What is Decortication ?
Under normal condition the lungs expand freely in the chest cavity, there is a thin layer of normal fluid which provides lubricant effect on the lung surfaces.
This is a normal CT scan of lung
This video shows thoracoscopy / VATS view of a normal chest cavity with lung artificially collapsed. The lung surface is smooth, shiny and transparent due to pleura covering it. The fineness of the surface is due to the normal pleural fluid acting as a lubricant.
The normal fluid lubricating the lung surface in diseased condition is replaced by excess abnormal fluid filling the chest cavity known as pleural effusion. This can be due to infection(bacteria), tuberculosis, heart failure, cancer etc.
They can manifest as breathlessness or early fatigue on exertion or even at rest
Cxr showing fluid collection on the chest
CT scan of chest showing fluid collection and lung compression
Consult your Doctor, as early detection results in early treatment and avoidance of sequelae of pleural effusion [fluid collection] on the lung.
When pleural effusion in detected in the early stage 1 and depending upon the severity of breathlessness a simple needle aspiration under ultrasound guidance is both diagnostic and therapeutic.
Images showing ultrasound guided needle drainage, pigtail drainage and chest tube drainage
In those individuals who present late it can result in the fluid getting infected called empyema.
In the early stage empyema the fluid forms a proteinaceous peel layer over the lung pleural surface limiting its expansion freely ,this is also known as stage 2 or fibrinopurulent phase. This is may not drainable despite putting chest tubes because of the thick organised fluid
CT scan of lung showing stage 2 effusion not drainable despite the chest tube in the chest
A video showing fibrinopurulent fluid stage2 effusion with multiple pockets
The natural history of such cases when not treated leads to the formation of an organized thick fibrous peel covering the lung surface as well as contracting the volume of the chest on the effected side. This is also known as stage 3 organized phase.
Video showing stage 3 organised thick peel trapping the lung
CT lung showing trapped lung due to organized collection in chest
CT scan is the imaging of choice to show the extent of lung trapping and failure for lung expansion despite adequate drainage of fluids.
Surgery is required for such cases to release the trapped lung called DECORTICATION.
The procedure is done under general anesthesia, Traditionally it was done using an open surgical approach involving a big 15 -20 cm skin incision with rib spreading called thoracotomy.
Presently the procedure can be done using keyhole or minimally invasive technique called thoracoscopy / VATS.
Dr Darlong has described two KEYHOLE techniques to deal with stage 2 and stage 3 empyema which has been published in ctsnet.org the largest online journal of cardiothoracic surgeons in the world.
Video of single incision / Uniportal VATS for stage 3 EMPYEMA
video of 2 key hole incision VATS for stage 2 EMPYEMA
LINK TO DR DARLONG’S DESCRIBED TECHNIQUES IN CTSNET.ORG
- Single incision thoracoscopic decortications stage 3 organized pleural effusion
- Dual incision thoracoscopic decortication stage 2 fibrinopurulent effusion
BENEFITS OF VATS DECORTICATION
Smaller incision
- Lesser trauma to tissue
- Lesser pain
- lesser respiratory complications
- Lesser wound infection
- Early wound healing
- Early hospital discharge
- Early return to work
Minimally invasive technique offers surgery to higher risk who were otherwise not suitable for open surgery