Key Points

• The principles behind decortication to improve lung function and expansion date back more than 100 years.
• In selected patients, early decortication prevents the development of fibrothorax.
• Early and complete drainage of the pleural space is the best way to prevent the need for decortication and the late development of fibrothorax.
• Minimally invasive approaches, including robotic and video-assisted thoracoscopy (VATS), are reasonable alternatives to open thoracotomy for decortication in experienced hands.

Under normal conditions, the pleural cavity is a potential space interposed between the chest wall and the lung. The visceral and parietal linings of this cavity are 1 to 2 mm thick and serve as permeable membranes for transport of cells and fluid. Under pathologic conditions such as infection, these relationships may be altered, leading to the development of chronic effusions, trapped lung, fibrothorax, and eventually severely impaired respiration. These pathologic conditions must be well understood as they can present challenging management problems with lifelong implications for patients.