INDICATIONS/CONTRAINDICATIONS AND PREOPERATIVE PLANNING

Anatomic resection of the lung is indicated both in malignant and nonmalignant diseases of the lung.

The patient who is a candidate for a lung resection should have a sufficient pulmonary reserve to tolerate the planned resection.

The most important determinants of morbidity and mortality in a patient who will undergo a pulmonary resection are functional and physiologic status of the cardiac and respiratory systems. Preoperative assessment of a lung resection candidate, therefore, should include pulmonary, cardiac, cerebrovascular, and nutritional status of the patient.

For a lung cancer patient preoperative staging includes chest computed tomography, positron emission tomography scan, and if indicated endobronchial ultrasound-guided mediastinal lymph node fine needle biopsy or mediastinoscopy.

SURGERY

Anesthesia

The use of double-lumen endotracheal tubes or bronchial blockers has made hilar dissection easier for the surgeons and is the standard of care. Bronchoscopic confirmation of the double-lumen tube during insertion and positioning of the patient is a standard of care procedure.

Positioning of the Patient

The patient is generally placed in the lateral decubitus position. For anterolateral thoracotomy the positioning of the patient is semilateral decubitus position.

During positioning it is important to apply paddings to prevent development of pressure points on the contralateral lower extremity. To prevent injury to contralateral brachial plexus and shoulder girdle an axillary roll should be placed. Another important issue is to stabilize the cervical spine in neutral position to prevent cervical spine complications.

Incision

In many centers posterolateral thoracotomy is the standard incision for most of the pulmonary resections. Muscle-sparing posterior thoracotomy and axillary thoracotomy are the other options for pulmonary resections. The authors use a small anterolateral thoracotomy to perform all of the pulmonary resections as well as lung transplantation. For a right upper lobectomy the thorax is generally entered through the bed of fifth rib.

Technique

Submammary skin incision is performed. For a standard right upper lobectomy the chest cavity is entered through the bed of fifth rib with the transection of the cartilaginous portion of the fifth rib 1 cm lateral to the sternum without injuring the internal mammary artery.

After entering the thoracic cavity, if present, the adhesions between the lung and the chest wall are managed by a blunt dissection with a sponge, scissors, or with cautery depending on the type of adhesions. In case of mediastinal adhesions the phrenic nerve must be identified and protected. After mobilization of the whole lung, inferior pulmonary ligament is transected with cautery up to the level of inferior pulmonary vein. During this dissection, if present, pulmonary ligament lymph nodes are removed for staging if the case is a cancer operation.

The anterior mediastinal pleura is incised around the hilum of the right lung, lateral to phrenic nerve, up to the azygos vein, and down to lower border of the superior pulmonary vein (Fig. 9.1).

A blunt dissection with a sponge can be used to displace azygos vein superiorly to expose the upper portion of the right main bronchus and the origin of the right upper lobe bronchus. Below to the connection point of superior vena cava and azygos vein, there is a lymph node and areolar tissue overlying the pulmonary artery. Right upper lobe has two branches coming from the pulmonary artery; the truncus anterior and posterior ascending arteries. The truncus anterior is the first branch getting of the pulmonary artery and most of the time is a large branch, which bifurcates to two branches. However, it should always be remembered that the pulmonary artery has mostly anatomic variations. The truncus anterior is carefully dissected and encircled with silk (Fig. 9.2). It can be either ligated with suture (0-0 silk) and divided or transected with an endovascular stapler (Fig. 9.3

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