What is the Decortication of the Lung?
Decortication of the lungs is a surgical procedure that is done to remove fibrous tissue that envelopes the lungs, the chest wall, and the diaphragm, to enable the normal expansion and deflation of lungs during respiration. The pleural space which is the space between the lungs and the overlying membrane called the pleura can be affected by pathological conditions resulting in the filling up of this space with fluid or tissue leading to the formation of pleural rind that prevents the normal inflation and deflation of the lungs and leads to breathing difficulties.
- Lung decortication
- VATS decortication
- Decortication Lung Surgery
Is a decortication procedure an elective or an emergency procedure?
Decortication of lungs is an elective procedure.
Types of procedure
Decortication may be of the following types:
- Simple decortication surgery
- A surgery with pleurectomy
- A surgery with extended pleurectomy
Decortication may be of the following types based on the approach
- Open Approach decortication surgery or thoracotomy
- Thorascopic decortication of lungs or VATS decortication
Decortication of the lungs indications
The main indications for a decortication procedure include:
- When the pleural peel has been present for 4-6 weeks
- The symptoms are severe and disabling
- There is evidence of a trapped lung on imaging tests
- Malignant mesothelioma of the lungs
- Tuberculous empyema that has not responded to drugs will require empyema decortication
- Clearance of infection or hemothorax that has not responded to other therapeutic procedures
Contraindications and risk factors
There are no absolute contraindications for the decortication of lungs other than the poor general health of the individual. Relative contraindications may include:
- Presence of pleural space infections
- Large airway narrowing
- Uncontrolled lung infections
- Lung infection or disease of the other lung
- Severe chest wall disease/infection
- Terminal disease
Investigations before pulmonary decortication
Some investigations that need to be done before a decortication of lungs surgery include:
- Laboratory tests
- CBP & ESR
- Coagulation profile and blood typing
- Complete metabolic panel
- Liver and renal function tests
- Arterial blood gas measurement
- Imaging tests
- Pulmonary Function tests
- Exercise stress test
- Cardiac Work Up for arrhythmias, coronary artery disease
Before performing a pulmonary decortication the following is done:
- Risks and benefits of the procedure are explained
- Cessation of smoking at least 2- 4 weeks before the procedure
- Anticoagulant medication may need to be stopped 1-2 weeks before the procedure
- Nothing by mouth after midnight on the night before the surgery
- Antibiotics may be started a few days before the procedure
- Bronchoscopy is done before the surgery to identify any airway pathology or obstruction
How is the decortication of the lungs done?
Duration: A decortication procedure may last for a few hours depending on the extent of the underlying condition.
What is the anesthesia for the decortication of the lungs? The surgery is performed under general anesthesia with endotracheal intubation.
Description of the procedure:
Open decortication (Thoracotomy):
The individual is made to lie on the side with the affected side up and the entire chest area is cleaned and sterile draping is done. An Endotracheal Intubation is done. After the general anesthesia has taken effect a thoracotomy is done usually in the 5th or 6th intercostal space. A rib resection may also be done if required. If the pleura are fused then a pleurectomy may be done to remove the fused pleural layers. For empyema, rib dissection is done before the start of the procedure to avoid injury to other ribs, and for better visualization of the entire chest. Severe cases of empyema may require multiple rib dissections before an empyema decortication is done. The peel that is restricting the lung expansion is carefully removed with the help of a scalpel while taking care to not injure or damage the lung tissue. Once the peel and the pleural rind are removed, the lung is checked if it is re-expanding. Any leaks in the lung tissue are sewn or closed with sealants. Two chest tubes are placed for drainage. The chest is irrigated and all the blood is suctioned out.
The individual is made to lie on the side with the affected side up and the entire chest area is cleaned and sterile draping is done. An Endotracheal Intubation is done. After the general anesthesia has taken effect, a local anesthetic is given at the site of the trocar entry for the ports. The procedure is usually done via three ports or four ports and sometimes via a single port. VATS decortication is preferred during the early stages and acute cases when the peel is easier to remove and better avoided in chronic cases. The peel is usually removed with a grasper or a peanut dissector. A simple pleurectomy or a radical pleurectomy is done as required. Once the peel and the pleural rind are removed and pus or other fluids are suctioned out, the chest cavity is irrigated, two chest tubes are inserted via the port site, the scope is removed. The underlying tissue and the skin are closed. VATS decortication is the preferred procedure for decortication of lung empyema in the early stages. This is associated with better outcomes, lesser postoperative pain, and early recovery than Open Decortication.
After a decortication procedure, the following will usually be done:
- The individual is moved to a recovery room and then to an intensive care unit to be monitored.
- Mechanical ventilation is done to assist with breathing during the recovery period.
- Transfer to a normal room can happen in 2 days if no complications arise.
- The chest tubes are monitored every 8 hours air and fluid leakage and left in place until the lung has fully re-expanded.
- Encouraged to move as soon as able to help lungs heal and recover faster.
- Chest physiotherapy and tracheal suctioning are regularly done.
- Respiratory physiotherapy is initiated.
- Cardiovascular monitoring is done.
- Physical therapy is started to prevent deep vein thromboembolism.
- X-ray chest is done before discharge.
Common post-procedure occurrences
- Pain and soreness at the site of surgery
- Breathlessness and fatigue
Medications: Antibiotics and pain relievers are prescribed at the time of discharge.
Discharge: Usually 7-10 days after the procedure in the absence of any complications.
Review: The review is usually every week for the first month after discharge, and then at regular intervals thereon. A chest X-ray is done at the time of the first review.
Resumption of normal activities: Usually with some restrictions in 4-6 weeks after the procedure
Role of diet/exercise/lifestyle changes
Some measures that may be needed:
- Continue respiratory physiotherapy
- Exercise and eat healthy
- Cessation of smoking
- Reduce the risk of infections
- Avoid smoke, chemical fumes, and pollution
What are the complications of open and vats decortication procedures?
Some of the complications associated with decortication lung surgery include:
- Infections: Perioperative sepsis syndrome
- Bronchopleural fistulas
- Persistent air leakage: More often seen when pleurectomy is done very deep
- Heart arrhythmias
- Myocardial infarction
- Thoracotomy Pain Syndrome
The prognosis of lung surgery is generally good although they are largely dependent on the age and general health of the individual, the underlying condition, and the presence of comorbidities. Pulmonary decortication shows better results in younger individuals.
Indications for hospitalization if required
Hospitalization is required for pulmonary decortication.
Suggested clinical specialist/department to consult for the procedure
Lung surgery is performed by specialists from the Department of Cardiothoracic surgery in consultation with Pulmonologists.