deep breaths, and
- coughing.
The conditions that cause fibrothorax are:
- Pneumonia (lung infection)
- Empyema (pleural space infection)
- Iatrogenic infection and scarring after pleural tap (infection following the diagnostic/therapeutic removal of fluid or air from the pleural space)
- Sepsis (infection in the blood)
- Hemothorax (blood accumulation in pleural space)
- Long-term exposure to chemicals (e.g. asbestos)
How is decortication performed?
Decortication is performed under general anesthesia. There are two types of decortication based on the technique. Depending upon the extent of disease, the surgeon decides which technique to choose at a given time.
Open thoracotomy
- This is an open surgical procedure. The surgeon makes an incision (surgical cut) of around four inches over the chest. This technique allows the surgeon to directly view and analyze the surgical area and extent of the disease.
- The thick peel covering the lungs is exposed and removed. Remnant blood and debris present in the pleural cavity are removed to prevent infection and future scarring.
- The expansion of the lungs is checked on the table and the skin and underlying tissues are sutured (stitched).
Video-assisted thoracoscopic surgery (VATS)
- Small incisions are made on the skin above the chest cavity to insert a thoracoscope (camera with a light source) and surgical instruments.
- The peel is carefully removed piece by piece to avoid air leaks. Any remnant blood and debris are cleared.
- The underlying tissues and skin are sutured.
Post-surgical care
- After the surgical procedure, patients may experience pain, swelling, and bruising.
- The doctor may prescribe painkillers and antibiotics.
- The average stay in the hospital after VATS is two to three days and three to five days after surgery. Patients are mobile within 24 hours after surgery.
- Chest physiotherapy may be advised after surgery.
What are the complications of decortication?
The success rate of decortication surgery is high, with low morbidity and mortality rates. Like any major surgery, decortication may be associated with certain risks and complications, which are usually manageable.
Some common complications are:
- Infection
- Air leak from the lung
- Bleeding
- Broncho-pleural fistula (an abnormal connection between the pleural space and the lung)
- Respiratory failure
- Cardiac complications
- Damage to surrounding structures
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