Pneumonectomy, Lobectomy and Segmental Resection

Pneumonectomy, Lobectomy and Segmental Resection CLAIR BASINGER, M.D. * WILLIAM E. ADAMS, M.D., F.A.C.S. **

ONLY a few diseases of the lung are not benefited by some form of resective surgery at the present time. Many advances have been made since the first pneumonectomy by Graham! and the later reports of Rienhofl.2 With the increasing knowledge of pulmonary physiology, progress in anesthesia, development of new antibiotic and chemotherapeutic agents and improvement in operative techniques, lesions may now be removed with decreasing risk to the patient. The mortality of lobectomy with mass ligation of hill'tr structures was 60 per cent in 1918. The incidence of empyema at this time was 60 per cent and bronchopleural fistula occurred in 40 per cent of the patients treated by resection. With the development of individual ligation of the hilar vessels and separate closure of the bronchus begun by Churchill and Belsey3 and elaborated on by Blades and Kent,4 the risk of operation and serious complications was reduced to well under 10 per cent. The safety of the procedure was further enhanced by the advent of chemotherapy and antibiotics, so that in 1955, several series of one hundred or more consecutive cases of lobectomy have been reported in which there has been no mortality. Along with these advances, the thoracic surgeon has been able to conserve more and more normal functioning lung tissue by a better understanding of the pathological processes and their relation to segments of the diseased lobe. The recent work of Chamberlain 5 and Overholt 6 in the field of segmental resection for tuberculosis best exemplifies these advances. In such a manner it becomes possible to extend the benefits of surgery to increasing numbers of patients who formerly could not tolerate large pulmonary resections. It is our purpose to describe some of the techniques of pneumonectomy and lobectomy, as well as From the Department of Surgery of the University of Chicago, Chicago.

* Instructor in Surgery, University of Chicago School of Medicine. ** Professor of Surgery, University of Chicago School of Medicine. 41

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segmental resection, and outline the safeguards and the prevention of complications in these procedures wherever possible. GENERAL PRINCIPLES OF MANAGEMENT

In any form of resective surgery of the lung, it is of the utmost importance to maintain adequate oxygenation, both during the operation and in the postoperative period. It is important to provide frequent reexpansion of the lung during long operative procedures so that adequate oxygenation and ventilation can be accomplished during the actual surgical procedure. Recording oximetry has been extremely useful in providing specific information in regard to the degree of oxygen saturation of the circulating blood during and after the operative procedure. Recent investigations have shown the importance of preventing acidosis during thoracic surgical procedures by better elimination of carbon dioxide through more adequate ventilation. Providing oxygen alone will not prevent the development of acidosis, hence the importance of providing complete ventilation of the lungs at all times cannot be overemphasized. Endotracheal tubes find their greatest use for the surgical patient with lung abscess, severe cavitary pulmonary tuberculosis, or with bronchiectasis in which large amounts of pulmonary secretions are anticipated. In these patients the maintenance of a patent tracheobronchial tree, free of secretions, is of extreme importance so that adequate ventilation can be accomplished. The Overholt prone position has sometimes been found useful in this problem by preventing the flooding of the uninvolved lung during the operation. The maintenance of patent air passages is of importance preoperatively and during the actual surgical procedure as well as in the immediate and late postoperative period. The patient's own defense mechanism of a reflex cough should not be crippled by the overenthusiastic use of narcotics. Support of the chest wall after operation whenever the patient coughs has been found to be of great benefit in aiding in the removal of secretions. The maintenance of a normal circulating blood volume has been a well established surgical practice. It has become more evident in recent years that many of the patients in the old age group as well as those with chronic diseases of the lung, such as tuberculosis or bronchiectasis, have a diminished blood volume. It may be necessary in these cases to give whole blood preoperatively to bring the circulating blood volume up to normal values. Replacement blood transfusions during the surgical procedure have been utilized wherever pulmonary resection has been carried out. In patients undergoing lobectomy as well as segmental resection of the lung, the prompt expansion of the remaining lobes or segments is always important. The use of an anterior catheter to remove air from the apex of the chest and a posterior catheter for the removal of blood

Pneumonectomy, Lobectomy, Segmental Resection products and exudation in the postoperative period has aided re-expansion. These catheters are connected to suction drainage which is mairltained at -25 to -30 cm. of water during the first 24 hours and at -30 to -40 cm. thereafter. This method of catheter-suction drainage of the chest following resective surgery has provided uniformly good re-expansion of the remaining segments or lobes. Antibiotics intramuscularly are utilized for seven to ten days postoperatively. TECHNIQUES

PneUInonectOInY

Pneumonectomy is done primarily for carcinoma of the lung (Fig. 12) and to a much lesser extent for tuberculosis. The approach generally

Fig. 12. A, Intrabronchial Lipiodol demonstrating complete obstruction of left main bronchus. Bronchoscopic biopsy revealed a squamous cell carcinoma. B, Partially obliterated left pleural space 14 days postpneumonectomy.

employed is a posterolateral one in which the fifth or sixth rib is resected sUbperiosteally. Short posterior segments of the rib above or below this one have been frequently removed for a more adequate exposure of the hilar area. Mter the hilum has been exposed (Fig. 13), the phrenic nerve is crushed for immobilization of the diaphragm. Mter mobilization of the lung is accomplished by lysing all adhesions to the chest wall, the pleura overlying the vagus nerve is incised. The posterior pulmonary plexus of the vagus nerve is divided early in the hilar dissection to prevent any reflexes being transmitted that might interfere with heart action. The dissection is now carried out from above downwards, including all adjacent hilar lymph nodes in the dissection. The pulmonary artery is mobilized as well as the superior and inferior pulmonary veins. Each vessel is doubly ligated proximally with a double strand of 00 linen suture material. Mter distal ligatures are placed, the vessels are transected. When only short segments of the vessels are available, a trans-

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Clair Basinger, William E. Adams

fixion suture is added for safety. At times these vessels are ligated or sutured within the pericardial cavity and occasionally only the wall of the auricle remains for closure. Double strand suture material has been found especially useful in ligating large pulmonary vessels. In the older age patients, with varying degree of arteriosclerosis of the pulmonary arteries, cutting through such a diseased vessel during ligation has been a real hazard. This can be minimized by utilizing a double strand ligature since there is less chance of tearing through the wall of the vessel by this technique. The bronchus is now further mobilized and subcarinal lymph nodes are swept into the dissection. A non crushing bronchial clamp is placed

Fig. 13. Hilum of right lung viewed from a posterolateral approach. On the right is shown the segmental bronchi arising from their respective upper, middle and lower lobe bronchus.

l1cross the main-stem bronchus near the carina, and, after transection of the bronchus, a meticulous closure is carried out utilizing 00 or 000 interrupted silk sutures. Generally, the sutures are placed from the posterior musculomembranous portion to the anterior cartilage rings of the bronchus to prevent tearing of the former, thus preventing a leakage of air around the sutures. After the bronchial closure has been accomplished and tested under water for any leaks, the stump is then covered over with any adjacent tissues and pleura wherever possible. One million units of penicillin and 1 gram of dihydrostreptomycin are then instilled into the pleural cavity prior to closure of the chest. Closure of the chest is accomplished by pericostal sutures as well as a'continuous suture for air-tight closure of the resected rib bed. The chest wall muscles are then closed in layers. A needle is inserted into

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the pneumonectomy space and aspiration of air is carried out until a final pressure of -10 to -15 cm. of water has been accomplished. Lobectoll1Y

A lower lobectomy is commonly performed for bronchiectasis, as well as cystic disease, whereas upper lobectomy is more frequently performed for tuberculosis or benign tumors. The approach for lobectomy is either through the seventh rib, which is resected subperiosteally, or the seventh interspace is entered without removing a rib. In either case, short segments of the posterior rib above or below the interspace are resected subperiosteally for more adequate exposure. The dissection of the hilum

Fig. 14. Hilum of the left lung as seen from the posterolateral exposure. On the right is shown the segmental bronchi arising from the left upper and left lower lobe bronchus.

(Fig. 14) is carefully done and in lower lobectomies, as well as right middle lobectomy, the fissures provide the landmark to the hilar dissection. It is wise to follow the avascular plane provided by the fissures in starting the dissection for the vessels. The pulmonary artery and venous branches to the lobe are mobilized and identified. Prior to individual ligation, great care should be exercised in the accurate identification of all vessels to the lobe. Abnormal veins or arteries entering the lobe should be looked for and positively identified before ligating. A noncrushing clamp is then applied to the bronchus as far proximally as will allow an adequate closure of the stump with 0000 interrupted silk sutures. The problem of closing the bronchial stump in a lobectomy is much less than in a pneumonectomy, since the remaining lung tissue helps to cover the stump after expansion of the remaining segments is accomplished. An anterior catheter placed high in the apex

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Clair Basinger, William E. Adams

of the chest as well as a posterior catheter to drain the pleural space of blood components are then placed through separate stab wounds. After the chest bas been closed in the manner described under Pneumonectomy, the pleural space is then aspirated of air and fluid via these catheters, and maintenance of catheter-suction drainage of - 25 to - 30 cm. of water is promptly inaugurated. Segm.ental Resection

This procedure is frequently done for tuberculosis of the upper lobes in which the apical and posterior segments are most often involved (Fig.

Fig. 15. A, Multiple areas of infiltration in right upper lobe poorly delineated by postero-anterior x-ray study. B, Laminogram demonstrating multiple cavities in iapical and posterior right upper lobe. C, Same patient three months after right apico-posterior segmental resection for cavitary pulmonary tuberculosis.

15). Also, tbe superior segment of tbe lower lobe is not infrequently resected for tuberculosis. The lingular segment of the left upper lobe is commonly found to be the site of bronchiectasis along with disease in the lower basilar segments. In each case as much uninvolved and functioning lung tissue is preserved as is possible by segmentectomy. The approach for this operation is generally the same as for lobectomy. After the chest has been entered and the lobes mobilized, the lesion is localized to the appropriate segment. Dissection of the hilum is begun as for lobectomy (Fig. 16). After the pulmonary artery and its brancbes to the lobe have been exposed, accurate identification of branches to all segments is completed and the vessels ligated proximally with 00 linen. The pulmonary veins are handled in a similar fashion. Dissection of the lobar bronchus is next carried out and a non crushing clamp applied. The lung is then re-expanded to outline the remaining segments and

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Pneumonectomy, Lobectomy, Segmental Resection

assure that the bronchial closure will not interfere with expansion of adjacent segments. After the bronchus has been transected between clamps, gentle retrograde dissection is begun. The intersegmental vein lies between segments and is preserved except for small branches which are clamped and ligated. Careful retrograde removal along the intersegmental plane is completed and any evident air leaks are ligated or sutured. It is usually impossible to secure all air leakage following segmentectomy, so large anterior and posterior Pezzer catheters are placed. Following closure of the chest as

~''''''G['-''':J'''TERIOR

ARTERY

POSTERIOR SEGMENTAL BRONCHUS

Fig. 16. Appearance of the left hilum following resection of the apico-posterior segments of the left upper lobe. The apico-posterior bronchi are closed by interrupted sutures.

described above, the chest catheters. are immediately connected to suction drainage maintained at -25 to -30 cm. water pressure for the first 24 hours. By 48 hours the negative pressure is usually increased to -35 to -40 cm. water pressure and maintained at this level while the catheters remain within the chest. COMPLICATIONS AND TREATMENT

The most common complication following pulmonary resection is atelectasis. Although active coughing, deep breathing exercises and drugs to liquefy secretions may have preceded the development of this complication, an even more active sequence of therapy must be promptly undertaken. Oxygen therapy may be necessary temporarily. Tracheal suction by nasopharyngeal catheters, if done early and adequately, will

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Clair Basinger, William E. Adams

relieve the majority of patients with atelectasis. Bedside bronchoscopy may be necessary and will cure all but a few of these patients. Tracheotomy should never be delayed if a patient, with or without atelectasis but with excessive secretions, is unable to cough and produce sputum properly in the postoperative period. Early and effective tracheotomy, especially in patients with lowered pulmonary reserve and in debilitated individuals unable to maintain patent air passages, may be life-saving. Infrequently, coagulation of fibrin and clot formation will occur after lobectomy and segmental resection in spite of catheter drainage of the chest. The judicious use of streptokinase-streptodornase is indicated but only where catheter suction drainage is in place and can be instituted promptly if necessary. The occasional bronchopleural fistula following pneumonectomy remains as one of its most serious complications. The development of this complication usually is accompanied by a reduction in pulmonary reserve and the formation of an empyema. The seriousness of this problem may be further increased by an aspiration pneumonitis from the empyema space via the fistula. Oxygen therapy, adequate chemotherapy locally and systemically, multiple aspirations, closed and open drainage all have their important place in management of this problem. The question of obliterating the space by thoracoplasty in this complication must be individualized. C· In the patient above 50 years of age undergoing pneumonectomy there is often altered pulmonary reserve. At the present time pulmonary function tests are available and their clinical evaluation is significant in planning therapy. Due to the development of a severe pulmonary hypertension in some older individuals and the subsequent right heart strain, pneumonectomy will not be tolerated. For this reason pulmonary artery pressures, before and after occlusion of the vessel, may give valuable information regarding prognosis and planning therapy in these patients. REFERENCES 1. Graham, E. A. and Singer, J. F.: Successful Removal of an Entire Lung for

Carcinoma of the Bronchus. J.A.M.A. 101: 1371-1374, 1933. 2. Rienhoff, W. F., Jr.: Pneumonectomy: A Preliminary Report of the Operative Technique in Two Successful Cases. Bull. Johns Hopkins Hosp. 53: 390393,1933. 3. Churchill, E. D. and Belsey, R.: Segmental Pneumonectomy in Bronchiectasis: the Lingula Segment of the Left Upper Lobe. Ann. Surg. 109: 481-499, 1939. 4. Blades, B. and Kent, E. M.: Individual Ligation Technique for Lower Lobe . Lobectomy. J. Thorac. Surg. 10: 84-98, 1940. 5. Chamberlain, J. M. and Ryan, T. C.: Segmental Resection in Pulmonary Diseases. J. Thorac. Surg. 19: 199, 1950. 6. Overholt, R. H., Woods, F. M. and Ramsay, B. H.: Segmental Pulmonary Resection. Details of Technique and Results. J. Thorac. Surg. 19: 207,1950. 950 E. 59th Street Chicago 37, Illinois