Technical Considerations

Right Pneumonectomy

A serratus anterior muscle sparing incision is performed in the 5th intercostal space using a posterolateral thoracotomy. The serratus sparing maneuver is optional since the serratus may be taken to improve exposure as necessary. Alternatively, some surgeons prefer to spare the latissimus dorsi and take the serratus anterior.

An exploratory thoracotomy is performed and an assessment is made for re-sectability. If there are miliary metastases throughout the parietal pleura, it can be presumed this is unresectable disease and biopsies are taken to establish the diagnosis. The lesion itself is examined carefully to ensure resectability. The mediastinal nodes are carefully examined. There should have been a preoperative evaluation by a chest CT scan to evaluate mediastinal nodes. If they were smaller than 1 to 1.5 cm in diameter, then thoracotomy is indicated for a primary lung lesion. Nonetheless, on exploratory thoracotomy, evaluation of the mediastinal nodes is mandatory.

If at the time of thoracotomy a positive mediastinal node is identified, excision of the primary lesion is still indicated since the thoracotomy has already been done and it has been shown that resection of the tumor and mediastinal node removal imparts a higher survival than if the diagnosis of mediastinal involvement is made preoperatively by mediastinoscopy. This implies a less advanced stage of the carcinoma when the diagnosis is made intraoperatively rather than preoperatively.

The general order of anatomic structures on the right is pulmonary vein most anteriorly, then pulmonary artery, then bronchus most posteriorly. The right mainstem bronchus is eparterial, i.e. it is superior to the level of the right pulmonary artery and is posterior to it.

The key relationship in performing a right pneumonectomy (as well as a right upper lobectomy) is developing a plane between the right superior pulmonary vein and the main pulmonary artery (Fig. 12.4a-e). The sequence of the operation is as follows:

1) The right superior pulmonary vein is ligated with silk ligature. It is usually necessary to ligate the tributaries of the right superior pulmonary vein separately. The pulmonary artery is now exposed. The right upper lobe pulmonary artery is taken and then the right main pulmonary artery is taken. It is usually not possible to take the right main pulmonary artery itself without taking the right upper lobe pulmonary artery separately. This is because the right pulmonary artery is shorter than the left and care must be taken that the tie on the right main pulmonary artery does not slip off.

2) Next the inferior pulmonary ligament and right lower lobe pulmonary vein are taken. The pulmonary vein is at the superior most aspect of the inferior pulmonary ligament.

Fig 12.4. Right pneumonectomy. (a) Exposure of right pulmonary hilum via posterolateral thoracotomy.Reprinted with permission from Pneumonectomy. Waldhausen JA, Pierce WS, Campbell DB, eds. Surgery of the Chest, 6th ed. pp. 97,99. © Mosby-Year Book, Inc.

Fig 12.4.b. Right pulmonary artery taken. Reprinted with permission from Pneumo-nectomy. Waldhausen JA, Pierce WS, Campbell DB, eds. Surgery of the Chest, 6th ed. pp. 97,99. © Mosby-Year Book, Inc.

Fig 12.4.c. Superior pulmonary vein taken. Inferior pulmonary vein will be taken next. Reprinted with permission from Pneumonectomy. Waldhausen JA, Pierce WS, Campbell DB, eds. Surgery of the Chest, 6th ed. pp. 97,99. © Mosby-Year Book, Inc.

Fig 12.4d. Right mainstem bronchus staple transected.

Fig 12.4e. Hilum after lung is removed. Reprinted with permission from Pneumonectomy. Waldhausen JA, Pierce WS, Campbell DB, eds. Surgery of the Chest, 6th ed. pp. 97,99. © Mosby-Year Book, Inc.

3) Next the right mainstem bronchus which is posterior to the right pulmonary artery is taken with a TA bronchial stapling instrument. The lung is removed. A pleural flap is then placed over the bronchus or alternatively an intercostal muscle bundle. The main hazards with respect to a right pneumonectomy include uncontrolled hemorrhage from a poorly visualized right pulmonary artery, damage to the esophagus, and an excessively short right mainstem bronchus. In this case sleeve resection of the trachea may be needed.

Left Pneumonectomy (Fig. 12.5)

Through the fifth intercostal space, a standard posterolateral thoracotomy is performed. The important features anatomically are: 1) the relationship with the left pulmonary artery to the aortic arch with reference to the ligamentum arteriosum and the left recurrent nerve; 2) the accessibility of the left pulmonary artery and both pulmonary veins intrapericardially; 3) inaccessability of the left mainstem bronchus since it is behind the arch of the aorta. The steps are as follows:

1) First the left superior pulmonary vein, which is located anteriorly, is ligated with silk.

2) The left pulmonary artery is taken with a vascular stapling instrument or with silk ties. Unlike the right pulmonary artery, it is rarely necessary to take the left upper lobe pulmonary artery separately, since this first branch of the left pulmonary artery arises at quite a distance from the left pulmonary artery. On the right side, it is usually necessary to separately ligate the upper lobe arterial branch.

3) Next the inferior pulmonary ligament is taken down and the left inferior pulmonary vein is taken, usually by a vascular stapling instrument.

4) Next the left mainstem bronchus [which is located inferior and anterior to the left pulmonary artery (i.e. hyparterial)] is taken with a bronchial stapling instrument. A pleural flap is placed over the left mainstem bronchus to eliminate chances of a leak and to buttress over anastomosis.

Fig 12.5. Left pneumonectomy. (a) Exposure of left pulmonary hi-lum via posterolateral thoracotomy. Reprinted with permission from Vanecko RM, Neptune WB. Lung. In: Nora PF, ed. Operative Surgery, 3rd ed. Philadelphia: W.B. Saunders Co., 1990: p. 319.

Fig 12.5b. Left superior pulmonary vein and left pulmonary artery taken. The left inferior pulmonary vein will be taken next. Reprinted with permission from Vanecko RM, Neptune WB. Lung. In: Nora PF, ed. Operative Surgery, 3rd ed. Philadelphia: W.B. Saunders Co., 1990: p. 319.

Fig 12.5c. The left mainstem bronchus is transected. A staple gun is usally used prior to the transection. Reprinted with permission from Vanecko RM, Neptune WB. Lung. In: Nora PF, ed. Operative Surgery, 3rd ed. Philadelphia: W.B. Saunders Co., 1990: p. 319.

Right Upper Lobectomy (Fig. 12.6a-f)

This is performed through either 4th or 5th intercostal space. Most surgeons prefer entering the 5th intercostal space through a posterolateral thoracotomy. The anterior surface of the hilum is dissected by incising the mediastinal pleura to expose the pulmonary veins. Again the most anterior structure is taken first, i.e. the right superior pulmonary vein is identified. The right upper lobe pulmonary vein is ligated. Care is taken to preserve the right middle lobe vein since injury to this may cause venous stasis and infarction of the right middle lobe. The right upper lobe pulmonary vein is then divided exposing the large anterior branch of the right pulmonary artery. The fissure is developed and the large truncus anterior branch of the right pulmonary artery is taken anterosuperiorly near the hilum. It should be noted that this is taken outside the fissure. The only branch to the right upper lobe which is taken in the fissure is the recurrent ascending posterior artery. This is a very important point since taking only the truncus anterior

Fig. 12.6a. Right upper lobectomy. Pulmonary artery and vein identified. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 652. © WB Saunders Co.

Main bron- pulmonary a. Superior pulmonary v.

Main bron- pulmonary a. Superior pulmonary v.

Fig. 12.6a. Right upper lobectomy. Pulmonary artery and vein identified. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 652. © WB Saunders Co.

Fig. 12.6b. Right upper lobe pulmonary artery is taken and upper lobe pulmonary veins ligated. Reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy, p. 137. © Mosby-Year Book, Inc.

Fig. 12.6c. Upper lobe pulmonary veins are cut. Care is taken to avoid injury particularly to the right middle lobe vein. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. p. 653. © Mosby-Year Book, Inc.

Fig. 12.6d. Interlobar fissure developed. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 653. © Mosby-Year Book, Inc.

Fig. 12.6d. Interlobar fissure developed. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 653. © Mosby-Year Book, Inc.

Fig. 12.6e. The posterior ascending artery is identified within the fissure and taken. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. p. 653. © WB Saunders,

Fig. 12.6f. Right upper lobe bronchus identified from behind and staple resected.

without entering the fissure will miss the recurrent ascending posterior branch and could be torn when removing the right upper lobe. The right upper lobe bronchus is the final structure and is taken with a TA-30 4.8 mm staple gun.

Next the right middle lobe may be plicated to the right lower lobe with 2-0 chromic stitches to prevent torsion. It should be noted that mobilization of the inferior pulmonary ligament is critical since it permits the remaining lung to be better able to occupy the remaining pleural space.

Middle Lobectomy (Fig. 12.7a-e)

This is approached again via standard lateral decubitus position. A posterolat-eral thoracotomy is employed, again entering the 5th interspace using a serratus sparing incision if possible. The inferior pulmonary ligament is mobilized. The mediastinal pleura is incised to identify and ligate the right middle lobe vein. This is a branch of the right superior pulmonary vein.

Next the right middle lobe pulmonary artery is identified and taken. One must be careful to avoid the posterior recurrent ascending branch to the upper lobe as well as the superior segmental branch to the lower lobe. All these vessels come off very close to one another. Finally the right middle lobe bronchus is taken. This is found beneath the right pulmonary artery. Again care must be taken to avoid injury to the superior segmental bronchus which comes out very close to the right middle lobe orifice.

Right Lower Lobectomy (Fig. 12.8a-d)

The right lower lobectomy is performed through the 6th intercostal space. The inferior pulmonary ligament is divided up to the level of the inferior pulmonary vein; this is then taken, either with ligatures or preferably now with a TA vascular

Fig 12.7a. Right middle lobectomy. Right middle lobe pulmonary vein taken. Reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy, p. 139. © Mosby-Year Book, Inc.

Fig 12.7b. Middle lobe pulmonary artery taken within the fissure, avoiding the ascending posterior and superior segmental arteries. Reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy, p. 139. © Mosby-Year Book, Inc.
Fig 12.7c. An incomplete fissure is further developed. Reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy, p. 139. © Mosby-Year Book, Inc.

Fig 12.7d, left. The middle lobe bronchus is staple transected. (12.7e, right) The right lung is inflated except for the middle lobe, which is then staple resected.

Fig 12.8a. Right lower lobectomy. Inferior pulmonary ligament mobilized. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 658. © WB Saunders Co.

Fig. 12.8b. Right inferior pulmonary vein taken. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. p. 658. © WB Saunders Co.

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stapling instrument. The right lower lobe pulmonary artery is then exposed to the fissure. This superior segmental artery is taken. This is at the level of the right middle lobe pulmonary artery and care must be taken not to injure this artery. Then the basal portion of the right lower lobe pulmonary artery is identified and

Fig 12.8c. The pulmonary artery is identified in the fissure and the superior segmental artery and basal artery are taken separately. © Mosby-Year Book, Inc.

Fig 12.8d. The right lower lobe bronchus is stapled from behind. Figs. 11.8c,d are reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy, p. 145. © Mosby-Year Book, Inc.

taken. The right lower lobe bronchus is exp osed and the superior segmental bronchus is carefully identified to avoid narrowing of the right middle lobe bronchus when taking the right lower lobe bronchus with a stapler.

As one can see from the above discussion, the general plan of the procedure is generally the same for all lobes. Sequentially, the vein, then artery, then bronchus are divided in that order. Alternatively, one may take the artery first to allow for pulmonary devascularization prior to removal.

Left Upper Lobectomy (Fig. 12.9a-e)

This is done via a posterolateral thoracotomy through the 4th or 5th intercostal space. The left upper lobe is swept down from the apex of the left pleural space. The left upper lobe pulmonary artery is taken as it curves over the left upper lobe bronchus. Notice that on the left side the bronchus is hyparterial, i.e. it is inferior and anterior to the left pulmonary artery. It is easiest to identify the anterior and apical-posterior segmental arteries of the left upper lobe pulmonary artery in the base of the fissure. The lingula branch is then identified. All these branches are then ligated, and the left upper lobe pulmonary artery is ligated proximally.

As mentioned before, it may be possible on the left side to simply ligate the left upper lobe pulmonary artery proximally and distally, since this artery is longer than on the right side. The left superior pulmonary vein is then taken, preferably with a TA vascular stapling device. The left upper lobe bronchus is then taken with the TA-30 4.8 mm stapling device.

Fig 12.9a. Left upper lobectomy. The left upper lobe is retracted inferiorly; pleura is incised between the left pulmonary artery and the left upper lobe. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 661. © WB Saunders Co.

Fig 12.9b. Apical-posterior and anterior branches are taken from this superior approach. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 661. © WB Saunders Co.

Fig 12.9c. Interlobar fissure is developed and lingular arteries taken within the fissure. Reprinted with permission from Surgery of the Chest, 5th ed. Sabiston and Spencer, eds. Lung Infections and Diffuse Interstital Lung Disease, Peter Van Trigt; p. 661. © WB Saunders Co.

Fig. 12.9d. Left superior pulmonary vein taken anteriorly. Reprinted with permission from Surgery of the Chest, Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy; p. 129. ©Mosby-Year Book, Inc.

Fig. 12.9e. Left upper lobe bronchus staple-transected from behind.

Going back to the separation of the arteries, one needs to separately take the anterior, apical-posterior and lingular arteries. The posterior and apical arteries are taken anterosuperiorly outside the fissure; the lingula artery and anterior arteries are taken from the fissure aspect.

Left Lower Lobectomy (Fig. 12.10a-c)

This is similar in nearly all respects to right lower lobectomy. It is done through a 6th intercostal space via a posterolateral thoracotomy. The inferior pulmonary vein is taken at the superiormost aspect of the inferior pulmonary ligament. The left lower lobe pulmonary artery is then taken in the fissure near the takeoff of the lingular artery. The left lower lobe bronchus is then taken by a stapling device being sure to avoid the left upper lobe bronchus which is close to the take-off of the superior segmental bronchus of the lower lobe. Clear definition is important to avoid injury of the left upper lobe bronchus.

Segmentectomy

Although all segments of the right upper lobe may be taken by segmentectomy, this is rarely done because the segmental bronchi are usually short and very difficult to take separately. Therefore, generally segmental right upper lobe resections are not performed. Similarly right middle lobe resections are generally not performed. For the right lower lobe, right superior segmentectomies may be readily performed as may right basilar segmentectomies. On the left side for the left upper lobe, a left apical posterior segmentectomy may be performed; likewise, a left anterior segmentectomy may be performed. A lingular segmentectomy may also

Fig. 12.10. Left lower lobec-tomy. Fig. 11.10a. Left inferior pulmonary ligament mobilized and left inferior pulmonary vein taken. Reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumo-nectomy; p. 131 © Mosby-Year Book, Inc.

Fig. 12.10b. The pulmonary artery is identified in the fissure and the superior segmental and basal branches are taken. Reprinted with permission from Surgery of the Chest, 6th ed. Waldhauser JA, Pierce WS, Campbell DB, eds. Pneumonectomy; p. 131 © Mosby-Year Book, Inc.

Fig. 12.10c. The left lower lobe bronchus is staple transected and the lower lobe removed.
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