Operations on Lungs and pleura

OPERATIONS ON THE LUNG

Pneumonectomy

Extrapericardial pneumonectomy is carried out for tumours involving a main bronchus. The whole lung is removed and the resulting cavity will fill with protein-rich fluid and fibrin over a period of weeks. Lateral shift of the mediastinum, upward shift of the diaphragm and reduction of the intercostal spacing on the operated side reduce the size of the cavity. Intrapericardial pneumonectomy is a more radical procedure involving the removal of part of the pericardium. This is required when the tumour growth involves the pericardium.

Operations on Lungs and pleura


Lobectomy

This means removal of a complete lobe with its lobar bronchus. On the right side, two lobes can be removed together – the upper and middle or middle and lower.

Removal of the upper lobe on the right, known as a ‘sleeve resection’ can sometimes include a section of right main bronchus.

Segmental resection

A segment of a lobe along with its segmental artery and bronchus are removed.

Wedge resection

This is a small local resection of lung tissue.

Lung volume-reduction surgery

Lung volume-reduction surgery is a procedure designed to improve respiratory function in patients with severe bullous emphysema. These patients present with hyperinflated lungs and a flattened diaphragm. By excising the bullous tissue and shaping the remaining lung, expansion of the healthy lung and doming of the diaphragm can be achieved. This will result in improved respiratory mechanics and symptomatic relief of dyspnoea (breathlessness). Patients should undergo a period of pulmonary rehabilitation pre-operatively to maximise their respiratory function

Complications of pulmonary surgery

Respiratory

• Sputum retention ± infection

• Atelectasis/lobar collapse

Persistent air leak/pneumothorax

• Bronchopleural fistula (breakdown of the bronchus from which the lung tissue has been resected, more likely to occur following pneumonectomy and generally occurs about 8–10 days after surgery)

• Pleural effusion

• Surgical emphysema

• Respiratory failure

Circulatory

• Haemorrhage

• Cardiac arrhythmia: atrial fibrillation will occur inapproximately 30% of lung resection patients

• Deep vein thrombosis

• Pulmonary embolus

• Myocardial infarction

Wound

• Infection

• Chronic wound pain

• Failure to heal

Neurological

• Stroke

• Recurrent laryngeal nerve (RLN) damage (the RLN supplies the vocal chords and trauma during surgery will impair the patients’ ability to cough)

• Phrenic nerve damage, resulting in paralysis of the hemi-diaphragm

Loss of joint range

• Loss of shoulder range on operated side

• Postural changes

OPERATIONS ON THE PLEURA

Pleurectomy

Recurrent pneumothoraces will require surgical treatment. In young patients this is usually on the second or third occasion. In a small number of patients, bilateral pleurectomy will be required. In the older patient presenting with pneumothorax as a complication of COPD, surgery may be required on the first occasion. The procedure involves removing the parietal layer of pleura from the chest wall in the area adjacent to the lung injury. This leaves a raw area to which the lung becomes adherent and thus unable to ‘collapse’ again. At the same time any bullous lung tissue can be either ligated or excised.

Decortication

Decortication is carried out following chronic empyema.The procedure involves the removal of the thickened, fibrous layer of visceral pleura from the surface of the lung. This allows the lung to re-expand into the space previously occupied by the empyema.

OPERATIONS ON THE OESOPHAGUS

Oesophageal resection

Tumours in the lower third of the oesophagus are resected via a left thoracolaparotomy. The upper third of the stomach is removed and the oesophagus from about 10 cm above the tumour margins. The remaining stomach is passed through the hiatus of the diaphragm into the posterior pleural cavity and a circular anastamosis created between the distal oesophagus and tip of the gastric tube. Tumours in the middle third are more easily dealt with via a right thoracotomy and separate laparotomy. This is known as an Ivor–Lewis procedure. The stomach is passed into the right pleural cavity and the anastamosis constructed above the level of the aortic arch. Tumours of the upper third will require resection of virtually all the oesophagus and the anastamosis will be made via an incision in the neck. The stomach is placed as with the previous procedures.

Repair of oesophageal perforations

Oesophageal perforations are treated surgically by direct repair. The site of the perforation will decide the nature of the operation. Some perforations can be treated conservatively and allow natural healing of the perforation without operative intervention

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