Pulmonary resection

The technique of pulmonary resection had dramatically changed from mass ligation of pulmonary hilum to individual ligation of hilar structures and recently to video-assisted thoracoscopic pulmonary resection. However, the safe performance of lung resection requires a perfect knowledge of hilar anatomy and a technique with which the surgeon is familiar.

1. PULMONARY RESECTION
Professor
Abdulsalam Y Taha
School of Medicine
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. Pertinent Anatomy
10/15/142

3. Anatomic resections of the lung (including
pneumonectomy and lobectomy)
are the standard operative techniques employed
to treat both neoplastic and
nonneoplastic diseases of the lung. Any surgeon
who intends to operate on
the pulmonary system must be keenly aware of
the anatomy of the pulmonary
vasculature, the bronchi, and the relation between
the two. There is no
substitute for this degree of familiarity.
10/15/143

4. 10/15/144

5. 10/15/145

6. 10/15/146

7. 10/15/147

8. 10/15/148

9. A broncho-pulmonary segment consists of a tertiary bronchus,
the portion of lung it ventilates, an artery, and a vein.
10/15/149

10. The right side of the mediastinum is the ( blue side)
dominated by the arch of the azygos vein, the SVC,
and the right atrium. 10/15/1410

11. The left side of the mediastinum is the red side,
dominated by the arch and descending portion of the aorta,
the left common carotid and subclavian arteries. 10/15/1411

12. 10/15/1412

13. 10/15/1413

14. 10/15/1414

15. A
HISTORY
Although the five patients operated on by Block (1883),
Kronlein (1884) and Ruggi (1885) died following attempted
partial resection of their tuberculous lungs, Tuffier
successfully resected the apex of the right lung of a 25
years old man in 1891. The use of the individual ligation
technique as proposed by Blades and Kent made
pulmonary resection a safe procedure in general. In 1933,
both Graham and Rienhoff, independently performed
successful pneumonectomy using this technique. The
following decades have been refinements of surgical
techniques and anaesthetic management in the field of
thoracic surgery. The efforts of surgeons of the 1930s and
1940s culminated in the perfection of pulmonary resectional
techniques currently practiced. In Iraq, pulmonary resection
started in the treatment of pulmonary tuberculosis in early
1950s. 10/15/1415

16. Indications:
* Primary and secondary lung malignancies.
* Benign tumours.
* Suppurative diseases(Broncheictasis, lung abscess and
tuberculosis(.
* Parasitic infestation( pulmonary hydatid cyst(.
* Fungal infections( aspergillosis(.
* Pulmonary sequestration.
* Pulmonary arterio-venous fistula.
* Infantile lobar emphysema(ILE(.
* Chest trauma
Any pulmonary procedure can change into pulmonary
resection, therefore every thoracic surgeon should master it.
10/15/1416

17. Types of Pulmonary Resection
*Simple pneumonectomy
*Radical pneumonectomy
*Simple lobectomy
*Radical lobectomy
*Bilobectomy: performed in the right lung,
conserving either the upper or the lower
lobe.(when a tumour extends across a lobar
fissure, or invades bronchus intermedius, or
endobronchial tumour or absent fissure(
*Extended resection: when a lobectomy or
pneumonectomy is combined with enbloc
resection of involved contagious structures.
*Segmentectomy
*Wedge resection
*Palliative resection
*Sleeve lobectomy: when the primary tumour
encroaches upon the lobar orifice,
precluding complete resection with margins
by standard lobectomy.
Radical resection refers to lobectomy or
pneumonectomy combined with enbloc
mediastinal lymphadenectomy.
10/15/1417

18. Thorough preoperative evaluation and
preparation of the patient reduces the morbidity
and mortality of thoracotomy and pulmonary
resection. Pulmonary function tests and analysis
of arterial blood gases help determine the
feasibility of pulmonary resection. Postoperative
pulmonary function is estimated by calculating
the preoperative function and projected
resection of pulmonary parenchyma. Patients
are excluded from surgical therapy if estimated
post-operative pulmonary function falls below
minimum acceptable values.
10/15/1418

19. Anaesthesia
Although pulmonary resections can be performed with
bilateral lung ventilation, careful hilar dissection is
greatly facilitated by using unilateral lung ventilation.
The advent of double-lumen endotracheal tubes and
bronchial blockers has made it possible to isolate the
ipsilateral lung and has made it easier for surgeons to
carry out complex hilar dissections with the required
precision. In patients with centrally located tumors, care
must be taken with tube placement: inadvertent trauma
to an endobronchial tumor during placement of a
double-lumen tube can lead to significant bleeding and
compromise of the airway. Bronchoscopic confirmation
of tube position is recommended after the patient has
been positioned.
10/15/1419

20. INCISIONS
Posterior lateral thoracotomy remains the standard
incision for anatomic pulmonary resections;
however, safe and complete resections can also
be performed through a variety of smaller
incisions, including posterior muscle-sparing,
anterior muscle-sparing, and axillary
thoracotomies. In most cases, the thorax is
entered at the fifth intercostal space, an approach
that affords excellent exposure of the hilar
structures. The anterior muscle-sparing
thoracotomy is generally placed at the fourth
intercostal space because of the more caudal
positioning of the anterior aspects of the ribs.
Although a sternotomy may be employed to gain
access to the upper lobes, it does not provide good
exposure of the lower lobes and the bronchi.
10/15/1420

21. The technique of pulmonary resection had
dramatically changed from mass ligation of
pulmonary hilum to individual ligation of hilar
structures and recently to video-assisted
thoracoscopic pulmonary resection. However,
the safe performance of lung resection
requires a perfect knowledge of hilar anatomy
and a technique with which the surgeon is
familiar.
10/15/1421

22. Traditionally, during a lobectomy, the arterial
branches are divided first, followed by the venous
branches. However, if conditions exist that limit
exposure (e.g., a centrally placed tumor or
significant inflammation and scarring(, the
surgeon should start with the structures that
provide the most accessible targets. Veins may
be ligated first. Proponents of this approach
believe that it may limit the escape of circulating
tumor cells (an event that rarely, if ever, occurs(;
opponents claim that initial vein ligation may lead
to venous congestion and retention of blood that
is subsequently lost with the specimen, though
peribronchial venous channels will frequently
prevent this result.
10/15/1422

23. The bronchus may also be ligated first.
However, there are two points that should
be kept in mind if this is done. First, the
distal limb of the bronchus (the specimen
side( should be oversewn to prevent
drainage of mucus into the chest. Second,
after division of the bronchus, the lobe is
much more mobile; therefore, to prevent
avulsion of the pulmonary artery branches,
care should be taken not to employ
excessive torsion or traction.
10/15/1423

24. The techniques used for dissection, ligation, and
division of pulmonary arteries and their branches
differ from those used for other vessels. Pulmonary
vessels are low-pressure, high-flow, thin-walled,
fragile structures. Accordingly, for rapid and safe
dissection, a perivascular plane, known as the plane
of Leriche, should be sought. This plane may be
absent in the presence of long-standing
granulomatous or tuberculous disease, after major
chemotherapy, after thoracic radiotherapy, and in
cases of reoperation. In these situations, proximal
control of the main pulmonary artery and the two
pulmonary veins may be necessary before the more
peripheral arterial dissection can be started. Before
any pulmonary vessel is divided, it should be
controlled either with two separate suture ligatures
proximal to the line of division or with vascular
staples; stapling devices are especially useful for
larger vessels.
10/15/1424

25. Exposure of the bronchus should not
involve stripping the bronchial surface of its
adventitia. Aggressive dissection may
compromise the vascular supply and lead
to impaired healing and bronchial
dehiscence. Overlying nodal tissues should
be cleared, and major bronchial arteries
should be clipped just proximal to the point
of division. Bronchial closure has been
greatly facilitated by the use of automatic
staplers.
10/15/1425

26. When bronchial length is limited, one
may perform suture closure of the
bronchial stump rather than attempt to
force a stapler around the bonchus.
Whenever there is a high risk of
bronchial stump dehiscence (e.g., after
chemotherapy, radiotherapy, or
chemoradiotherapy; in patients for
whom adjuvant therapy is planned; or
after right pneumonectomy), a
vascularized rotational tissue flap (e.g.,
from the pericardium, the pericardial fat
pad, or intercostal muscle) should be
used to reinforce the bronchial closure.
10/15/1426

27. Shown is the surgeon's view of the
right interlobar fissure. The
fissures have been completed, and
the segmental arteries to the
upper, middle, and lower lobes
have been identified. The posterior
ascending branch to the upper
lobe most commonly varies with
respect to size and origin. This
vessel may be absent or diminutive
and may arise from the superior
segmental branch to the lower
lobe. The posterior segmental vein
draining into the superior
pulmonary vein (not seen) is
clearly visualized in the right upper
lobe, lateral to the pulmonary
artery branches.
Right Upper Lobectomy 10/15/1427

28. Shown is the surgeon's view of
the anterior right hilum. The
apical venous branches of the
superior pulmonary vein
obscure the interlobar
pulmonary artery and, to a
lesser degree, the truncus
anterior branch. Division of
these venous branches during
upper lobectomy improves
exposure of the truncus
anterior. The splitting of the
main pulmonary artery into its
two main branches may occur
more proximally, and care
should be taken to identify both
branches before either one is
divided. Another significant
possible variation is a branch
of the middle-lobe vein that
arises from the intrapericardial
portion of the superior
pulmonary vein.
10/15/1428

29. Shown is the surgeon's view of the
posterior right hilum. The carina, the
right mainstem bronchus, the right upper
lobe, and the bronchus intermedius are
easily seen. The interlobar sump node
has been removed and the fissure
completed, and the posterior ascending
branch of the pulmonary artery is visible.
Care should be taken not to injure this
vessel during division of the fissure. It
can be ligated via this approach if it
cannot be adequately exposed from the
fissure. Both the truncus anterior and the
posterior ascending branch of the
pulmonary artery lie directly anterior to
the right upper-lobe bronchus, and care
should be taken not to injure these
vessels during bronchial encirclement.
The bronchial arteries course along the
medial and lateral edges of the bronchus
intermedius.
10/15/1429

30. Shown is the
surgeon's view
of the right
middle-lobe
bronchus.
Gentle
retraction of
the basilar
segmental
artery to the
lower lobe
posteriorly
allows clear
visualization of
the origin of the
middle-lobe
bronchus.
10/15/1430

31. Shown is the surgeon's view of the right inferior pulmonary vein.
For encirclement of this vein, dissection may also have to be
performed on its anterior surface. The branch to the superior
segment can be seen overlying the origin of the superior
segmental bronchus. 10/15/1431

32. Shown is the surgeon's view of the right fissure after division of the lower-lobe vessels.
The decision whether to divide the bronchi separately or to transect them with a single
oblique application of the stapler depends on the proximity of the middle-lobe bronchus
to the superior segmental and basilar bronchi. 10/15/1432

33. Shown is the surgeon's view of the left interlobar fissure. The recurrent laryngeal nerve can be
seen coursing lateral to the ligamentum arteriosum. The arterial branches supplying the left
upper lobe between the apicoposterior segmental branch and the lingular branch can vary
substantially in number and size. Another frequently encountered variation is a distal lingular
branch that arises from a basilar segmental branch.
10/15/1433

34. Shown is the surgeon's
view of the anterior left
hilum.
The apical branches of
the superior pulmonary
vein
course anterior to the
apicoposterior branches
of the
pulmonary artery. If
additional vessel length
is needed
because of the
presence of a central
tumor, the
pericardium may be
entered and the vein
divided at that location.
10/15/1434

35. Shown is the surgeon's view of the left fissure after division of the upper-lobe arteries.
Care should be taken not to injure the pulmonary artery inadvertently when applying a stapler. 10/15/1435

36. Shown is the surgeon's view of the left inferior pulmonary vein.
The left side, unlike the right side, affords only limited access
to the subcarinal space. However, the length of the inferior
pulmonary vein outside the pericardium is greater on the left
side than on the right.
10/15/1436

37. Shown is the surgeon's view of the left fissure after division of the lower-lobe vessels.
In this procedure, a single oblique transection of the entire left lower-lobe bronchus
can be employed without any concern that a proximal bronchus will be compromised;
this step would not be feasible in a right lower lobectomy, in that the right middle-lobe
bronchus arises from the bronchus intermedius.
10/15/1437

38. Shown is the surgeon's view of the posterior left hilum. The carina is
located deep under the aortic arch. A left-side double-lumen tube or
bronchial blocker may have to be withdrawn to afford better exposure
of the proximal left mainstem bronchus. The orientation of the
superior pulmonary vein and the pulmonary artery (anterior and
superior to the bronchus, respectively) should be noted.
10/15/1438

39. Right pneumonectomy
10/15/1439

40. Left pneumonectomy
10/15/1440

41. Segmentectomy
10/15/1441

42. RUL bronchoplasty
10/15/1442

43. LUL bronchoplasty
10/15/1443

44. LUL sleeve
resection with
bronchoplaty
10/15/1444

45. LMB sleeve
resection with
bronchoplasty
10/15/1445

46. LMB sleeve
resection with
bronchoplasty
10/15/1446

47. LLL bronchoplasty
10/15/1447

48. Pleural flap reinforcement
of bronchial closure
10/15/1448

49. Open bronchus technique
for bronchial closure
10/15/1449