Lobectomy: Thoracoscopic



Lobectomy: Thoracoscopic


Tyler Grenda

Jules Lin





PATIENT HISTORY AND PHYSICAL FINDINGS



  • A detailed history and physical must be performed prior to any treatment including past medical and surgical history, allergies, medications, social, and family history.


  • The patient’s previous history of tobacco use as well as any chemical or asbestos exposures should be determined. Cessation of tobacco use preoperatively should be strongly encouraged for 4 weeks prior to any surgical intervention.


  • The history should include the patient’s current functional status and exercise tolerance.


  • A complete physical examination should be performed with particular attention to auscultation of the heart and lungs and any evidence of cervical or supraclavicular lymphadenopathy or peripheral edema.


  • Routine laboratory studies including a complete blood count and basic chemistry panel should be included as part of the preoperative evaluation.






FIG 1A. Chest x-ray shows a peripheral left upper lobe nodule (arrowhead). B. Chest CT shows a peripheral left upper lobe nodule suspicious for a lung carcinoma (arrowhead). C. Left: This PET scan shows an intensely FDG-avid right upper lobe mass (arrowhead). Right: There is also a moderately FDG-avid right hilar lymph node suspicious for regional metastatic disease (arrowhead).


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Patients typically present with abnormal chest radiograph (FIG 1A) or chest computed tomography (CT) findings. If available, the findings should be compared to previous imaging to determine any interval changes. Lesions that are stable for more than 2 years are generally considered benign. Indeterminate lesions less than 1 cm in size can be followed on serial imaging according to the recommendations of the Fleischner Society.1


  • A chest CT (FIG 1B) should be obtained in all patients with a suspicious lung nodule to evaluate the size and characteristics of the nodule; proximity to the chest wall, vessels, airway, and mediastinum; additional pulmonary lesions; and hilar or mediastinal lymphadenopathy. The CT should include the upper abdomen to evaluate the liver and adrenal glands for metastatic disease.


  • A positron emission tomography (PET) scan (FIG 1C) provides additional information regarding the metabolic activity of the pulmonary nodule and areas of uptake that are suspicious for regional nodal or distant metastatic disease
    and should be obtained in all patients suspected of having a non-small cell lung carcinoma.2 In patients with abnormal findings on fluorodeoxyglucose (FDG)-PET imaging, sampling of the abnormal lymph node should be performed prior to lung resection either by endobronchial ultrasound (EBUS) or mediastinoscopy.


  • For patients with non-small cell lung carcinoma who are surgical candidates, anatomic lobectomy and mediastinal lymph node dissection for complete oncologic resection and staging is recommended.3


  • Due to the low morbidity and mortality after wedge resection, our preference for nodules that are highly suspicious for lung carcinoma based on PET or serial imaging is to perform a VATS wedge resection for a tissue diagnosis. Needle biopsies are performed less often and are reserved for cases where the diagnosis is less clear or for central lesions that would require a lobectomy for diagnosis alone.


SURGICAL MANAGEMENT


Preoperative Planning



  • Preoperative risk assessment determines whether a patient will tolerate pulmonary resection based on pulmonary reserve (pulmonary function tests [PFTs]) and other comorbidities.4 Patients with significant cardiovascular risk factors or symptoms should undergo preoperative cardiac evaluation.


  • Patients with a preoperative forced expiratory volume in 1 second (FEV1) of more than 60% predicted and diffusing capacity of lung for carbon monoxide (Dlco) of more than 50% predicted are candidates for lobectomy. Patients not meeting these criteria should undergo further evaluation with a quantitative ventilation perfusion scan to determine their postoperative predicted pulmonary function with a minimum postoperative value of 40% predicted.


  • Cardiopulmonary exercise testing is occasionally helpful in patients whose symptoms do not correlate with the severity of their pulmonary function results.


  • For patients who will not tolerate an anatomic lobectomy, alternatives include a sublobar resection such as a segmentectomy or wedge resection, stereotactic body radiation therapy (SBRT), radiofrequency ablation (RFA), or definitive chemoradiation. These patients are best discussed in a multidisciplinary setting.


  • Relative contraindications for VATS lobectomy are listed in Table 1.


  • In the preoperative area, the history and physical should be reviewed and consent should be obtained. The operative side should be appropriately marked.


  • Once in the operating room, a flexible bronchoscopy should be performed to verify airway anatomy and rule out any endobronchial lesions.


  • Single-lung ventilation is achieved with a left-sided double lumen endotracheal tube, which is generally preferable to a bronchial blocker.








Table 1: Relative Contraindications to Thoracoscopic Lobectomy

















Complete resection unable to be achieved with a lobectomy (Need for sleeve resection or pneumonectomy)


A central lesion making it difficult to staple the bronchus or pulmonary arterial branches


Chest wall or mediastinal invasion (T3 or T4)


Nodal disease adherent to the vessels


Neoadjuvant chemoradiation


Positive N3 disease


Patient unable to tolerate single-lung ventilation



Positioning



  • The patient should be placed in the lateral decubitus position, tilted slightly posteriorly. The bed is flexed taking care to drop the hips out of the way of the camera port (FIG 2). The arms should be positioned in an arm holder in neutral position. The patient should then be secured and all pressure points padded.


  • Following positioning, the endotracheal tube position should be confirmed again by the anesthesiologist.






FIG 2 • The patient is placed in the lateral decubitus position. It is important to drop the hip out of the way of the camera, which is placed in the most inferior port.



Jul 24, 2016 | Posted by in GENERAL | Comments Off on Lobectomy: Thoracoscopic

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