- Email: [email protected]
Right upper lobectomy
Right Upper Lobectomy
Edward W. Humphrey, MD, Minneapolis, Minnesota
The description
that
follows
depicts
a right
upper
lobe&my performed for a carcinoma of the lung. On occasion, a carcinoma involving the right upper lobe bronchus cannot be completely removed by this operation because of spread or potential spread to the main bronchus. An adequate tumor-free margin can often be obtained by resecting the main bronchus from the carina to the takeoff of the bronchus to the middle lobe or to the superior segment of the lower lobe. The bronchus intermedius is then anastomosed to the carina. Most lobectomies performed for cancer of the lung cause no difficult technical problems. Those performed for an inflammatory condition, however, may because the planes of dissection are obliterated and the vessel walls softened. The pulmonary arteries may tear more easily than the adhesions to the surrounding lung tissue. A lobectomy performed in a patient with numerous calcified lymph nodes in the
hilnra “I nf thn lnmo v-1 P~II uw” slan y’““““” nrnannt UILLI”~“I”“, AiffL,~ltina *IYuu “IIU ‘uL’6
hnm,vxa U”UUuu”
a ligature placed on a branch of the pulmonary artery near a calcified node may tear the artery rather than occlude it. The two most frequently encountered complications after a right upper lobe&my are prolonged air leak from the remaining lung tissue and persistant space in the apex of the right thorax. Neither of these complications alone is particularly troublesome but if the two occur together, the space may become infected, the air leak may fail to close, and an empyema may develop. An intrathoracic space associated with a persistent air leak should never be left undrained, and if it continues, a thoracoplasty may become necessary. I do not perform a so-called tailoring thoracoplasty at the time of the original lobectomy because it interferes significantly with the patient’s ability to cough. Of all decisions made before andkduring a lobecCo-.. :,,...,,+ 2111u ,...A c”llaequallLIy _,.-_ ^_..^ -c,.. +L.--^C L,“UlJ,tL.-. UIC:-,\nC IU”JCIIIe*ac;L, bllt: I,,“SL difficult is the determination of whether or not the From the Department of Surgery, University of Minnesota and the Veterans Administration Medical Center, Minneapolis, Minnesota. Reauasts for reDrints should be addressed to Edward W. Humohrav. MD. Minn&polis Vetarkns Administration Medical Center, 54th Skeet anb’48th Avenue, South, Minneapolis, Minnesota 55417.
patient’s pulmonary function is adequate to prevent his becoming a pulmonary cripple from the lobectomy. The dry weight of the right upper lobe is approximately 19 percent of the total dry weight of the lung. The percentage of the total vital capacity represented by the right upper lobe depends however, on the amount of disease in that lobe. In addition to the decrease in vital capacity from the upper lobectomy, the surgeon must also expect the function of the remaining right lung to decrease by 50 percent for 3 to 4 weeks following thoracotomy. As a rule of thumb, if the 1 second forced expiratory volume is less than 700 ml after surgery, the patient’s cough will be ineffective and the risk unacceptable. Technique The patient is placed in a lateral thoracotomy position, the incision begins at the anterior axillary line and follows the course of the fifth rib, then curves around the angle of the scapula and extends superiorly for 5 cm at a distance half way between the posterior border of the scapula and the spinous processes. The fifth rib is resected subperiosteally or the rib is left intact and the chest is entered through the bed of the rib after the periosteum has been separated from its deep surface. Before placing a Finochietto rib spreader in the incision, the intercostal nerve is divided at the posterior angle of the incision in an attempt to prevent the post-thoracotomy syndrome. This syndrome, which is postulated to occur because of traction on a posterior root of a spinai nerve by the rib spreader, may result in incisional pain lasting for years after the thoracotomy. After the rib spreader is inserted, the lung is very carefully palpated bimanually. The mediastinum is then explored for enlarged lymph nodes or other abnormalities, especially below the carina and between the trachea and superior vena cava. The right lobe of the liver may also be palpated for metastasis through the diaphragm. If a lesion suggesting a metastasis is felt, the diaphragm may be nnpnpd and thn lminn hinnaid A LII”I”” mAat IuyuL”u”“‘J lonc.tntc.ma nonb ,” ..__ u.... IL... L..“I”.. “‘..y”.“U. z1 p,clti&% IS placed on the lung, and the lung is retracted posteriorly. This exposes the view of the hilus and the mediastinum (Figure 1). It is often necessary to spend considerable time dividing adhesions between the parietal and visceral pleura before a dissection of the hilus can be started. Before the chest is closed, it is usually necessary to free the lung from the chest wall completely to permit it to rise in the chest,
Right Upper Lobectomy
pkt-kwrve F&ne1.lRo&ttdyDshdkatestt~anterkrpntknotthe&#it hul#the1mimt&expused.
and it is easiest to do this immediately. The one exception occurs when an upper lobectomy is performed in a patient with Pancoasts’ syndrome. In this situation, the area of adherence between the tumor and the chest wall should be left undisturbed until after the hilar structures have been divided. The dotted line in Figure 1 indicates that portion of the hilus to be exposed by the dissection. If bleeding occurs near the phrenic nerve, the bleeding vessel should be clamped and ligated rather than cauterized so as to minimize the risk of damage to the nerve. The pleura over the anterior portion of the pulmonary hilts is divided between the phrenic nerve and the lung, beginning at the inferior margin of the superior pulmonary vein and extending superiorly between the axygos vein and the bronchus. The dissection then progresses down the posterior aspect of the hilus past the takeoff of the upper lobe bronchus. Using mostly blunt dissection, the anterior structures of the hilus are exposed. First, the anterior trunk of the right pulmonary artery is isolated. It lies immediately anterior to the upper lobe bronchus and may be partially covered by the apical vein from the right upper lobe. In Figure 2, a ligature has been passed around this trunk proximal to its bifurcation. All branches of the pulmonary artery are ligated proximally and distally with 2-O Tevdek sutures and a proximal 3-O suture ligature, as shown in the insets of Figure 2. Great care must be taken in handling and isolating branches of the pulmonary artery, for these vessels have very little tensile strength. A crushing clamp should never be placed on a pulmonary artery, nor should the dissection around a pulmonary artery ever be carried out by spreading tissues with a forceps or scissors. Often, calcified lymph nodes in the hilus will be firmly attached to these vessels. Any attempt to spread the tissue of the hilus may cause the pulmonary artery to tear before the adhesions that bind the lymph node to the vessel. For the same reason, the proximal ligature on a branch of the pulmonary artery should be placed far enough from the main pulmonary artery to prevent the branch from being partially avulsed by the ligature. With the anterior trunk of the pulmonary artery ligated and divided, the upper lobe division of the superior pul-
vohmu 148, Novotlau 1884
F&fm 2. An antutor v&w d th# structure on the supukr p& dthar&#th&m7hollgdunbaroumitt~entukrtn1r&.lh~ thwiJudB(bot&m)&6traWthmm#hntkrðIg8ndtMslQ bmnchus d tha putmonaly a/Wry.
monary vein is isolated. In Figure 2, the venous tributary from the posterior segment is hidden behind the rest of the upper lobe division. This division usually consists of three tributaries. One running superficially on the mediastinal surface of the lung (the apical vein is shown encircled by a ligature in Figure 3); one running deep behind the bronchus, the posterior vein; and a third, the anterior vein, running between the middle lobe and the upper lobe. If the tumor is in cloee proximity to the junction of these veins, the superior division may be taken as a whole, but great care must be taken in passing a forceps behind the whole superior division, for often the posterior vein joins the other two tributaries posterior and close to the junction of the upper lobe vein with the middle lobe vein, and the posterior vein may be torn by such a maneuver. The veins should not, as a rule, be divided before dividing the anterior trunk, because the lobe becomes so congested that it is difficult to retract. If possible, these tributaries of the upper lobe vein should be ligated and divided separately because as in the operation illustrated in Figure 4,15 to 20 percent of patients have either an an-
675
Humphrey
[email protected],theantwkwtnmkdtheasceMtg of the pdnonary mtery,aa well 8s the apkal, poet&, andant~~alvebuhavebeen~td. Theantertoruh drahut hto one of the middle bbe velns.
branch
[email protected]~fwu~-slhr~at&wai~~~ hinn the mt#te lok. l7m two 8tapte Ihes and the bdertobar pottton of ttw prlmonaty artery are am.
terior vein draining into one of the middle lobe veins or one of the middle lobe veins draining into an upper lobe vein. If, in these patients, the upper lobe vein is ligated at its junction with the principal middle lobe vein, the postoperative chest radiograph will show diffuse haziness of the middle lobe. This is not due to torsion of the lobe as often mentioned, but rather to interruption of venous drainage. To prevent this, the dissection should be continued far enough along the anterior vein to determine what con-
676
F&m95. m TA@ostapbrf8bebtguwdtocbwthellddd+akk SW of the mtmw ftssure belon, d&h.
nections to the middle lobe may exist. As shown in Figure 4, if a connection is found, the tributary to the upper lobe is ligated beyond the junction with a middle lobe vein. After the pulmonary vein tributaries from the upper lobe have been divided, the interlobar portion of the pulmonary artery should be exposed until the ascending artery to the upper lobe is encountered. With a finger lying over the interlobar portion of the artery, it is possible to dissect down on one’s finger at the junction between the major and minor fissures of the right lung. The ascending artery is then completely exposed and can be safely ligated and divided. In Figure 4, the ligated stump of the ascending artery may be seen distal to the stump of the anterior trunk. A risk of avulsing or cutting the ascending branch exists when an attempt is made to dissect blindly down into the fissure before the interlobar portion of the pulmonary artery has been isolated. In approximately 25 percent of patients, more than one ascending artery will be found. On occasion, the ascending artery may take origin from the artery to the superior segment of the lower lobe. Care should be taken during the dissection of the fissure not to overlook these occurrences. More often than not, the middle lobe is partially or completely fused to the upper lobe. The area of fusion must be divided before the upper lobe can be removed. In previous years, this division was accomplished by dissecting along the interlobar portion of the pulmonary vein. Such a dissection is time-consuming and may result in significant air leaks. The separation is now performed, as shown in Figure 5, by placing two rows of staples at the junction between the middle and upper lobes with either the CIA stapler or, as shown in the figure, with the TA 96 stapler with 4.8 mm staples. Care must be taken to protect the middle lobe vessels during this action. The lung tissue between the two rows of staples is then divided. The exposure after division of the upper from the middle lobe is depicted in Figure 6. The entire interlobar portion of the pulmonary artery is exposed, and the lymph nodes superior to this artery are freed from the pulmonary artery and kept with the upper lobe bronchus. The hilus of the middle lobe should be dissected as little as possible, be-
ThaAmukanJoumalol6wguy
Right Upper Lobectomy
i
middle lobe
‘\
F@e #. llm 1.4 30 staphr betng used to chasetha bronchusto ttb U~hde.
cause this pedicle is very narrow and may twist in the postoperative period. The upper lobe ie retracted anteriorly and the posterior portion of the hilts is exposed. The bronchus to the upper lobe is freed from its surrounding tissues, and this posterior area of dissection is connected to the interlobar area of the dissection by freeing the region of the bronchus intermedius immediately below the takeoff of the upper lobe bronchus. There is usually a lymph node in the angle between the upper lobe bronchus and the bronchus intermedius, which may be calcified and firmly adherent to the bronchus. Since, in most patients, the superior segment of the lower lobe is partially fused to the upper lobe, it is necessary to complete the fiiure between these two regions in the same manner that the upper lobe was separated from the middle lobe. The artery to the superior segment of the lower lobe lies immediately inferior to the plane of division and should be visualized before placing the staples. Figure 7 is an anterior view of the hilua after the middle and lower lobes have been separated from the upper lobe and the veins and arteries to the upper lobe have been divided. Figure 8 shows the anatomy of the bronchus to the right
votumo148, Novombol1QM
upper lobe with the upper lobe retracted anteriorly. The axygos vein may be seen crossing the right side of the trachea. In patients with chronic lung disease, a large bronchial artery often runs over the posterior aspect of the upper lobe bronchus. This artery should be separately ligated and divided before dividing the bronchus. The TA 30 stapler with 3.5 staples is used to close the bronchus to the upper lobe as shown in Figure 9. The staple line should be at a right angle to the upper lobe bronchus so that no areas with poor blood supply are left. Bronchopleural fistula has not resulted from the use of staple closure of the bronchus over the last 15 years, which is a major improvement over suture closure. After the staple line has been placed, a Sarot bronchus clamp is placed distal to the staples, the bronchus is divided, and the lobe removed. Warm saline solution is poured into the chest cavity to cover the stump of the right
677
Humphrey
upper lobe bronchus, and the anesthesiologist is requested to apply an airway pressure of 20 cm of water to the endotracheal tube to aid in detecting any air leaks from the bronchial stump. If the closure is airtight, a flap of pleura from the posterior mediastinum is freed and sutured over the cut end of the right upper lobe bronchus as shown in Figure 10. If, during the lobectomy, it is necessary to remove a large area of mediastinal pleura, a flap of pericardium posterior to the phrenic nerve may also be used for covering the bronchial stump. This covering is thought to enhance the healing of the bronchial stump. If not previously performed, the pulmonary ligament is divided to permit the lower and middle lobes to rise in the thoracic cavity and so decrease the likelihood of an apical air space. Care must be taken not to injure the inferior pulmonary vein, which forms the superior margin of this ligament. There are small troublesome vessels in the pulmonary ligament that may be the source of considerable postoperative bleeding if they are not cauterized or ligated.
670
I have never found it necessary to crush the phrenic nerve to obliterate the intrathoracic space. This maneuver markedly interferes with the patient’s ability to cough in the postoperative period and very frequently leads to atelectasis. Three intercostal chest catheters are inserted into the chest. One is placed at the base of the lung, one runs posterior to the hilus up to the apex of the chest, and one is placed anterior to the hilus approximately two thirds of the distance to the apex of the chest. Because the principal function of these tubes is to evacuate air, not blood, cutting extra holes in the catheters is unnecessary. Patients with chronic obstructive lung disease have fragile lungs that may be eroded by catheters. If such erosion occurs, it is very helpful to advance the catheters slowly over a period of days to permit the parietal and visceral pleura to adhere and so obliterate the tube track. If there are holes over a great length of the catheter, its advancement is greatly limited.
Edward W. Humphrey, MD, Minneapolis, Minnesota
The description
that
follows
depicts
a right
upper
lobe&my performed for a carcinoma of the lung. On occasion, a carcinoma involving the right upper lobe bronchus cannot be completely removed by this operation because of spread or potential spread to the main bronchus. An adequate tumor-free margin can often be obtained by resecting the main bronchus from the carina to the takeoff of the bronchus to the middle lobe or to the superior segment of the lower lobe. The bronchus intermedius is then anastomosed to the carina. Most lobectomies performed for cancer of the lung cause no difficult technical problems. Those performed for an inflammatory condition, however, may because the planes of dissection are obliterated and the vessel walls softened. The pulmonary arteries may tear more easily than the adhesions to the surrounding lung tissue. A lobectomy performed in a patient with numerous calcified lymph nodes in the
hilnra “I nf thn lnmo v-1 P~II uw” slan y’““““” nrnannt UILLI”~“I”“, AiffL,~ltina *IYuu “IIU ‘uL’6
hnm,vxa U”UUuu”
a ligature placed on a branch of the pulmonary artery near a calcified node may tear the artery rather than occlude it. The two most frequently encountered complications after a right upper lobe&my are prolonged air leak from the remaining lung tissue and persistant space in the apex of the right thorax. Neither of these complications alone is particularly troublesome but if the two occur together, the space may become infected, the air leak may fail to close, and an empyema may develop. An intrathoracic space associated with a persistent air leak should never be left undrained, and if it continues, a thoracoplasty may become necessary. I do not perform a so-called tailoring thoracoplasty at the time of the original lobectomy because it interferes significantly with the patient’s ability to cough. Of all decisions made before andkduring a lobecCo-.. :,,...,,+ 2111u ,...A c”llaequallLIy _,.-_ ^_..^ -c,.. +L.--^C L,“UlJ,tL.-. UIC:-,\nC IU”JCIIIe*ac;L, bllt: I,,“SL difficult is the determination of whether or not the From the Department of Surgery, University of Minnesota and the Veterans Administration Medical Center, Minneapolis, Minnesota. Reauasts for reDrints should be addressed to Edward W. Humohrav. MD. Minn&polis Vetarkns Administration Medical Center, 54th Skeet anb’48th Avenue, South, Minneapolis, Minnesota 55417.
patient’s pulmonary function is adequate to prevent his becoming a pulmonary cripple from the lobectomy. The dry weight of the right upper lobe is approximately 19 percent of the total dry weight of the lung. The percentage of the total vital capacity represented by the right upper lobe depends however, on the amount of disease in that lobe. In addition to the decrease in vital capacity from the upper lobectomy, the surgeon must also expect the function of the remaining right lung to decrease by 50 percent for 3 to 4 weeks following thoracotomy. As a rule of thumb, if the 1 second forced expiratory volume is less than 700 ml after surgery, the patient’s cough will be ineffective and the risk unacceptable. Technique The patient is placed in a lateral thoracotomy position, the incision begins at the anterior axillary line and follows the course of the fifth rib, then curves around the angle of the scapula and extends superiorly for 5 cm at a distance half way between the posterior border of the scapula and the spinous processes. The fifth rib is resected subperiosteally or the rib is left intact and the chest is entered through the bed of the rib after the periosteum has been separated from its deep surface. Before placing a Finochietto rib spreader in the incision, the intercostal nerve is divided at the posterior angle of the incision in an attempt to prevent the post-thoracotomy syndrome. This syndrome, which is postulated to occur because of traction on a posterior root of a spinai nerve by the rib spreader, may result in incisional pain lasting for years after the thoracotomy. After the rib spreader is inserted, the lung is very carefully palpated bimanually. The mediastinum is then explored for enlarged lymph nodes or other abnormalities, especially below the carina and between the trachea and superior vena cava. The right lobe of the liver may also be palpated for metastasis through the diaphragm. If a lesion suggesting a metastasis is felt, the diaphragm may be nnpnpd and thn lminn hinnaid A LII”I”” mAat IuyuL”u”“‘J lonc.tntc.ma nonb ,” ..__ u.... IL... L..“I”.. “‘..y”.“U. z1 p,clti&% IS placed on the lung, and the lung is retracted posteriorly. This exposes the view of the hilus and the mediastinum (Figure 1). It is often necessary to spend considerable time dividing adhesions between the parietal and visceral pleura before a dissection of the hilus can be started. Before the chest is closed, it is usually necessary to free the lung from the chest wall completely to permit it to rise in the chest,
Right Upper Lobectomy
pkt-kwrve F&ne1.lRo&ttdyDshdkatestt~anterkrpntknotthe&#it hul#the1mimt&expused.
and it is easiest to do this immediately. The one exception occurs when an upper lobectomy is performed in a patient with Pancoasts’ syndrome. In this situation, the area of adherence between the tumor and the chest wall should be left undisturbed until after the hilar structures have been divided. The dotted line in Figure 1 indicates that portion of the hilus to be exposed by the dissection. If bleeding occurs near the phrenic nerve, the bleeding vessel should be clamped and ligated rather than cauterized so as to minimize the risk of damage to the nerve. The pleura over the anterior portion of the pulmonary hilts is divided between the phrenic nerve and the lung, beginning at the inferior margin of the superior pulmonary vein and extending superiorly between the axygos vein and the bronchus. The dissection then progresses down the posterior aspect of the hilus past the takeoff of the upper lobe bronchus. Using mostly blunt dissection, the anterior structures of the hilus are exposed. First, the anterior trunk of the right pulmonary artery is isolated. It lies immediately anterior to the upper lobe bronchus and may be partially covered by the apical vein from the right upper lobe. In Figure 2, a ligature has been passed around this trunk proximal to its bifurcation. All branches of the pulmonary artery are ligated proximally and distally with 2-O Tevdek sutures and a proximal 3-O suture ligature, as shown in the insets of Figure 2. Great care must be taken in handling and isolating branches of the pulmonary artery, for these vessels have very little tensile strength. A crushing clamp should never be placed on a pulmonary artery, nor should the dissection around a pulmonary artery ever be carried out by spreading tissues with a forceps or scissors. Often, calcified lymph nodes in the hilus will be firmly attached to these vessels. Any attempt to spread the tissue of the hilus may cause the pulmonary artery to tear before the adhesions that bind the lymph node to the vessel. For the same reason, the proximal ligature on a branch of the pulmonary artery should be placed far enough from the main pulmonary artery to prevent the branch from being partially avulsed by the ligature. With the anterior trunk of the pulmonary artery ligated and divided, the upper lobe division of the superior pul-
vohmu 148, Novotlau 1884
F&fm 2. An antutor v&w d th# structure on the supukr p& dthar&#th&m7hollgdunbaroumitt~entukrtn1r&.lh~ thwiJudB(bot&m)&6traWthmm#hntkrðIg8ndtMslQ bmnchus d tha putmonaly a/Wry.
monary vein is isolated. In Figure 2, the venous tributary from the posterior segment is hidden behind the rest of the upper lobe division. This division usually consists of three tributaries. One running superficially on the mediastinal surface of the lung (the apical vein is shown encircled by a ligature in Figure 3); one running deep behind the bronchus, the posterior vein; and a third, the anterior vein, running between the middle lobe and the upper lobe. If the tumor is in cloee proximity to the junction of these veins, the superior division may be taken as a whole, but great care must be taken in passing a forceps behind the whole superior division, for often the posterior vein joins the other two tributaries posterior and close to the junction of the upper lobe vein with the middle lobe vein, and the posterior vein may be torn by such a maneuver. The veins should not, as a rule, be divided before dividing the anterior trunk, because the lobe becomes so congested that it is difficult to retract. If possible, these tributaries of the upper lobe vein should be ligated and divided separately because as in the operation illustrated in Figure 4,15 to 20 percent of patients have either an an-
675
Humphrey
[email protected],theantwkwtnmkdtheasceMtg of the pdnonary mtery,aa well 8s the apkal, poet&, andant~~alvebuhavebeen~td. Theantertoruh drahut hto one of the middle bbe velns.
branch
[email protected]~fwu~-slhr~at&wai~~~ hinn the mt#te lok. l7m two 8tapte Ihes and the bdertobar pottton of ttw prlmonaty artery are am.
terior vein draining into one of the middle lobe veins or one of the middle lobe veins draining into an upper lobe vein. If, in these patients, the upper lobe vein is ligated at its junction with the principal middle lobe vein, the postoperative chest radiograph will show diffuse haziness of the middle lobe. This is not due to torsion of the lobe as often mentioned, but rather to interruption of venous drainage. To prevent this, the dissection should be continued far enough along the anterior vein to determine what con-
676
F&m95. m TA@ostapbrf8bebtguwdtocbwthellddd+akk SW of the mtmw ftssure belon, d&h.
nections to the middle lobe may exist. As shown in Figure 4, if a connection is found, the tributary to the upper lobe is ligated beyond the junction with a middle lobe vein. After the pulmonary vein tributaries from the upper lobe have been divided, the interlobar portion of the pulmonary artery should be exposed until the ascending artery to the upper lobe is encountered. With a finger lying over the interlobar portion of the artery, it is possible to dissect down on one’s finger at the junction between the major and minor fissures of the right lung. The ascending artery is then completely exposed and can be safely ligated and divided. In Figure 4, the ligated stump of the ascending artery may be seen distal to the stump of the anterior trunk. A risk of avulsing or cutting the ascending branch exists when an attempt is made to dissect blindly down into the fissure before the interlobar portion of the pulmonary artery has been isolated. In approximately 25 percent of patients, more than one ascending artery will be found. On occasion, the ascending artery may take origin from the artery to the superior segment of the lower lobe. Care should be taken during the dissection of the fissure not to overlook these occurrences. More often than not, the middle lobe is partially or completely fused to the upper lobe. The area of fusion must be divided before the upper lobe can be removed. In previous years, this division was accomplished by dissecting along the interlobar portion of the pulmonary vein. Such a dissection is time-consuming and may result in significant air leaks. The separation is now performed, as shown in Figure 5, by placing two rows of staples at the junction between the middle and upper lobes with either the CIA stapler or, as shown in the figure, with the TA 96 stapler with 4.8 mm staples. Care must be taken to protect the middle lobe vessels during this action. The lung tissue between the two rows of staples is then divided. The exposure after division of the upper from the middle lobe is depicted in Figure 6. The entire interlobar portion of the pulmonary artery is exposed, and the lymph nodes superior to this artery are freed from the pulmonary artery and kept with the upper lobe bronchus. The hilus of the middle lobe should be dissected as little as possible, be-
ThaAmukanJoumalol6wguy
Right Upper Lobectomy
i
middle lobe
‘\
F@e #. llm 1.4 30 staphr betng used to chasetha bronchusto ttb U~hde.
cause this pedicle is very narrow and may twist in the postoperative period. The upper lobe ie retracted anteriorly and the posterior portion of the hilts is exposed. The bronchus to the upper lobe is freed from its surrounding tissues, and this posterior area of dissection is connected to the interlobar area of the dissection by freeing the region of the bronchus intermedius immediately below the takeoff of the upper lobe bronchus. There is usually a lymph node in the angle between the upper lobe bronchus and the bronchus intermedius, which may be calcified and firmly adherent to the bronchus. Since, in most patients, the superior segment of the lower lobe is partially fused to the upper lobe, it is necessary to complete the fiiure between these two regions in the same manner that the upper lobe was separated from the middle lobe. The artery to the superior segment of the lower lobe lies immediately inferior to the plane of division and should be visualized before placing the staples. Figure 7 is an anterior view of the hilua after the middle and lower lobes have been separated from the upper lobe and the veins and arteries to the upper lobe have been divided. Figure 8 shows the anatomy of the bronchus to the right
votumo148, Novombol1QM
upper lobe with the upper lobe retracted anteriorly. The axygos vein may be seen crossing the right side of the trachea. In patients with chronic lung disease, a large bronchial artery often runs over the posterior aspect of the upper lobe bronchus. This artery should be separately ligated and divided before dividing the bronchus. The TA 30 stapler with 3.5 staples is used to close the bronchus to the upper lobe as shown in Figure 9. The staple line should be at a right angle to the upper lobe bronchus so that no areas with poor blood supply are left. Bronchopleural fistula has not resulted from the use of staple closure of the bronchus over the last 15 years, which is a major improvement over suture closure. After the staple line has been placed, a Sarot bronchus clamp is placed distal to the staples, the bronchus is divided, and the lobe removed. Warm saline solution is poured into the chest cavity to cover the stump of the right
677
Humphrey
upper lobe bronchus, and the anesthesiologist is requested to apply an airway pressure of 20 cm of water to the endotracheal tube to aid in detecting any air leaks from the bronchial stump. If the closure is airtight, a flap of pleura from the posterior mediastinum is freed and sutured over the cut end of the right upper lobe bronchus as shown in Figure 10. If, during the lobectomy, it is necessary to remove a large area of mediastinal pleura, a flap of pericardium posterior to the phrenic nerve may also be used for covering the bronchial stump. This covering is thought to enhance the healing of the bronchial stump. If not previously performed, the pulmonary ligament is divided to permit the lower and middle lobes to rise in the thoracic cavity and so decrease the likelihood of an apical air space. Care must be taken not to injure the inferior pulmonary vein, which forms the superior margin of this ligament. There are small troublesome vessels in the pulmonary ligament that may be the source of considerable postoperative bleeding if they are not cauterized or ligated.
670
I have never found it necessary to crush the phrenic nerve to obliterate the intrathoracic space. This maneuver markedly interferes with the patient’s ability to cough in the postoperative period and very frequently leads to atelectasis. Three intercostal chest catheters are inserted into the chest. One is placed at the base of the lung, one runs posterior to the hilus up to the apex of the chest, and one is placed anterior to the hilus approximately two thirds of the distance to the apex of the chest. Because the principal function of these tubes is to evacuate air, not blood, cutting extra holes in the catheters is unnecessary. Patients with chronic obstructive lung disease have fragile lungs that may be eroded by catheters. If such erosion occurs, it is very helpful to advance the catheters slowly over a period of days to permit the parietal and visceral pleura to adhere and so obliterate the tube track. If there are holes over a great length of the catheter, its advancement is greatly limited.