Decortication Technique

As with all thoracic surgical procedures, bronchoscopy is performed before patient positioning. It is essential to identify any large-airway pathology (eg, bronchial stenosis, broncholith, malignancy, or mucus plug) that may be the cause of lung collapse.

The patient is intubated, and the operation is done with the patient under general anesthesia. Single-lung ventilation is rarely necessary, because the lung on the affected side is already compressed from the fibrothorax. In fact, surgery becomes easier when the lung is expanded.

Video-assisted thoracoscopic surgery (VATS) is an option for most patients with thoracic pathology. Various studies have found VATS to be associated with better outcomes, less pain, and quicker recovery than the open approach. ^[26]

VATS is currently the gold standard for early cases of empyema. There is some evidence to suggest that it may also be an effective and safe choice for late-stage empyema in selected cases. ^{[27, 28, 29]}  However, a systematic review and meta-analysis by Sokouti et al did not find VATS decortication to be clearly superior to open decortication in the treatment of empyema thoracis. ^[30]

VATS is a better alternative to thoracotomy and is typically done with general anesthesia, using a camera and two trocar ports. (A uniportal approach has also been described. ^{[31, 32, 33]} ) The VATS technique is very similar to the open technique, except for the instruments used to retract and dissect. ^[34]

Local anesthetic is injected into the skin sites where the ports are to be inserted into the chest cavity. In general, the camera is usually in the midaxillary line, and the two additional ports are placed on either side of the camera. The entire operation can be performed through these three ports; rarely, a fourth port may be required for retraction of the tissues or for suctioning of smoke, pus, or blood.

During the early disease process, the peel is usually thin and easily removable from the lung parenchyma; in such cases, VATS is the ideal treatment modality. The thoracoscopic approach can help remove the peel, clean the necrotic debris, and break up any loculations. When the disease process becomes chronic, thoracoscopy is often difficult because the ribs may be fused and the peel may be very thick. The risk of injury is very high in chronic cases; thus, thoracoscopy is best avoided.

The fibrin peel is removed in a piecemeal fashion from the parietal and visceral pleura. Great care is required in removing thin peel from the visceral pleura because this can lead to air leaks. During the procedure, the scope may be switched to a different port to yield a better view of the lung. The peel may be removed with a grasper or peanut dissector.

Once the peel has been removed and the pus suctioned out, the chest cavity is irrigated. Two chest tubes are inserted via the port sites. The scope is removed, and the underlying subcutaneous tissues and skin are closed.

The patient should be placed in the lateral decubitus position. The chest is entered at the premarked intercostal space (usually the fifth or sixth intercostal space). An axillary thoracotomy also may be performed, but this exposure is only good for apical disease and does not give great exposure to the lower chest. (See the image below.)

Although some surgeons prefer to spare the latissimus dorsi and the serratus, this is sometimes difficult to do in patients with empyema. Often, the muscles are edematous or contracted and hard to dissect off the chest wall. However, every effort must be made to preserve the muscles because they may be needed to cover residual airspace or air leak.

In many cases of chronic empyema, the procedure can be made easier by first resecting a rib in a subperiosteal fashion. This maneuver also provides an intercostal muscle flap, avoids breaking another rib during chest opening, and facilitates good exposure of the entire chest.

In most chronic cases, the pleura are fused, and it is simply easier to perform pleurectomy. If the adhesions between the visceral and parietal pleura are not dense, then one may proceed with sharp dissection of the adhesions.

Once the correct plane of dissection is visualized, the peel can be removed relatively easily. In most cases, however, the peel is removed in segments. The entire lung must be checked to confirm that the peel has been fully removed; otherwise, the lung may fail to reexpand.

A pleurectomy that is too deep may cause parenchymal injury with resulting air leaks. These air leaks can prolong hospital stay. The anesthesiologist should be asked to inflate the lung gently during the procedure. This allows the peel to become more prominent and more easily detachable from the lung surface. Traction and countertraction are key. Of course, it is inevitable that some minor injury to lung parenchyma will result, but the resultant air leaks usually seal over very quickly.

Sometimes, it may be necessary to use a scalpel to make an incision in the thick peel and define the plane of dissection. The peel can be grasped with a hemostat and then dissected with a peanut dissector or the back end of a DeBakey forceps.

Patience is essential in performing decortication. Proceeding too quickly simply increases the chance of injury to the lung parenchyma and consequent air leakage. The peel should be followed laterally, medially, and superiorly over the lung surface. It is vital to remove the peel from the lung fissures and all the way down to the diaphragm.

In most cases, the thickest segment of the peel is along the costodiaphragmatic surface. Most of the peel here can be removed with finger dissection, but care should be exercised in placing the fingers along the medial border. In this area, it is possible to injure the phrenic nerve, the blood vessels, or the diaphragm. If the peel thins out or is difficult to remove, one should not persist but should move to another site. Some segments of the peel should be sent for pathologic and microbial analysis.

Once the peel is removed, the lung is checked to confirm that it is capable of complete reexpansion. Any large parenchymal air leaks that are noted may be oversewn, but this step often is not necessary. Several commercially available pulmonary sealants can reasonably be used to close air leaks.

One chest tube is placed along the base of the diaphragm, and one is placed in the apex. The chest should be irrigated, and all blood should be suctioned because it can be a nidus for infection. ^[35]

For some patients, neither VATS nor an open thoracotomy may be appropriate; in such cases, there are other options.

On rare occasions, thoracoplasty with multiple rib resections may be considered to obliterate any infection in the residual space by bringing the chest wall down to fill the space. One may leave a chest tube for prolonged periods; remove a segment of the rib in the most dependent position to allow for drainage.

These secondary options are only for frail and ill patients. For most patients with diffuse pleural disease, decortication is still the criterion standard. ^[36]

The management of a patient who has undergone decortication is essentially the same as that of a patient who has undergone lobectomy. However, recovery of lung function is faster after decortication than after lobectomy.

The decision to initiate or continue mechanical ventilation is usually based on an assessment of gas exchange, impending respiratory failure, and the ability to protect the airways. Some patients have an indwelling arterial line placed by the anesthesiologist in the operating room (OR) to facilitate one-lung anesthesia. Arterial blood gas sampling should be frequently done to assess both arterial oxygen tension (PaO₂) and arterial carbon dioxide tension (PaCO₂). Most patients do well with oxygen delivery by a face mask or nasal cannula. The majority of patients can be extubated in the OR.

If a monitored bed on the surgical floor is not available, an overnight stay in the intensive care unit (ICU) is recommended. The majority of patients who undergo thoracic procedures are observed in the ICU or in a stepdown unit for 12-24 hours. If the course is uneventful, the patient may be discharged to a monitored surgical floor. To reduce fluid overload, most thoracic patients are kept on the dry side. Unless the patient is not eating at all, intravenous (IV) fluids are maintained at a minimum.

Postoperative management of the chest tube is dictated by culture results, intraoperative findings, and the patient's clinical status. Chest tubes are monitored for both air leakage and fluid drainage every 8 hours. Blood work is usually done once on the following day to assess hemoglobin and renal function. Postoperative chest radiography is routine. Unless the patient has a problem, some physicians only order radiographs before and after removal of a chest tube.

Judicious use of analgesia is necessary. Patient-controlled analgesia (PCA) is routinely available in most hospitals and helps ease the pain for the next several days. Once the chest tubes are removed, the patient can be placed on transdermal fentanyl, augmented by nonsteroidal anti-inflammatory drugs (NSAIDs). Whenever possible, surgeons should attempt an intercostal block. Very fine catheters can be placed along the posterior rib angles. Bupivacaine and epinephrine can be infused intermittently via these catheters.

Other factors in postoperative care include chest physiotherapy, tracheal suctioning, and ambulation. To prevent atelectasis, incentive spirometry is vital and should be apart of preoperative teaching. The cardiovascular system also must be closely monitored after surgery. Arrhythmias and myocardial infarction can occur; thus, cardiac monitoring for the first 48 hours is required. The incidence of cardiac complications is higher in the elderly and those with preexisting cardiac risk factors.

Most patients remain in the hospital until the chest tubes have been removed and they are able to tolerate oral feeding. Physical therapy is a vital component of postoperative care and should be encouraged. Deep vein thrombosis (DVT) prophylaxis is highly encouraged, even if patients are ambulatory. Because patients may be present or past smokers, oxygen and nebulizer therapy is often administered. The average stay after a thoracotomy procedure ranges from 3 to 5 days, but patient who undergo VATS may be able to go home within 48-72 hours.

Numerous series show that VATS allows for rapid recovery, significantly less pain, and reduced postoperative complications. Irrespective of the type of surgery performed, most patients need a prescription-strength pain pill for a few days at home. Others may benefit from a fentanyl patch.

All patients are seen within 5-7 days after discharge. At the first postoperative visit, the staples may be removed, and a wound check is performed. Chest radiography is done to assess for the presence of full lung expansion, pneumothorax, or pleural effusion. All patients are encouraged to continue with physical therapy.

Decortication is associated with a wide range of complications, including infections (perioperative sepsis syndrome), bronchopleural fistulas, bleeding, and persistent air leakage. Prolonged air leakage or bronchopleural fistula may necessitate a second surgical procedure in some cases.

Most air leaks seal within a few days, but large leaks may persist for weeks. A retrospective case-control study by Testori et al suggested that intraoperative administration of 50% hypertonic glucose solution could reduce the duration of air leakage after extended pleurectomy-decortication for malignant pleural mesothelioma. ^[37]

Bleeding can occur from the lung or the pleural surface or from lysis of adhesions. Thus, it is vital to ensure good hemostasis before leaving the OR. Most surgeons secure blood vessels with a suture as well as a clip.

Residual air space is a frequent problem and can occur when there is injury to the lung parenchyma.

Infection of the pleural space can occur when a residual air space persists. In some cases, the patient may need a muscle flap or an apical tent to close off the residual space and eliminate the infection.

Respiratory failure is not a direct complication of surgery. Patients who have borderline lung function are more likely than healthy people to develop respiratory distress in the postoperative period. If the preoperative workup was not adequate or if a high-risk patient underwent surgery, the patient may require prolonged ventilation and even a tracheostomy.

Cardiac complications may include acute myocardial infarction and arrhythmias.