Overview
Definition:
Open decortication is a surgical procedure performed to remove a thick, inelastic layer of fibrous tissue (peel or membrane) that encases the lung, restricting its expansion
This condition, often referred to as a "trapped lung" or "entrapment," typically results from chronic inflammation, infection (like empyema), or prior hemothorax, leading to significant respiratory compromise.
Epidemiology:
The incidence of trapped lung requiring decortication is variable and often associated with untreated or inadequately treated pleural infections such as empyema
Risk factors include community-acquired pneumonia, hospital-acquired pneumonia, thoracic surgery, and trauma
It is more commonly seen in immunocompromised individuals or those with underlying lung disease.
Clinical Significance:
Trapped lung significantly impairs pulmonary function by limiting lung expansion, leading to dyspnea, reduced exercise tolerance, and chronic cough
It can also predispose to recurrent infections
Effective decortication is crucial for restoring lung volume, improving gas exchange, and alleviating symptoms, thereby enhancing the patient's quality of life and overall prognosis
This procedure is a key area of study for surgical residents preparing for DNB and NEET SS examinations.
Indications
Absolute Indications:
Significant respiratory compromise due to lung entrapment
Persistent symptoms (dyspnea, chest pain, cough) refractory to medical management
Documented presence of a thick peel on imaging that prevents full lung expansion
Failed prior less invasive procedures (e.g., thoracoscopic decortication).
Relative Indications:
Recurrent pleural effusions or infections in the context of pleural thickening
Asymptomatic but significant pleural peel compromising lung function on imaging
Following complicated pleural effusions, hemothorax, or empyema, even with minimal initial symptoms, to prevent future complications.
Contraindications:
Severe comorbidities precluding major thoracic surgery (e.g., end-stage COPD, severe cardiac disease)
Uncontrolled coagulopathy
Active widespread infection outside the pleural space
Patient refusal or inability to consent.
Preoperative Preparation
History And Physical:
Detailed history focusing on duration and severity of symptoms, prior thoracic procedures, infections, and comorbidities
Physical examination to assess respiratory status, oxygen saturation, and presence of chest wall abnormalities.
Investigations:
Chest X-ray (PA and lateral) to assess pleural thickening and lung volume
CT scan of the thorax with intravenous contrast is essential to delineate the extent of the peel, identify loculations, assess lung parenchyma, and rule out underlying parenchymal disease
Ultrasound of the chest to characterize pleural fluid
Pulmonary function tests (PFTs) to assess baseline lung function and predict postoperative recovery
Bronchoscopy may be indicated if suspicion of endobronchial disease or to obtain biopsies
Blood tests including complete blood count, renal function tests, liver function tests, coagulation profile, and arterial blood gas analysis
ECG and echocardiography if cardiac comorbidities are present.
Optimization:
Pulmonary physiotherapy and breathing exercises to improve lung capacity
Antibiotic prophylaxis if infection is suspected or present
Nutritional assessment and support
Optimization of cardiac and renal function
Smoking cessation counseling.
Procedure Steps
Surgical Approach:
The procedure is typically performed via a posterolateral thoracotomy incision
The extent of the incision depends on the need for surgical exposure and the surgeon's preference.
Pleural Entry And Peel Identification:
The thoracic cavity is entered, and the visceral and parietal pleura are inspected
The thickened peel encasing the lung is identified
Adhesions between the peel and the lung parenchyma are carefully dissected.
Decortication Process:
Using blunt and sharp dissection instruments (e.g., periosteal elevators, specialized instruments), the peel is meticulously separated from the lung surface
Careful attention is paid to avoid injuring the lung parenchyma
The dissection progresses circumferentially around the lung, aiming to release it completely.
Pleural Lavage And Drainage:
After complete decortication, the pleural cavity is thoroughly irrigated with saline to remove debris and fibrin
One or more chest tubes are inserted for drainage and re-expansion of the lung
The chest tubes are connected to an underwater seal drainage system.
Closure:
The intercostal muscles and ribs are approximated, and the thoracotomy incision is closed in layers.
Postoperative Care
Pain Management:
Aggressive pain control is crucial, utilizing epidural analgesia, patient-controlled analgesia (PCA) with opioids, or multimodal analgesia including NSAIDs.
Respiratory Care:
Early mobilization and ambulation are encouraged
Incentive spirometry and deep breathing exercises are vital to promote lung expansion and prevent atelectasis
Chest physiotherapy may be required
Monitoring of respiratory rate, oxygen saturation, and chest tube output.
Chest Tube Management:
Chest tubes are typically managed with suction until lung re-expansion is complete and drainage is minimal
They are usually removed when output is less than 100-150 mL/24 hours and air leak has resolved
Serial chest X-rays monitor lung expansion and pleural space status.
Monitoring And Antibiotics:
Close monitoring of vital signs, fluid balance, and signs of infection
Prophylactic or therapeutic antibiotics may be continued based on intraoperative findings and intraoperative cultures
Nutritional support and monitoring for potential complications.
Complications
Early Complications:
Bleeding requiring reoperation
Persistent air leak
Re-expansion pulmonary edema (especially if lung is severely entrapped and expanded too rapidly)
Injury to lung parenchyma (hemorrhage, bronchopleural fistula)
Infection (empyema, pneumonia)
Hemodynamic instability
Injury to adjacent structures (diaphragm, intercostal vessels).
Late Complications:
Chronic pain at the thoracotomy site
Bronchopleural fistula
Recurrent pleural effusion or empyema
Significant restrictive lung disease if decortication was incomplete or if underlying parenchymal disease is severe
Adhesions and lung entrapment recurrence.
Prevention Strategies:
Meticulous surgical technique to avoid parenchymal injury and excessive bleeding
Careful dissection and release
Appropriate chest tube management
Gradual lung re-expansion
Aggressive pain control to facilitate deep breathing and mobilization
Prompt recognition and management of infections
Judicious use of antibiotics
Thorough preoperative assessment and optimization.
Prognosis
Factors Affecting Prognosis:
The extent of lung entrapment prior to surgery
The duration of symptoms
The presence and severity of underlying lung parenchymal disease
The patient's overall health status and comorbidities
The completeness of the decortication procedure
Postoperative complications.
Outcomes:
With successful decortication, patients typically experience significant improvement in dyspnea and exercise tolerance
Lung volumes and function tests generally improve over several months
The goal is to restore near-normal lung function and alleviate symptoms, improving quality of life.
Follow Up:
Regular follow-up appointments with chest X-rays and pulmonary function tests are recommended to monitor lung recovery, detect any recurrence, and manage long-term respiratory health
Duration and frequency of follow-up are individualized based on patient condition and surgeon's discretion.
Key Points
Exam Focus:
Understand the pathophysiology of lung entrapment and the rationale for decortication
Differentiate open from thoracoscopic decortication indications
Memorize key indications and contraindications
Recognize imaging findings suggestive of trapped lung
Be aware of potential intraoperative and postoperative complications.
Clinical Pearls:
CT scan is paramount for preoperative planning, delineating peel thickness and lung parenchyma
Aggressive pain management is critical for effective postoperative rehabilitation
Monitor for re-expansion pulmonary edema, especially after prolonged entrapment
Complete release of the peel is the surgical goal.
Common Mistakes:
Inadequate preoperative imaging leading to incomplete understanding of the pathology
Overly aggressive dissection causing lung parenchyma injury
Insufficiently complete decortication, leaving residual peel
Delayed or inadequate pain management hindering patient recovery
Ignoring signs of infection or air leak
Assuming all trapped lungs can be fully liberated.