Lobectomy

Lobectomy

1. JAMIA MILLIA ISLAMIA CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES Lobectomy SUBMITTED BY – MD ASIF SUBMITTED TO- Dr. JAMAL ALI MOIZ BPT 4 TH YEAR

2. Introduction Each of your lungs is made up of sections called lobes. . A lobectomy is a type of lung cancer surgery in which one lobe of a lung is removed because it contains malignant tumors. A lobectomy is also occasionally performed for other conditions, such as tuberculosis, severe COPD, or trauma that interrupts major blood vessels near the lungs. A lobectomy is done to remove a diseased or damaged portion of the lung, most often due to lung cancer. Specifically, lobectomy is most commonly performed for non-small cell lung cancers (NSCLC) in which the tumor is confined to a single lobe. This procedure is less invasive and conserves more lung function that a pneumonectomy, a surgery that involves removing an entire lung. In contrast, it is somewhat more extensive than a wedge resection, a surgery that removes the tumor and a small amount of surrounding tissue.

3. Indications Benign conditions  1. Infectious: Any chronic infectious process not controlled with antibiotics therapy can benefit from surgical resection. Tuberculosis is the most common reason for lobectomy worldwide.  Tuberculosis and its sequelae. Although antitubercular antibiotics remain the standard treatment for the patient with tuberculosis, selected patients with localized disease or its complication like a large cavity, localized bronchiectasis can undergo lobectomy after optimal medical therapy. They have high postoperative mortality and morbidity and require close follow up.  2. Non-infectious  Developmental anomaly  Congenital bronchial atresia, pulmonary sequestration, bronchogenic cyst, congenital cystic adenomatous malformation.

4. Bleeding Massive hemoptysis due to aspergilloma, cavity, AV malformation, and bronchiectasis are controllable with lobectomy. Lobectomy in trauma is indicated in hilar vessels or bronchi hilar injuries; the associated mortality is up to 40%. Malignant conditions Lobectomy is the standard surgical approach for stage I-II non–small cell lung cancer.   As lung cancer is most common in the right upper lobe, right upper lobectomy is the most common procedure done for lung cancer. Other less common neoplastic indications include mucoepidermoid tumors, adenoid cystic tumors, and sarcomas. Lobectomy may also be an option in a patient with localized pulmonary metastasis

5. Contraindications The outcome of the procedure is largely dependent on patient selection. Information about the patient's physiological ability to tolerate lobectomy will help to risk-stratify the potential operative candidacy. Patients with forced expiratory volume in 1 second (FEV1) less than 800 cc or diffusion capacity of carbon monoxide (DLCO) less than 40% are considered high-risk patients. These patients are better served with sub-lobar resection or nonoperative therapy. If possible, lobectomy should also be avoided in patients with recent myocardial infarction and severe cardiovascular disease. VATS lobectomy should also be avoided in patients with a tumor larger than 6 cm due to technical challenges.

6. Equipment required Conventional lobectomy procedures, a rib retractor is the mainstay surgical tool. Long instrumental is essential to reach the hilar structures, and vascular instrumental must be at hand due to the risk of major vessel injuries. Lung parenchyma and hilar structures transection could be done by stapler or cut incision with hand-sewn techniques repair. Open Lobectomy The essential equipment for open lobectomy is; rib spreader, scapula retractor, periosteal elevator.  VATS Lobectomy The basic equipment for VATS lobectomy is; video system, 10 mm 30-degree video-thoracoscope, light source power, energy dissection devices (ultrasonic dissector-coagulator or bipolar electrocautery devices), Long curved VATS instruments with double articulation, vascular clips, curved-tipped endoscopic staplers, plastic endobag, wound protectors for the utility port and 10 mm trocars.

7. Conventional Open Lobectomy Posterolateral thoracotomy is the conventional open approach. Its uses have been decreasing over time; however, under complex conditions (both in lung cancer and benign disease), it is preferred. Highlight complex conditions are; Centrally located tumors, tumors >6 cm, endobronchial tumors, thick adhesions due to inflammatory processes, complex congenital lung malformations. The hilum approach and hilum dissection sequence depend on the surgeon's preference (posterior to anterior, anterior to posterior). For hilar division and repair, staplers or hand-sewn techniques are the choices.

8. VATS Lobectomy Currently, the most common minimally invasive techniques are Duke, Copenhagen, and uniportal VATS.  The common ports between these techniques are; Anterior utility port incision, Anterior surgeon's position (patient abdomen), Anterior hilum approach (anterior mediastinum), Anterior to posterior hilum dissection sequence.  The anterior utility port is a 5 cm length incision performed in the fourth or fifth intercostal space between the anterior and middle axillary lines. It is constant in the five types of lobectomy (right superior, right middle, right lower, left superior, left lower lobectomies). Duke approach has two incisions, the utility port, and the camera port; the last is a 5 to 10 mm counter-incision adjacent to the posterior vertex of the utility port incision in the same intercostal space. 

9. The Copenhagen technique is a three portal approach, the anterior utility port incision, the camera port incision 1 cm located at the top of the diaphragm in the axillary anterior line and a 1.5 cm working port incision located at the same level of the camera port straight down the line from the scapula.  Uniportal VATS has only the anterior utility port incision. Initially, VATS lobectomy for lung cancer was indicated for early-stage disease. After gaining experience and skill with VATS, some surgeons pioneered VATS procedures for advanced cases, such as bronchoplasty, vascular sleev resections , and chest wall resection VATS sleeve lobectomy is technically feasible and safe compared with thoracotomy. VATS lobectomy was recommended as an acceptable procedure for the treatment of clinical stage I NSCLC . Intraoperative blood loss, Duration of chest tube drainage, or length of hospital stay, With a significant decrease in the duration of chest drainage, Length of hospital stay, post-thoracotomy pain F aster recovery time and return to work.

10. Hilum Approach, Hilum Dissection Sequence, and Fissure technique Traditional lobectomy techniques describe division of pulmonary parenchyma within the fissures for access to the pulmonary artery. This results in air leaks, which may prolong chest tube drainage and hospitalization times . We describe a technique for lobectomy in which all lung parenchyma is divided using a stapler. The cornerstone of lobectomy is the individual dissection of the vein, arteries, and airway for the lobe. Currently, the most popular is the anterior approach (anterior mediastinum). the dissection sequence is anterior to posterior in a single direction. Fissure less technique is when the division of the pulmonary fissures with direct stapling over the visceral pleura is performed lately in the surgery.  The fissure-last technique is when the fissure is open late in surgery to expose arterial structures. Fissure-first technique(tunnel technique)- the fissure is open first in surgery. It is a consideration when the hilum dissection is complicated, and the vascular and bronchial structures plane dissections are challenging to identify; however, the fissure-less technique has been the recommended approach due to minor risk of postoperative air leak. 

11. The fissureless technique is a useful procedure for the treatment of patients with dense fissures because it reduces the risk of prolonged postoperative air leakage With this technique, it is very important to insert the stapler for division of the bronchus smoothly and safely because injury to the pulmonary artery, behind the bronchus, might cause catastrophic bleeding. We always try to dissect the bronchus enough to ensure smooth stapling. In conclusion, thoracoscopic fissureless left upper lobectomy is safe and feasible, and is a useful technique for  avoiding postoperative air leakage. Procedures of fissure technique Preoperative imaging Detecting dense fissure Dissecting dense fissure The dense fissure was divided using staplers Intraoperative sealing test revealed no air leakage.

12. Clinical Significance Lobectomy surgery effectiveness depends on etiology and the surgical approach (open lobectomy and VATS lobectomy).  VATS has been the preferred approach due mainly to the results in postoperative recovery. However, when VATS is not indicated, open lobectomy is performed to improve patient transoperative safety. VATS lobectomy for infectious focal bronchiectasis or cavities can be performed safely with low rates of mortality (0% to 1%) and morbidity (9% to 23%), the mean length hospital stay is four days, also VATS lobectomy for congenital lung diseases is feasible and effective in selected patients, with a conversion rate is 4%. NCCN (National Comprehensive Cancer Network) recommends VATS lobectomy for lung cancer resection; research has shown VATS lobectomy to have minor complications rates and better long-term survival compared to open thoracotomy lobectomy for NSCLC.

13. Complications Lobectomy complications incidence depends on etiology, patient diagnosis, and resected lobe. Complications after lobectomy usually occur in the early postoperative period (within 48 hours), unlike pneumonectomy, which presents late complications due to the risk of pleural fluid infection.  A National Cancer Database review found that lobectomy mortality is  2.6%, and morbidity is 10% to 50%, mortality and comorbidity risks increases in patients over 75 years old. The main postoperative lobectomy complications are Prolonged air leak (15% to 18%), Subcutaneous emphysema, Pneumonia/mucus plugging/atelectasis (6%), Pleural empyema (1% to 3%), Persistent space (9.5%) atrial fibrillation (33%), Right middle lobe torsion (0.09 to 0.4%), Hemorrhage (2.9%), chylothorax (0.7% to 2%), Phrenic nerve injury and Recurrent laryngeal nerve injury, wound infection, tumor embolization (less than 1%) and very rarely bronchopleural fistula.

14. Reference Video-assisted thoracoscopic surgery lobectomy for non-small cell lung cancer Mingyon Mun1 · Masayuki Nakao1 · Yosuke Matsuura1 · Junji Ichinose1 · Ken Nakagawa1 · Sakae Okumura1 MMCTS Thoracoscopic fissureless left upper lobectomy for the patient with a dense fissure Lobectomy Gerardo Rea; Mohan Rudrappa. Fissureless Lobectomy R. Thomas Temes, MD, Christopher D. Willms, MD, Santiago A. Endara, MD, and Jorge A. Wernly, MD