Decortication

Decortication is a surgery to remove an abnormal membrane (pleura) around your lung. When this membrane becomes thick and fibrous, it can keep your lung from expanding like it should when you breathe.

Reasons for lung decortication include longstanding pleural effusions (fluids like pus or blood), pleural tumors or a trapped lung (fibrothorax). In many cases, these can happen because of disease or infection, like pneumonia.

Healthcare providers may do this major surgery if they’ve tried using a needle or tube to drain fluid from your pleura. When the fluid won’t drain, it may stay and become fibrous. Then, you may need decortication to remove the “peel.”

Sometimes, a provider will remove a pleural tumor (pleurectomy) and perform decortication in the same surgery. You may hear healthcare providers refer to this as a “P/D.”

What approach will the surgeon use?

In most cases, a surgeon will perform an open thoracotomy decortication. This is the gold standard. It means a surgeon will make a cut and access your pleura directly. In some cases, a surgeon may perform this with a minimally invasive approach. With this technique, they remove the membrane in pieces through a small cut.

A minimally invasive approach can help you recover faster and with less pain. But it can be difficult for a surgeon to remove a thick peel this way without major bleeding, which makes it hard for them to see the area.

Minimally invasive approaches include:

• Video-assisted thoracic surgery (VATS) decortication: A surgeon makes multiple small cuts and inserts tools through them. They put a camera in one cut to guide their use of the other tools.
• Robotic decortication: This is like VATS because it uses small cuts and a camera. But instead of holding the tools, a surgeon controls robotic arms from a console in the room.

How should I prepare for decortication?

Your provider will want to know your medical history. They’ll ask you if you’ve used tobacco, had radiation or had contact with asbestos. You’ll also need to get several tests, which may include:

• An echocardiogram to check lung pressures and see how well your heart works
• A stress test to make sure you’re fit for a lengthy surgery
• A chest X-ray and CT to show the problem area
• Thoracoscopy to get tissue samples
• Pulmonary function tests to see how well your lung works
• Other tests, like MRI or bronchoscopy, to check for tumors

What happens during this procedure?

A surgeon will follow these steps for an open thoracotomy decortication:

1. Use a bronchoscopy to look at your airway and remove mucus there
2. Make a cut below your sixth rib
3. Put in a tool to separate your ribs
4. Remove part of your rib for better access (if needed)
5. Open your pleura and remove fluid
6. Cut out and remove the thickened membrane (“peel”)
7. Inflate your lung and close any air leaks with stitches
8. Place two or three chest tubes for drainage
9. Close your chest

How long does this procedure take?

Lung decortication surgery takes more than two hours. The time varies by approach. A minimally invasive surgery may take longer because a surgeon has to remove the membrane piece by piece. The pieces have to fit through a small opening. This isn’t an issue with an open procedure.

What are the potential benefits and risks?

A decortication procedure can improve your symptoms. It allows your “trapped” lung to expand so you can breathe better. Still, lung decortication is a major surgery.

Risks include:

• Air leak that lasts a while
• Bleeding
• Fluid buildup
• Infection
• Injury to nearby organs or blood vessels
• Lung collapse

What happens after this procedure?

After surgical decortication, you’ll likely be in the intensive care unit, where healthcare providers can monitor you closely. You may have a breathing tube in your throat for 24 to 48 hours. This helps keep your lung inflated and can lessen bleeding.

You can also expect to have chest tubes for at least 48 hours. A provider will remove the tubes when the fluid coming out is clear and totals less than 50 milliliters (2 ounces) a day.

After pleural decortication, you should have pain relief from an epidural or nerve block you received during surgery.

You may get a chest X-ray the next day to see how much your lung expanded. A provider may also check your oxygen level with an arterial blood gas analysis.

What is the prognosis?

Your prognosis (outlook) after a decortication procedure depends on your condition, the cause of the thickened pleura and the severity of the disease. A severe case may not improve much. But most people have good results. The lung can expand again, and it works better.

Contact your provider if you have:

• Chest pain
• Dizziness
• Shortness of breath
• Signs of infection