In the majority of patients for whom decortication is performed via a thoracotomy, the classic operative technique suggested by Williams4 and Samson5 is still used and will be described briefly in the following text. The basic tenets of the operation include complete pleurolysis, establishment of a decortication plane between the fibrous peel and the visceral pleura, and decortication of all pleural surfaces, including the diaphragm.
After induction of general anesthesia, flexible bronchoscopy is performed to rule out the presence of endobronchial obstruction. The use of a double-lumen endotracheal tube is preferred because frequent ventilatory changes (i.e., intermittent inflation of the affected lung) may be used during the procedure. Although a posterolateral thoracotomy traditionally has been preferred, a muscle-sparing thoracotomy still can be used without impairment in visualization. The chest is entered through the sixth interspace to provide better exposure of the lower lobe and the diaphragm, where the peel is usually thicker and the adhesions denser. Unless the chest is severely contracted and the ribs tightly apposed, rib resection usually is not required. One or two ribs may be shingled posteriorly to facilitate exposure, however.
Before inserting the chest retractor, the pleural space is bluntly developed for a distance of a few centimeters, sometimes in an extrapleural plane as necessary (Fig. 132-4). The need for complete extrapleural dissection is controversial. Most surgeons advocate this maneuver to ensure complete chest wall expansion. The counterargument is that extrapleural dissection may lead to significant bleeding and also can be extremely tedious at the apex of the lung and over the mediastinum. Regardless of whether the parietal pleura is left in place, complete lysis of all pleural adhesions is required. Any loculated spaces are drained and the contents are sent for culture. Concern about contamination of the remainder of the pleural cavity by drainage of such spaces is not justified; the immediate priority in treatment of pleural infections is lung reexpansion and that should be accomplished as completely as possible.
Blunt development of the pleural space before inserting the chest retractor.
When the visceral peel is encountered, it is incised in layers until the underlying visceral pleura is identified (Fig. 132-5). The most favorable location to initiate the dissection is usually the lateral surface of the lung, away from the diaphragm, where the fibrous peel is usually thicker. The peel then is dissected bluntly off the pleura; we prefer to use a peanut dissector or the tip of a metal sucker for this purpose. The lung usually is kept inflated at this stage to facilitate separation of the peel (Fig. 132-6). As the decortication progresses; however, the inflated lung impairs visualization, and the final stages usually are performed with the lung collapsed. Minor air leaks from the raw surface of the pulmonary parenchyma are unavoidable but heal quickly if the lung is fully reexpanded. Depending on the degree of inflammation and the presence or absence of parenchymal disease, complete decortication may be impossible in certain areas without significant parenchymal injury. In these cases, it is better to leave some layers of the peel behind than to create a severe and difficult-to-manage air leak. In addition, the remaining peel can be incised in several locations, akin to relaxing incisions, thereby allowing some reexpansion of the underlying lung (Fig. 132-7).
The visceral peel is incised in layers until the underlying visceral pleura is identified.
The lung is inflated to facilitate separation of the peel.
When complete decortication is ill-advised, the intact peel is incised in several locations to allow for limited reexpansion of the lung.
After the decortication is complete, hemostasis is obtained, and the pleural cavity is irrigated and drained widely. We prefer to use three chest tubes. Two straight tubes are laid posteriorly in the costovertebral recess and anteriorly to the hilum, respectively, and directed toward the apex. The third (right-angle) tube is placed between the diaphragm and the lung base and directed posteriorly toward the posterior costophrenic recess.