Oxford Textbook of Fundamentals of Surgery

William E. G. Thomas (ed.) et al.

https://doi.org/10.1093/med/9780199665549.001.0001
Published: 2016 Online ISBN: 9780191810817 Print ISBN: 9780199665549

CHAPTER

2.8.2 Pulmonary surgery 

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Sasha Stamenkovic

https://doi.org/10.1093/med/9780199665549.003.0046 Pages 361–366

Published: July 2016

Abstract
Thoracic surgeons manage patients with many conditions other than lung cancer, and the spectrum of
operations is from tracheal resection for post-tracheostomy stenosis to chest wall reconstruction for
cosmetic reasons. There is an increasing use of minimally invasive techniques. Success relies on
careful attention to every detail of the patient’s journey, commencing with history taking and going
through to postoperative care. In this chapter, each of these stages is addressed individually with
discussion on the rationale of treatments, the types of operations performed, preoperative imaging
and work-up, surgical anatomy, operative techniques and pitfalls, and postoperative management and
complications. Video-assisted thoracoscopic techniques can aid the surgeon and also help to minimize
postoperative pain. The importance of systematic lymph node dissection in cancer cases is discussed.

Keywords: segmentectomy, sleeve lobectomy, PET scan, enhanced recovery, systematic lymph node
dissection, video-assisted thoracoscopic surgery
Subject: Surgery, Cardiothoracic Surgery, Urology, Paediatric Surgery, Peri-operative Care, Trauma and
Orthopaedic Surgery, Upper Gastrointestinal Surgery, Colorectal Surgery, Surgical Oncology, Neurosurgery,
Breast Surgery, Transplant Surgery, Vascular Surgery, Surgical Skills
Series: Oxford Textbooks in Surgery
History

Hippocrates is recorded as performing the rst chest drainage for pleural infection. Since then, chest
surgery largely was con ned to operations for parapneumonic infections and war injuries. In the twentieth
century, thoracic surgery continued to evolve as the treatment of tuberculosis (TB), and with parallel
advances in anaesthesia in between the world wars, was in the domain of general surgeons who were
starting to develop a specialist interest in the chest. With the advent of antituberculous drugs, thoracic
surgeons used the inventions of double-lumen intubation and positive-pressure ventilation to manage
patients with lung cancer. The rst pneumonectomy for bronchogenic lung cancer was performed in 1933

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and since then the surgical goal has been complete clearance of cancer with as much lung preservation as
possible. The result is a decrease in pneumonectomies over the last 20 years and the increase of smaller lung
resections.

Thoracic surgeons manage patients with many conditions other than lung cancer, and the spectrum of
operations is from tracheal resection for post-tracheostomy stenosis to chest wall reconstruction for
cosmetic reasons. There is a move, as with many other specialties, to embrace minimally invasive
techniques for more and more thoracic operations and this is even more meaningful for chest surgery, as
these techniques aim to reduce potentially the worst pain a surgeon can cause.

Reasons for resection

Diagnostic operations
Histology is taken to inform the relevant team and to ensure the patient follows the correct therapeutic
pathway. Often this is done after less invasive biopsies and non-diagnostic results.

Treatment operations
Treatment may be undertaken for a number of reasons:

◆ Curative intent: to remove cancer or infection

◆ Debulking: with adjuvant chemotherapy and/or radiotherapy

◆ Damage limitation in the case of trauma

◆ Palliative: for treatment of pain, temperature, and breathlessness

◆ Transplantation.

Chest imaging is necessary for planning. Operations in the chest are performed either with an open or
video-assisted thoracoscopic surgery (VATS) technique. More and more operations are being done by VATS.
Types of resection

◆ Wedge resection: this is removal of the smallest amount of lung including tumour with good clearance

◆ Segmentectomy: anatomical dissection of an anatomical segment of a lobe, separating bronchus,

artery, and vein

◆ Lobectomy: anatomical resection of a whole lobe

◆ Sleeve lobectomy: anatomical resection of whole lobe including a portion of the major airway to the

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lobar bronchus, with anastomosis of the two ends

◆ Pneumonectomy: resection of whole lung.

Imaging

Chest X-ray, computed tomography (CT) chest, CT head, positron emission tomography (PET)-CT,
ventilation/perfusion (V/Q), and magnetic resonance imaging (MRI) scans can all be useful.

Chest X-ray
Chest X-ray is the simplest imaging technique, allowing the distinction of air versus bone and soft tissue
shadows.

◆ Posterior-anterior lm (PA): lm immediately in front of the patient, camera behind. These are taken
in the X-ray department and used for ambulant patients. The scapulae should be out of the way
(raised arms). The lung edges and vascular shadows can be interpreted.

◆ Anterior-posterior lm (AP): lm behind and camera in front. These are used for bed-bound patients.
There is magni cation of the mediastinum, making it di cult to interpret aortic size and
cardiomegaly.

◆ The horizontal ssure is visible on PA or AP lms.

◆ Areas are labelled in zones: upper, mid, and lower. The reason for this is that it is often di cult to
identify which lobe a lesion is in—the apex of lower lobe is actually quite high and the middle
lobe/lingula can touch the diaphragm.

◆ Lateral chest X-ray: the oblique and horizontal ssures, the relative heights of the hemi-diaphragms,
and the actual lobes can be seen. It is, therefore, possible to determine which lobe a lesion sits in. This
modality has been largely superseded by other more modern imaging techniques.

CT chest scan
CT chest scans give a lot more information than chest X-rays.

Axial views are commonest, with ‘slices’ made through the body. Other options include CT chest/abdomen,
high-resolution CT, and CT pulmonary angiogram (CTPA) Mediastinal windows show contrast in vascular
structures against grey areas of non-contrast (e.g. lymph nodes (LNs)). Lung windows show which lobe the
abnormality is in and show disease (e.g. bullous emphysema or brosis).
CT head
This is performed to stage cancer.

Some metastases may be asymptomatic. Symptomatic patients with negative CT head should have an MRI
head scan.

Positron emission tomography (PET and PET-CT fusion scanning)

These are performed if radical cancer treatment (surgery or radical radiotherapy) is planned. The

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superimposition of CT onto the PET scan gives functional information.

In PET scans, glucose isomer is taken up by metabolizing tissue, resulting in hot spots.

The amount of ‘heat’ is graded and given in a systemic uptake value (SUV). The higher the SUV, the more
likely the lesion is to be cancerous, but exceptions exist (e.g. slowly growing tumours, abscesses, and
granulomata). In LNs, a higher SUV is likely to be malignant, with the same exceptions.

Ventilation/perfusion scan
This used to be the gold standard to diagnose pulmonary embolism, but now CTPA is used instead. V/Q scans
are performed to aid understanding of the lung function. Most scans are Q scans—how much blood
(perfusion) to which part of the lungs—which helps the surgeon to determine if the patient will manage
with one lung de ated. These scans also help to determine if lung resection possible.

Nuclear magnetic resonance imaging

This is used to examine soft tissues, often at the peripheries of the chest, for example, a mass close to
vertebrae (MRI to show relation with spinal cord) or a lesion at apex of chest (MRI to show brachial plexus
involvement).

Preoperative work-up

This should include the following:

◆ Stage—imaging gives clinical stage of lung cancers (cTNM):

• T de nes tumour size and xity; N shows type of lymph node involvement; M, metastasis.

◆ Fitness—assessed by lung function testing:

• Forced expiratory volume in 1 second:

• Gives idea of postoperative ability to cough

• Used to predict postoperative breathlessness

• Total lung carbon monoxide transfer—more accurate to assess risk of resection

• 6-minute walk test—assesses level of deconditioning and desaturation

• Arterial blood gases on air, pO2/pCO2

 • Cardiopulmonary exercise test—test VO2 max and anaerobic threshold

◆ Resectability: is the mass attached to vital structures—T4 does not mean irresectable

◆ Preassessment clinic (PAC): to allow anaesthetist review of patient.

Enhanced recovery

Enhanced recovery relies on the following components:

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◆ PAC is done before admission, permitting assessment of risk, further investigations, optimization of
chronic illnesses (diabetes), cessation of drugs (antiplatelets/anticoagulants), planning for di cult
airway, epidural, etc.

◆ Physiotherapy exercise information is given

◆ A planned day of surgery admission (DOSA) is arranged

◆ Carbohydrate loading is organized

◆ Nil-by-mouth/intravenous uid management is organized.

Anaesthetic room preparation

Preparation includes the following steps:

◆ Premedication is not routine, especially if DOSA

◆ Operating department professional accepts patient and prepares equipment

◆ World Health Organization surgical safety checklist

◆ Preoxygenation, rigid bronchoscopy is often performed.

◆ Intubation—double-lumen tube or single tube with bronchial blocker. The desired e ect is to de ate
the operated side and ventilate the non-operated side

◆ Arterial/central venous lines, bispectral index (cerebral monitoring), urinary catheter

◆ Positioning—commonly lateral position, rubber wedges are used to prevent pressure area damage. A
break in in the table maximizes rib separation, and therefore minimizes pain from operation

◆ Intercostal block, paravertebral or epidural catheter

◆ Application of diathermy plate and body warming.

Theatre preparation

This should include the following:

◆ Lighting, suction, and diathermy connection

◆ Imaging on display
 ◆ Exposure—depends on whether emergency or elective. Emergency operations may be for salvage, in
which case optimal positioning may not be possible. To minimize di culty with the operation and
complications to the patient, positioning the patient correctly is vital. For thoracic surgery, this needs
a degree of imagination as there are several axes of view into the chest (chest X-ray, CT,
bronchoscopic, transcervical, anterior/posterior VATS, robotic).

Surgical anatomy

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A review of current imaging will show the height of the diaphragm, enabling the correct incision to be made
into the chest.

Choosing the correct rib space and making the incision in the correct obliquity will allow an easier
operation. Upper lobectomies require a ‘hockey-stick’ incision to permit access to the upper hilum. Lower
lobectomies can be achieved through a more horizontal incision.

Anterior rib spaces are wider than posterior ones and therefore in a VATS operation, the anterior space is
used as the utility port to remove lobes.

Apical tumours may be approached by an incision that runs more posteriorly and cranially.

VATS operations also require careful planning, as all operating will have to be performed through ports, and
no rib spreading will be possible to gain more exposure.

The oblique and horizontal ssures are key anatomical landmarks to nd to make identi cation of di erent
lobes of the lung possible.

The anatomy of the lung hila follows a pattern. The anatomy of the pulmonary veins is mostly constant,
whereas that of the pulmonary artery branches is variable. The inferior vein and the vagus nerve are at the
posterior hilum and the superior veins and phrenic nerve are at the anterior hilum, on both sides. On the
right, cranial to the inferior vein, is the intermediate bronchus, then continuing in a clockwise direction is
the right main bronchus with the azygous vein arching around it, then the truncus branch of the pulmonary
artery overlapped by the upper lobe vein at the anterior hilum, and the middle lobe vein most inferiorly. On
the left, cranial to the inferior vein, is the left main bronchus, then continuing in a anti-clockwise direction
is the left pulmonary artery with the aorta arching around it, and at the anterior hilum is the upper lobe vein
and at the lingular vein.

There is a condensation of pleura attaching lung to diaphragm, known as the inferior pulmonary ligament,
which when stripped cranially reveals a LN (number 9) and then the inferior vein, and so is often the
starting point of any pulmonary surgery. Stripping this after an upper lobectomy also allows the lower lobe
to ascend in the chest during re-in ation. The heads of the ribs are visible posteriorly and the sympathetic
trunk can be seen descending on each of these. The internal thoracic artery is seen anteriorly on the chest
wall just lateral to the edge of the sternum. Apically the pulsation of the subclavian artery is visible which
helps to delineate the outline of the rst rib.

Open versus video-assisted thoracoscopic surgery

Open operations allow a hands-on and hands-in approach. Tactile feedback permits knowledge of how
thin/thick tissues are, nger-and-thumb circumnavigation around structures, easy retraction of lobes, and
arguably quicker dissection as a result.
However, open operations necessarily mean signi cant rib spreading, which can result in worse and longer-
standing neuropraxic injury, due to compression of the intercostal nerve. They can only a ord the view
under the incision, and shadows can be cast even with the use of a head-light. It takes longer to open and
close an incision from an open operation.

VATS operations can give a 360°, magni ed, high de nition well-illuminated view of the chest internally.
There is no rib spreading, so this minimizes the possibility of neuropraxic injury. It is quick to open and
close port incisions. An operation started as VATS (video-assisted thoracoscopic assessment) allows the
nding of surprise features that have not been seen on prior imaging, preventing unnecessary and
potentially damaging exploratory thoracotomies (open-close), for example, pleural metastases or tumour

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too close to the hilum for permitted resection. VATS allow planning of subsequent thoracotomy in cases of
chest wall resection.

VATS operations reduce the amount of tactile feedback in that only a nger can be placed into the chest.
Small nodules and those more centrally in a lobe are therefore more di cult to nd by VATS. No nger-
and-thumb circumnavigation is possible.

VATS instruments are longer as they are used through the fulcrum of the ports, so there is more movement
of the distal end relative to the proximal end—this means more judicious smaller movements are required
by the operator’s hand. The points of the instruments are needed to be more thought about if not always
on-screen, as the potential for collateral damage to other structures is always present. Similarly all metallic
conducting surfaces of instruments with diathermy attached have to be kept in full view to prevent
inadvertent touching of surrounding tissues.

The precise and delicate nature of VATS operations acts as a challenge to some surgeons and a reward to
others, and this probably explains why the majority of thoracic surgeons worldwide perform open
operations. This will probably change in the near future due to more home-TV gaming, better technology,
and the possible increase in the use of robotic surgery.

Operating kit and strategy

To gain entry into the chest, rib resection is sometimes necessary. After this, a retractor cranks open the ribs
to allow a large thoracotomy. Duval forceps hold onto the lung, a ‘ sh-slice’ lung retractor holds back lung,
and a swab-on-a-stick holds back other structures. ‘Peanut’ dissection is done with the use of pledgets
(mini-swabs) if tissue planes are thin whereas the use of diathermy and scissors is necessary for brous
tissues. To go around structures before taping, tying, or stapling, a right-angle Leahy, O'Shaughnessy, or
Sem forceps is used. If the plan is anatomical resection of the lung, it is usual to start with hilar dissection
and it is advisable to dissect the more proximal tissues rst to allow ‘proximal control’ before turning
attention to ssural dissection. There is no di erence in strategy for VATS operations.

A whole industry of stapling devices is available to the thoracic surgeon. In open operations, linear staplers
with staples either side and a sliding knife are used to divide ssures. Artery and vein branches, if large
enough, can be divided with right-angle staplers. These come with staples on one side and require the other
side to be tied o before using a knife to divide. The alternative is to double ligate and cut in-between. VATS
operations are carried out using laparoscopic devices. The VATS stapling is done with staples either side
with a sliding knife between. Stapler articulation is designed to make placement easier. Energy sources such
as ultrasound and heat can also be used in both open and VATS operations.
Transplantation

Most lung transplant operations involve removal of a whole lung and anastomosis of a donor lung in its
place. However, lobar lung transplantation allows an adult lobe to replace a small adult/child lung.

Single- or double-lung transplantation can be performed on or o cardiopulmonary bypass, depending on

the patient’s saturations and blood pressure, and also the degree of di culty.

Worldwide, the majority of lung transplantations are for emphysema, but in the United Kingdom, there is a
large population of patients with cystic brosis and pulmonary brosis. Rarely, this is also performed for

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primary pulmonary hypertension.

Reasons for di iculty and helpful hints

The commonest reason for a di cult operation is poor preparation. Careful review of the individual
patient’s investigations and imaging is imperative. The imaging will often show signs of adhesions, or a
raised hemidiaphragm, and so it is helpful in the planning of the correct rib space.

Prior medical/surgical and occupational history might predict a lung being stuck. Pleurisy/empyema or
previous rib fractures may cause adhesions of the lung to the chest wall including diaphragm. A previous
operation means the possible use of another rib space to enter the chest. Miners and stonemasons have
exposure to mineral dusts that can lead to adhesions and very brotic tissue planes around LNs. Asbestos
exposure can lead to asbestos plaques, which may also cause signi cant adhesions.

In particularly adherent lungs, a posteriorly placed nasogastric tube can help delineate the plane between
lung and oesophagus, thus limiting the chance of viscus perforation. Similarly, a breoptic bronchoscope
can be used to shine down a bronchus to allow easier dissection around it.

Non-surgical issues that a ect a successful operation

Tube position is critical to allow a fully de ated lung, but patients’ airways di er in width and length and
sometimes a double-lumen tube just does not t as it should. A lot of e ort goes into placing and checking
the position of the tube in the anaesthetic room, but it may still not be perfect, and the turning of the patient
and manipulation of the lung may potentially change the tube position.

Tube herniation can occur. There are two cu s to a double-lumen tube. One is in the tracheal tube, the other
in the distal bronchial tube. The bronchial cu can herniate to occlude the end of that lumen, resulting in
poor ventilation of the contralateral lung, and desaturation as a result.

Pulmonary hypertension can result in right ventricle strain during one-lung-ventilation. This shows in
electrocardiogram changes and also a drop in blood pressure. Some anaesthetists use pulmonary
vasodilators such as nitric oxide to facilitate a safe operation. Pulmonary hypertension also can cause more
bleeding of suture/staple lines.

A factor out of the anaesthetist’s control is shunting, that is, good perfusion of a lung that is de ated,
resulting in signi cant desaturation. This often happens in t patients with good lung function tests, and
there is no predictability. It means that one-lung ventilation is not possible and the operation has to be
performed with the lung in ated most of the time. The anaesthetist will check the tube position and ensure
there is no herniation of the tube cu reducing ventilation of the contralateral lung, as this also causes
signi cant desaturation.

Systematic lymph node dissection

In cancer cases, systematic nodal dissection (SND) is imperative. Up to the operation, the clinical stage is
decided by imaging and biopsies. At operation, the surgeon has the ability to check this stage by looking for
metastases in the chest that were not evident before. Once this is ruled out and a successful lung resection

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has been performed, attention is given to the LNs. A knowledge of drainage patterns is needed to understand
why SND is so important.

There is a standard LN map accepted by all lung cancer doctors. Cancer drains from a lobe of a lung into
intralobar then interlobar LNs. After this they may drain into hilar LNs and then on into mediastinal LNs.
Dissecting all LNs will give an accurate staging and, therefore, the patient will have the correct adjuvant
treatments and the correct prognosis.

All LNs are therefore collected and labelled separately. At VATS operations, it is easier to see LNs as they are
magni ed, and SND is standard practice. In operations where the diagnosis is not known, it is wise to
include SND. Similarly, even in patients where anatomical lung resection is not possible due to tness or
other issues, SND is important to do—these patients may not get adjuvant treatments but the prognosis
would be clearer.

When LNs are matted or stuck onto structures, it might imply that there is extranodal spread. This might
mean a more proximal dissection is required if the patient is su ciently t. Calci ed LNs implies long-
standing presence and often the cause is old TB.

Haemostasis

There is no substitute for careful dissection, as this will minimize the amount of haemostatic manoeuvres
required.

If the patient is particularly hypertensive during opening, there will need to be time spent to carefully stop
bleeding from subcutaneous and muscle layers. It may be possible for the anaesthetist to lower the blood
pressure temporarily. Prolene™ 3/0 is often kept on standby for the scrub nurse to give to the surgeon. This
is in case staples have failed or a suture tie has fallen o .

Unipolar diathermy is used to incise tissues and to stop bleeding from a pedicle of tissue. It can be applied to
appropriate VATS dissectors also. Solid haemostatic agents with a cellulose polymer are used to pack spaces
where there is a low-pressure focal ooze, and syringed or sprayed haemostatic sealants can be used for
more di use areas.

If a lobectomy is performed, a certain amount of tamponade can be achieved by the lung re-in ating at the
end of the procedure. If a pneumonectomy has been performed, it is imperative to ensure that there is no
bleeding at all as there is no tamponade e ect of the lung. If a rib resection has been performed, then bone-
wax can be used to seal the ends and if a rib fracture has occurred during retraction of the thoracotomy,
careful closure is required.
Irrigation

This follows a logical process. All irrigation should be with warm solutions to avoid any bradyarrhythmias.
If the operation is for cancer, surgeons prefer to use water to act as an osmotic killer of any residual cancer
cells. In mesothelioma surgery, some surgeons go one step further, using hyperthermic solutions or
chemotherapy irrigations. If the operation is for infection, surgeons will use saline or dilute concentrations
of povidone-iodine or tauroline.

After any resection, it is appropriate to test suture/staple lines with positive pressure up to 30 cm water,

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particularly if there is a bronchial stump, as this allows any repair to be performed immediately, and
prevents the unnecessary complication of other-lung contamination.

Drains

After lung resection, other than pneumonectomy, the purpose of draining the hemithorax is to allow lung
re-expansion, as well as monitoring pleural uid/blood loss, and air leak.

There is much written about two versus one drain post resection.

After pneumonectomy, the drain is there to monitor blood loss. It is clamped for the majority of the hour,
and unclamped for the last 5 minutes to see how much blood drains. It also acts as a portal for injecting air
into the pneumonectomy space if there is gross mediastinal shift.

Surgical analgesia

A paravertebral catheter (PVC) does not involve the epidural space and, therefore, has no hypotensive
e ects. It may better be termed an extrapleural catheter, as it perfuses this space with regional local
anaesthetic to bathe the intercostal nerves. If placed correctly and working well, this o ers good analgesia
to patients’ thoracic and drain wounds. If an extrapleural dissection has been necessary to remove lung or
tumour from the chest wall, there is less chance of a PVC working well and alternatives have to be
considered (e.g. epidural).

Phrenic nerve block involves a small volume injection of periphrenic tissue and may reduce the amount of
referred pain from drains. Intercostal nerve blocks involve an injection of 5 mL of local anaesthetic into the
intercostal bundle in the groove of the rib, as much as two rib spaces above and two below the incision,
taking care to aspirate to avoid intravascular injection.

Closure

The most important part of closure is to communicate with the scrub nurse to ensure that all instruments,
needles, and swabs are accounted for. The break in the table is taken down to facilitate rib approximation.
All layers are individually sutured with speci c-sized needles to ensure strength of closure. Extra local
anaesthetic is sometimes placed into the wounds and drain sites at the end.
Complications

Complications include the following:

◆ Air leak: the commonest complication (up to 25%)

◆ Infection: chest greater than urinary greater than wound risk

◆ Atrial arrhythmias: more common if pericardium dissected

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◆ Acute coronary syndrome: due to latent coronary artery disease

◆ Stroke

◆ Venous thromboembolism: vital to check prophylaxis is being given

◆ Bronchopleural stula: di erent to air leak, as that is parenchymal lung leak

◆ Lobar torsion: commonest is middle lobe after upper lobectomy.

Further reading
British Thoracic Society, Society for Cardiothoracic Surgery in Great Britain and Ireland Lung Cancer Guideline Group. Guidelines
on the radical management of lung cancer. Thorax 2010; 65 Suppl III:iii1–iii27.
WorldCat Web of Science

De Wever W, Ceyssens S, Mortelmans L, et al. Additional value of PET-CT in the staging of lung cancer: comparison with CT alone,
PET alone and visual correlation of PET and CT. Eur Radiol 2007; 17:23–32. 10.1007/s00330-006-0284-4
Google Scholar WorldCat Crossref PubMed Web of Science

Goldstraw P, Ball D, Jett JR, et al. Non-small cell lung cancer: Lancet 2011; 378:1727–40. 10.1016/S0140-6736(10)62101-0
Google Scholar WorldCat Crossref PubMed Web of Science

Kim AW, Johnson KM, Detterbeck FC. The lung cancer stage page: there when you need it—staginglungcancer.org. Chest 2012;
141:581–6. 10.1378/chest.11-3192
Google Scholar WorldCat Crossref PubMed Web of Science

Varela G, Jiménez MF, Novoa N, et al. Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy. Eur J
Cardiothorac Surg 2005; 27:329–33. 10.1016/j.ejcts.2004.11.005
Google Scholar WorldCat Crossref PubMed

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