The ability to select patients appropriately, perform a competent pulmonary lobectomy, and manage patients safely in the postoperative interval epitomizes the skills of a good general thoracic surgeon, more than any other aspect of the job. Lung cancer patients comprise a majority of general thoracic surgical patients, and lobectomy, particularly the extended versions (i.e., sleeve lobectomy and lung and chest wall resection), constitutes most of a general thoracic surgeon’s work. In no other endeavor does a thoracic surgeon have more impact on his or her patients.

However, the frequency with which an operation is performed often does not mean that it is well performed. A recent evaluation of the National Cancer Database revealed that many or most lobectomies in the United States were done without checking surgical margins or performing mediastinal lymph node dissections despite extensive evidence that these actions are important for long-term survival after cancer resections.¹

The reason for this lack of uniformity is not entirely clear but it is probably that many surgeons, both general and cardiac, regard general thoracic surgery as a secondary rather than primary occupation.² Whatever the reasons, appropriate performance of this common but potentially dangerous operation is important for our patients.

Lobectomies can be done in many different ways, but the sites of danger usually remain the same. In fact, a surgeon may choose an unusual approach because it lessens the chance of problems for a particular patient compared with the standard approach.

Staging

Preresection staging should be done for all patients undergoing lung resection. At this time, a complete history and physical examination focusing on involvement of lymph nodes and liver masses, followed by chest CT scan and PET scan, are appropriate. The latter evaluation will rule out distant metastases other than brain metastases. Patients without symptoms of headache are unlikely to have brain metastases, and therefore, head CT scan or MRI is not obligatory.

All patients with lung cancer may have mediastinal metastases. Although PET scans are quite sensitive for identifying mediastinal metastases, they remain less accurate than mediastinoscopy (see Chapter 70). Preoperative mediastinoscopy is indicated for all patients with a PET scan-positive mediastinum and should be considered for certain patients with a PET scan-negative mediastinum (i.e., those with enlarged nodes on CT scan or with hilar lesions). Although the PET scan remains useful for ruling out distant metastases, it should not be the only study performed to evaluate the mediastinum. Many patients have been denied resection because their PET scan was positive in the mediastinum, only to find a more knowledgeable physician who, on mediastinoscopy, diagnosed mediastinal granulomatous disease instead and then successfully resected the patient’s stage I cancer (Table 71-1).

Thoracoscopic examination and staging of the pleural space benefit patients undergoing lung resection³: Thoracoscopy may identify pleural metastases. Thoracoscopy can be used to determine a suitable incision for resection. Thoracoscopy is not indicated for all patients undergoing routine resection of an apparent stage I cancer but can be used to evaluate small pleural effusions or large cancers believed to be unresectable as a consequence of mediastinal invasion (Table 71-2).

Cardiopulmonary Evaluation (or Minimizing Preoperative Risk)

Immediate perioperative mortality (i.e., death within 2–5 days) is very rare after a lung resection. Most deaths occur within the first week. Postoperative mortality in lung resection patients results mostly from respiratory complications. Predicting perioperative mortality in lung resections relies on identifying those patients who

• 
  

  might have a perioperative complication and

  
  
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  might not survive it

Our literature has dealt with this problem primarily by focusing on preoperative lung function or predicted postoperative lung function as a means of identifying patients who would not survive a respiratory complication (Table 71-3).

Right Upper Lobectomy

Viewed from the patient’s side, the anatomy of the right hilum is a triangle with the pulmonary artery (PA) at the apex, the vein anterior, and the bronchus posterior (Fig. 71-1A). The azygos vein caps the triangle. It is often adhesed to the bronchus, the artery, or both and can be divided as a first step to gain proximal control of the PA and to perform the paratracheal lymphadenectomy.

Harvesting the mediastinal nodes is an important part of the procedure and can give more proximal exposure to the PA and bronchus, if needed, and is a good first step. The nodes are resected by dividing the azygos vein and harvesting the nodal packet (typically 3 × 1.5 × 1.5 cm) and by, in turn, dividing the mediastinal pleura posterior to the superior vena cava and anterior to the trachea. The nodes extend inferiorly to the PA and superiorly all the way to the subclavian artery at the thoracic inlet (Fig. 71-1B). However, overly aggressive manipulation in this area can lead to right true vocal cord paralysis. Consequently, the dissection should stop well inferior of the subclavian artery (Table 71-4).

Although many ascribe importance to the order of division of the hilar structures, there are no studies to confirm either a technologic or an oncologic benefit to a particular sequence. In any case, a small benefit would be superseded by a surgical mishap. Consequently, many do what is most appropriate for the particular patient (usually this means whichever is easiest). My preference is to divide the PA first, then the vein, then the bronchus, and finally the parenchyma, unless the artery is covered by the vein, in which case the vein, then artery, then bronchus are divided in that order. In both cases, the parenchyma is divided last to prevent air leaks.

The hilum is first approached by dividing the parietal pleura around the hilum, being careful to avoid the phrenic nerve, which should be swept medially. If the superior vein covers the PA anteriorly, the vein is approached and the middle lobe vein identified and preserved (Fig. 71-2). The vein then may be divided with a stapling device or with ligatures and suture ligatures proximally and distally. Pulmonary vessels should be controlled with two sutures proximally (e.g., either two ties or a tie and suture ligature) or a stapling device (e.g., gray, red, or white). Single ties or suture ligatures are not adequate. Small branches can be doubly clipped (Table 71-5).

After dividing the upper lobe branch of the superior vein and the main upper lobe PA (which may be present as two or three branches), a single small, more inferior branch of the ongoing PA usually ascends superiorly to the upper lobe (Fig. 71-3). This artery must be controlled and divided to complete the upper lobectomy, and often this can be the most challenging part of the procedure. Sometimes the vessel can be identified from the anterior aspect of the dissection, after the main arterial branch to the upper lobe has been divided. Otherwise, it is at risk when the bronchus is dissected and can be identified in the crotch between the takeoff of the right upper lobe bronchus. It should be divided before dissection and division of the bronchus. Small clips are recommended (Table 71-6), but may be avulsed if the parenchyma is subsequently divided with stapling devices. More recent experience demonstrates that an energy device (specifically Ligasure) safely divides the small vessel.