Lobectomy



Lobectomy


Phillip C. Camp Jr.

M. Victoria Gerken



Pulmonary lobectomies are most commonly performed for carcinoma. Resection of a more limited amount of pulmonary tissue allows preservation of the maximum amount of lung function. Even more limited segmental and subsegmental resections are possible and are described in the references at the end. Many of these procedures are now performed using video-assisted thoracoscopy, as described in references at the end.

SCORE™, the Surgical Council on Resident Education, classified partial pulmonary resection, open, as a “COMPLEX” procedure.

STEPS IN PROCEDURE



  • Single-lung ventilation, lateral decubitus position, posterolateral thoracotomy

Right Upper Lobectomy



  • Retract lung inferiorly and posteriorly


  • Incise pleura around the hilum


  • Identify superior pulmonary vein and dissect distally, preserving middle lobe vein


  • Isolate pulmonary artery and similarly dissect


  • Retract lung anteriorly and incise pleura overlying bifurcation of upper lobe bronchus and bronchus intermedius


  • Divide superior arterial trunk, followed by superior pulmonary vein


  • Divide the distal pulmonary artery and complete the division of the fissure, if necessary


  • Retract lung anteriorly and divide branches of vagus nerve to upper lobe


  • Divide bronchus with linear stapler, 4.8 cartridge


  • Finally, divide the posterior ascending pulmonary artery branch


  • Divide any remaining attachments


  • Incise inferior pulmonary ligaments to allow remaining lung to move cephalad


  • Check hemostasis and check for air leaks


  • Close thoracotomy incision with chest tubes

Right Middle Lobectomy



  • Initiate dissection at confluence of major and minor fissures


  • Identify middle lobe branch of pulmonary artery and divide it


  • Retract lung posteriorly and divide mediastinal pleura


  • Dissect and divide branches of superior pulmonary vein draining middle lobe


  • Place stapler across bronchus and close it


  • Before firing, confirm that basal segments of remaining lung still inflate


  • Divide bronchus


  • Proceed with closure as noted above

Right Lower Lobectomy



  • Start the dissection at the confluence of fissures


  • Identify pulmonary artery


  • Open the pleura over the interlobular artery


  • Mobilize the pulmonary artery


  • Ligate and divide the superior and then the basilar segmental branches separately


  • Divide inferior pulmonary ligament and incise pleura over the inferior pulmonary vein and bronchus intermedius


  • Mobilize and divide inferior pulmonary vein at pericardial reflection


  • Open posterior mediastinal pleura and divide bronchus


  • If necessary, complete fissure with stapler

Left Upper Lobectomy



  • Retract lung inferiorly, open pleura over superior hilum


  • Expose left main pulmonary artery and obtain proximal control


  • Incise pleura over medial aspect of the superior pulmonary vein


  • Complete the fissure if necessary


  • Dissect and divide branches of the pulmonary artery, followed by pulmonary vein


  • Divide the bronchus


  • Divide inferior pulmonary ligament to allow the remaining lung to fill the pleural space

Left Lower Lobectomy



  • Retract lung anteriorly and incise pleura from bronchus to level of inferior pulmonary ligament



  • Divide inferior pulmonary ligament to level of inferior pulmonary vein


  • Complete fissure if necessary


  • Dissect pulmonary artery and ligate branches to lower lobe


  • Similarly divide branches of pulmonary vein


  • Apply stapler across bronchus, check remaining lung for inflation


  • Fire stapler

HALLMARK ANATOMIC COMPLICATIONS



  • Bronchial stump leak


  • Injury to pulmonary artery or vein


  • Impingement on adjacent bronchus during bronchial division, resulting in segment of lung that is not aerated

LIST OF STRUCTURES

Right Main Pulmonary Artery



  • Superior branch


  • Posterior segmental artery

Right Superior Pulmonary Vein



  • Branches to anterior and apical segments


  • Posterior segmental vein


  • Right inferior pulmonary vein


  • Right upper lobe bronchus

Intermediate Bronchus



  • Middle lobe bronchus


  • Right lower lobe bronchus


  • Major fissure


  • Minor fissure


  • Middle lobe


  • Inferior pulmonary ligament

Left Pulmonary Artery



  • Arteries to the apicoposterior segment


  • Anterior segmental artery


  • Lingular artery


  • Branch to the superior segment of the lower lobe


  • Basilar segmental artery


  • Left inferior pulmonary vein

Left Superior Pulmonary Vein



  • Apicoposterior segmental vein


  • Lingular segmental veins


  • Anterior basal segmental vein

Left Lower Lobe Bronchus



  • Left upper lobe bronchus


Orientation (Fig. 29.1)

For orientation purposes, the branches of the right and left pulmonary artery are shown in Figure 29.1. The lobar anatomy of the lungs and corresponding bronchi are shown in Figure 29.2.


Right Upper Lobectomy


Ligation of the Pulmonary Arteries (Fig. 29.2)


Technical Points

Secure the left endobronchial double-lumen tube, allowing single-lung ventilation for the duration of the resection. Place the patient in the left lateral decubitus position and make a right posterolateral thoracotomy. A muscle-sparing thoracotomy is a feasible alternative, but should never be allowed to hinder the resection.

Retract the lung inferiorly and posteriorly and divide the pleura around the hilum.

Identify the superior pulmonary vein and dissect along it distally up to the lung parenchyma. Mobilize around the vessel in the appropriate plane. Identify and preserve the middle lobe vein, which typically enters the superior pulmonary vein. Be alert to aberrant venous drainage, including occasional direct connections to the vena cava.

The pulmonary artery lies just posterior and superior to the vein (Fig. 29.1A). Gently develop the appropriate plane, and dissect proximally and distally. The pulmonary artery is an extremely delicate and unforgiving vessel. Great care and attention to detail will aid in successful mobilization. Mobilize the pulmonary artery circumferentially and place an umbilical tape loosely around it to provide proximal control should bleeding occur.

Distal dissection will identify the truncus anterior (apicoanterior) branch. Dissection should be circumferential and should avoid spreading of surrounding tissue. Gently passing a blunt curved clamp can help define planes. Never pass the clamp against resistance. “Peanut” dissection is often useful for better defining the anatomy after you are in the correct plane. Free the pulmonary artery from the upper lobe branches and any attachments to the azygos vein.

Retract the lung anteriorly and incise the pleura overlying the bifurcation of the upper lobe bronchus and bronchus intermedius. Careful use of electrocautery will control small bronchial vessels in this area. Reliably, a lymph node is located at this point and is swept anteriorly. Anterior to the lymph node is the superior segment branch of the pulmonary artery to the lower lobe, which is much better seen from this aspect than by the anterior approach. After you have identified this branch, any intact portion of the posterior aspect of the major fissure can be completed (divided) with staplers. This posterior approach to the superior segment branch greatly improves the anatomic division and is rather efficient (Fig. 29.1B).

Divide the apical segmental vein, crossing the anterior segmental artery, either with vascular staples or with suture ligatures.







Figure 29.1 A: Branches of the right pulmonary artery. B: Branches of the left pulmonary artery.

Mobilize and divide the superior arterial trunk with a vascular stapler or suture ligature. Ligate apical and segmental branches.


Anatomic Points

Remember that the azygos vein arches from posterior to anterior immediately superior to the root of the right lung, and that, at least conceptually, the plane of the major pulmonary veins is anterior to that of the arteries. The right pulmonary artery, at the point where it leaves the pericardial sac, is anterior and somewhat inferior to the right mainstem bronchus. It enters the minor fissure and passes inferolaterally anterior to the upper lobe bronchus. Slightly before it enters the minor fissure, it gives off a superior branch from its superior aspect, which can supply all three segments of the upper lobe. Frequently; however, the superior trunk supplies only the apical and anterior segments, whereas the posterior segment is supplied by an ascending artery that branches off the superior aspect of the main pulmonary artery, somewhat distal to the superior branch.

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Sep 14, 2016 | Posted by in GENERAL SURGERY | Comments Off on Lobectomy

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