Decortication

Decortication

Decortication is a type of surgical procedure performed to remove a fibrous tissue that has abnormally formed on the surface of the lung, chest wall or diaphragm. Generally, there is a space (called pleural space) in between the lungs and the chest wall, which is lined with a very thin fluid layer for lubrication. This area is moist to allow the lungs to expand and contract smoothly when breathing. However, certain diseases or conditions can lead to excess fluid that can fill up this gap. The excess fluid buildup is known as pleural effusion. If not fixed, the excess buildup of fluid can eventually turn solid and form a fibrous capsule that restricts and entraps the lung, causing breathing problems.

How to Prepare for Decortication Procedure

Prior to the procedure, your doctor and treatment team will explain to you what to expect before, during and after the procedure and potential risks of the procedure. Talk to your doctor about:

All medications, herbal products and dietary supplements you are currently taking and ask for their recommendations about each.

Radiation exposure, especially for those that are pregnant.

Any allergies to medicines, latex, tape, iodine, and anesthetic agents.

Any history of bleeding disorders.

Any body piercings on your chest or abdomen.

Other recommendations include:

Eat a normal meal the evening before the procedure. However, do not eat, drink or chew anything after midnight before your procedure. If you must take medications, only take them with sips of water.

Leave all jewelry at home.

Remove all makeup and nail polish.

Wear comfortable clothing when you come to the hospital.

If you normally wear dentures, glasses, or hearing devices at home, plan to wear them during the procedure.

What to Expect Before Decortication Procedure

To determine whether you need this procedure, your doctor might perform a variety of diagnostic tests, including:

Blood tests

Ultrasound

Computed Tomography (CT scan)

X-Rays

What to Expect During Decortication Procedure

The procedure will typically take between 2 to 3 hours to complete. This procedure is typically performed in the cardiothoracic operating room (OR). Check with your doctor about the details of your procedure. In general, during a minimally-invasive decortication:

You will change into a hospital gown.

A nurse will start the intravenous (IV) line in your arm which will administer medications and fluids during the procedure.

Usually, your doctor will administer general anesthesia (make you feel sleepy).

Once you are sedated, your doctor may insert a breathing tube through your throat into your lungs and connect you to a ventilator. This will breathe for you during surgery.

The doctor makes a few tiny incisions in the chest.

Next, your lungs will be temporarily collapsed and moved aside to allow the doctor to reach the affected area.

The doctor inserts a thoracoscope (thin tube with a light and a camera) to assess the pleural space through a small incision.

When the area affected is identified, the doctor will make a few small incisions to peel off the fibrous pleural layer.

Once the pleural capsules are fully removed, the lungs are re-inflated.

The doctor will close up the incision(s) with stitches or staples, and you will be moved to the recovery area.

What to Expect After Decortication Procedure

After the procedure, you will be taken to the step down unit for 5 to 7 days. Other recommendations include:

General Guidelines

The breathing tube is removed when you wake up from anesthesia.

Ambulation is started on the first or second day of surgery.

Urine catheters and drainage tubes (chest tubes) are removed after 24 to 72 hours.

You can probably do your normal activities after the surgery. But, you may need to take it easy at first. No heavy lifting or vigorous exercises until your body has healed.

Receive several different medicines to relieve pain. Patients will be given long-acting oral pain medication, NSAIDS, IV pain medication and multi-level intercostal nerve blocks.

Your doctor will give you instructions to follow during your recovery.

Technique or Treatment

Posterolateral Thoracotomy

• Skin incision: The skin incision swings downwards, beginning at a level midway between the spinous process to the tip of the scapula. The anterior limit is the mid-axillary or anterior axillary line. This incision extends around 2 inches below the tip of the scapula. The incision is deepened using the electrocautery. The latissimus dorsi and the serratus anterior muscles are divided using the electrocautery. The tip of the scapula is grasped using an Allis forceps, and the ribs are counted in the subscapular space.

• Entry into the thoracic cavity is established via the fifth or the sixth interspace. It must be kept in mind that the electrocautery must divide the intercostal muscles at the upper border of the lower rib so that the neurovascular bundle is spared. A rib resection might be required if there is excessive crowding of the ribs.

• After the division of the intercostal muscles, the extrapleural space is entered. Care is taken not to enter the empyema cavity directly. The mediastinum is generally not involved in the inflammatory process. Therefore care must be taken to avoid injury to the mediastinal structures. Similarly, the apex of the lung must be freed carefully. Injury to the subclavian vessels may occur during the apical dissection and can cause hemorrhage. Care must also be taken to avoid injury to the esophagus (left-side decortication) or vena cava (right-side decortication) during medial dissection and diaphragm during the inferior dissection. The rind or the pleural peel must be removed from the lung parenchyma, including the fissures

• After removal of the thick peel, the anesthesiologist is asked to inflate the lung to locate the air-leaks. All the major air-leaks must be formally closed with suture. Adequate hemostasis must be ensured. Diathermy or bipolar forceps may be quite handy to achieve hemostasis.

• The intercostal drain is inserted in the thoracic interspace. Some surgeons insert two drains-one in the base (posterior) and one in the apex (anterior). These tubes remain in place until the appearance of signs (clinical and radiological) of lung expansion.

• Subsequently, a layered chest wall closure is done.

Video-assisted Thoracoscopic Surgery (VATS)

• VATS-decortication is usually performed via an anterior approach. Three ports can be inserted as per the surgeon's preference. A uniportal technique is also favored by some surgeons. A 30 degrees camera is used for visualization during the procedure. The preoperative computed tomogram is used as a guide to enter the uninvolved area of the thoracic cavity. 

• The cautery hook and suction cannula are effective instruments for dissection.

• Limits of the dissection are the same as in open surgery.

• The camera port can be switched to perform adhesiolysis at different portions of the pleural cavity.

• The chest tube can be inserted in the port sites.

The efficacy of VATS for pleural toileting in the early stages of empyema is already proven. Compared with video-assisted thoracoscopic surgery, mortality, major morbidity, prolonged length of stay, and discharge to other than home were higher with thoracotomy.  A meta-analysis by Pan et al. has shown similar outcomes of VATS-decortication as compared to thoracotomy and decortication. However, the relapse rate shows no significant difference.

Postoperative Care 

Postoperative care includes adequate analgesia, antibiotic therapy, hydration, and nutritional support. Sick patients often require mechanical ventilation. Therefore, intensive monitoring must be ensured during the initial postoperative period in these patients. Adequate care of the chest tubes must also be ensured. Apart from serial chest radiographs, periodic arterial blood gas analysis might be required in these patients.

Complications

The common complications of lung decortication include:

1. Hemorrhage: Blood loss from the raw lung surfaces can result in a significant hemorrhage. A postoperative blood profile should be done to ascertain the need for blood transfusion.

2. Persistent air-leak and bronchopleural fistula: Minor air-leaks can occur during decortication. However, these leaks resolve spontaneously after a few days. Large leaks must be closed with formal suturing to avoid the development of a bronchopleural fistula.

3. Persistent lung collapse: Collapse, and non-expansion of the lung parenchyma is frequently noticed in the postoperative period after decortication. Incentive spirometry and chest physiotherapy play a crucial role in the re-expansion of underlying parenchyma. However, a subset of patients may not show adequate lung expansion due to diseased/destroyed lung.

4. Injury to vital structures: Decortication must be performed carefully by experienced surgeons. Injury to vital structures, including subclavian vessels, diaphragm, esophagus, and pericardium, is common if the limits of peel removal are not followed.

5. Retained infective focus and sepsis: Removal of the pus and pleural toileting must be thoroughly performed during decortication. Retained pus is a nidus of infection and may lead to sepsis in the postoperative period.

6. Severe postoperative pain: Any thoracotomy, especially those with rib resection, may lead to significant pain in the postoperative period. Adequate postoperative analgesia is a must and may require a combination of intravenous and epidural analgesia.

7. Chest wall deformity and scoliosis

REFERENCES

https://www.rwjbh.org/treatment-care/surgery/thoracic-surgery/thoracic-surgery-tests-and-procedures/decortication/#:~:text=Decortication%20is%20a%20type%20of,thin%20fluid%20layer%20for%20lubrication.

https://www.ncbi.nlm.nih.gov/books/NBK564375/