Decortication: Freeing a Trapped Lung, Open vs. VATS Surgery, Risks and Recovery
Updated: 2 days ago
Written and medically reviewed by Dr. Baraa Alnahhal, MD · Last reviewed: November 2026 · How we review
Quick Answer: What is decortication?
Decortication is lung surgery that removes a fibrous layer of scar tissue (a peel) that has formed on the lining of the lung and stops it from expanding fully. Surgeons recommend it when draining fluid with a needle or chest tube hasn't worked, often after empyema. It can be open or minimally invasive and takes more than two hours. [1]
What the research says
Minimally invasive decortication may mean a faster, smoother recovery. A meta-analysis comparing VATS with open decortication for empyema found VATS had shorter operations (about 37 minutes less), shorter hospital stays (about 2.4 days less), fewer prolonged air leaks (9.7% vs. 17.1%), and lower complication (16.4% vs. 24.5%) and death rates (4.1% vs. 6.2%). Relapse rates were similar. The studies weren't randomized, so results may be biased. (Pan et al., Journal of Thoracic Disease, 2017) [2]
Lung function can improve for years. A systematic review of long-term outcomes after empyema surgery found that 60% to 65% of people had no shortness of breath 2 to 7 years later. In 6 of 7 studies, people with a trapped, scarred lung (fibrothorax) regained normal lung function, with FEV1 improving by 14% to 30% and FVC by 13% to 50%. The authors noted a high risk of bias. (Jolliffe et al., ANZ Journal of Surgery, 2024) [3]
Key takeaways
Decortication removes a thick scar layer that traps the lung. [1]
It's usually done after needle or chest tube drainage fails. [1]
Open thoracotomy is the gold standard; VATS and robotic surgery are less invasive options. [1]
Most people spend time in the intensive care unit (ICU) and have chest tubes for at least two days. [1]
Most people have good results and breathe better afterward. [1]
What is decortication?
The pleura is a two-layered membrane that lines the lungs and the inside of the chest wall. When fluid, pus or blood sits in the space between these layers for a long time, the body can form a tough, fibrous layer over the lung, called a peel or rind. This peel acts like a corset. It stops the lung from expanding, a problem called trapped lung (fibrothorax). [1]
Decortication is surgery to cut away this peel so the lung can expand and fill the chest again. [1]
Removing the peel lets the trapped lung inflate again.
When decortication is combined with removal of part of the pleura, it's called pleurectomy/decortication (P/D). This is one surgical option for mesothelioma. [1]
Why is decortication done?
Decortication is usually recommended when other treatments, such as draining fluid with a needle (thoracentesis) or a chest tube, haven't worked. It may treat: [1]
Long-standing pleural effusions, especially pus (empyema), often after pneumonia
Blood in the pleural space (hemothorax) that has clotted and scarred
Tumors of the pleura
Trapped lung (fibrothorax), when a fibrous layer keeps the lung from expanding
How do you prepare for decortication?
Your care team will review your health history, including tobacco use and any radiation or asbestos exposure. You may need tests such as: [1]
Echocardiogram and stress test to check your heart
Chest X-ray or CT scan
Thoracoscopy to look inside the chest
Pulmonary function tests
MRI or bronchoscopy
What are the types of decortication?
Your surgeon chooses the approach based on your lungs and the peel. [1]
Open surgery gives the most direct access; VATS and robotic surgery use smaller cuts.
Approach | How it's done | Possible pros and cons |
Open thoracotomy | Incision below the 6th rib with a rib spreader | Gold standard with direct access; larger incision |
VATS | Small incisions with a camera | Less pain and faster recovery; peel may come out in pieces |
Robotic | Surgeon controls robotic arms through small cuts | Similar benefits to VATS; may take longer |
Sources: [1]
Learn more in our guides to thoracotomy and video-assisted thoracic surgery (VATS). Minimally invasive methods may carry a risk of bleeding and can take longer than open surgery. [1]
What happens during open decortication?
You'll be under general anesthesia. The steps are usually: [1]
Bronchoscopy. The surgeon looks into your airways with a thin scope.
Incision. A cut is made on your side, below the 6th rib.
Rib spreader. The ribs are gently spread to reach the lung.
Rib removal if needed. Part of a rib may be removed for better access.
Open the pleura. The surgeon opens the pleura and removes any fluid.
Remove the peel. The thick fibrous layer is carefully cut away from the lung.
Inflate the lung. The lung is re-expanded and any air leaks are stitched.
Chest tubes. Two or three chest tubes are placed to drain air and fluid.
Close. The incision is closed.
Sources: [1]
Surgery usually takes more than two hours. Robotic surgery can take longer, while studies suggest VATS is often quicker than open surgery. [1]
What are the risks of decortication?
Possible complications include: [1]
Risk | What it means |
Prolonged air leak | Air keeps leaking from the lung surface |
Bleeding | Blood loss during or after surgery |
Fluid buildup | Fluid collects again around the lung |
Infection | In the chest or at the incision |
Injury | Damage to nearby organs or blood vessels |
Lung collapse | The lung may not stay fully inflated |
What happens after decortication?
Most people start recovery in the intensive care unit.
In the hospital: [1]
ICU care. Most people go to the intensive care unit after surgery.
Breathing tube. You may need a breathing tube for 24 to 48 hours.
Chest tubes. They stay in for at least 48 hours and come out when drainage is clear and less than about 50 milliliters (about 2 ounces) a day.
Pain control. An epidural or nerve block is often used.
Tests. You'll have a chest X-ray and an arterial blood gas test the next day.
What is the outlook after decortication?
Most people have good results. Once the peel is gone, the lung can expand and breathing usually improves. [1] [3]
When should you call your provider?
After you go home, contact your provider if you have: [1]
Chest pain
Dizziness
Shortness of breath
Signs of infection, such as fever, redness, swelling or drainage at the incision
Conclusion
Decortication frees a lung trapped by thick scar tissue so it can expand again. It's usually done when draining the fluid hasn't worked, often after empyema or a clotted hemothorax. Open surgery remains the gold standard, while VATS and robotic surgery are less invasive options. Recovery starts in the hospital, usually with ICU care and chest tubes, and most people breathe better afterward. [1]
If you have fluid around your lung that keeps coming back or a lung that won't fully expand, ask a thoracic surgeon whether decortication is an option for you.
Keep learning: Read our guides to pleurodesis and pleurisy. For more on fluid around the lungs, see MedlinePlus: Pleural effusion.
FAQ
What is decortication?
Decortication is lung surgery that removes a thick, fibrous layer of scar tissue from the lining of the lung so the lung can fully expand.
Why is decortication done?
It's usually done when needle or chest tube drainage hasn't worked for long-standing fluid, pus or blood around the lung, pleural tumors or a trapped lung.
What is a trapped lung?
A trapped lung (fibrothorax) is a lung covered by a tough fibrous peel that stops it from expanding fully.
Is decortication major surgery?
Yes. It's done under general anesthesia, usually takes more than two hours and often requires an ICU stay afterward.
What is the difference between open and VATS decortication?
Open decortication uses an incision below the 6th rib with a rib spreader. VATS uses small incisions and a camera and may mean less pain and a faster recovery.
How long does decortication take?
It usually takes more than two hours. Robotic surgery can take longer, while studies suggest VATS is often quicker than open surgery.
How long do chest tubes stay in after decortication?
Chest tubes stay in for at least 48 hours and come out when drainage is clear and less than about 50 mL a day.
What are the risks of decortication?
Risks include prolonged air leak, bleeding, fluid buildup, infection, injury to nearby organs or blood vessels and lung collapse.
What is pleurectomy/decortication?
Pleurectomy/decortication (P/D) combines removing the peel with removing part of the pleura. It's one surgical option for mesothelioma.
What is the outlook after decortication?
Most people have good results, and breathing usually improves once the lung can expand.
How do I prepare for decortication?
Your care team reviews your health history, including tobacco use and any radiation or asbestos exposure. You may need tests such as an echocardiogram and stress test, a chest X-ray or CT scan, a thoracoscopy, pulmonary function tests, or an MRI or bronchoscopy [1].
Does decortication hurt, and what anesthesia is used?
You are under general anesthesia during the operation. Afterward, pain is often controlled with an epidural or a nerve block while you recover in the hospital [1].
When should I call my doctor after decortication?
After you go home, contact your provider if you have chest pain, dizziness, shortness of breath, or signs of infection such as fever, redness, swelling or drainage at the incision [1].
Related Reading
Learn more in our guide to Hemothorax: What It Is, Why It Happens, and How It's Treated.
Learn more in our guide to What Is Mesothelioma? The Rare Cancer Linked to Asbestos — and What Treatment Looks Like.
Learn more in our guide to Pleurisy: Complete Guide to Symptoms, Causes, and Treatment.
Learn more in our guide to Hemopneumothorax: Understanding Combined Air and Blood in the Lungs.
Learn more in our guide to Pleurodesis: Chemical vs. Mechanical, Procedure, Success Rates and Recovery.
References
Cleveland Clinic. Decortication: Procedure and What It Treats. Cleveland Clinic. Last updated August 20, 2025. https://my.clevelandclinic.org/health/procedures/decortication
Pan H, He J, Shen J, et al. A meta-analysis of video-assisted thoracoscopic decortication versus open thoracotomy decortication for patients with empyema. J Thorac Dis. 2017;9(7):2006-2014. PMID 28840000. https://doi.org/10.21037/jtd.2017.06.109
Jolliffe J, Dunne B, Eckhaus J, et al. Long-term outcomes in surgically intervened empyema patients: a systematic review. ANZ J Surg. 2024;94(9):1491-1501. PMID 38895824. https://doi.org/10.1111/ans.19123
Medical disclaimer
This article is for general education only and does not replace advice from a qualified healthcare professional. Talk to your doctor about your own diagnosis and treatment, and seek emergency care right away for severe or sudden symptoms.
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