Introduction

Since ancient times there has been an understanding of the importance of the structures housed in the thorax. However, it was not until the advent of anaesthesia and control of ventilation that real progress could be made in thoracic surgery. In the first half of the twentieth century, thoracic surgery was mainly performed on patients suffering from pulmonary tuberculosis, and there was major progress in developing techniques for treating open chest wounds and pleural empyema during the First World War (1914–1918). The Second World War (1939–1945) saw the refining of treatments for early decortication in the haemothorax. In the early twentieth century, the accessibility of antibiotics helped to control and eliminate pulmonary tuberculosis and (by reducing the risk of infection) helped to ensure more satisfactory patient outcomes after surgery (Nabuco de Araujo, de Campos & Pêgo-Fernandes 2016).

In 1972 the double-lumen endotracheal tube was developed and this allowed the ventilation of only one lung. Surgeons could operate on the other lung more easily, at less risk to the patient. This was especially important in the development of minimally invasive surgery, as the pulmonary hilar structures are more accessible. Another expansion of thoracic surgery occurred with the development of endoscopy, which enhanced diagnosis techniques and treatment of the larynx, trachea and bronchi (Nabuco de Araujo, de Campos & Pêgo-Fernandes 2016).

Moving into the twenty-first century, thoracic surgery has become more accessible than ever with the development of sophisticated diagnostic interventions such as computerised tomography (CT), magnetic resonance imaging (MRI) scans and the introduction of new surgical techniques. The evolution of thoracic surgery is ongoing, with the continuing development and improvement of endoscopic interventions and the introduction of video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS).

The thorax is a flexible structural conical frame, made of bones, cartilage and muscles, that encompasses the vital organs – i.e. heart and lungs in addition to major blood vessels and other structures. The pre-, intra- and postoperative care of thoracic surgical patients is essentially unique and different from cardiac surgery. In addition to the general routine preparation, assessment and the World Health Organisation (WHO) Surgical Safety Checklist (National Patient Safety Agency 2009), the following points are important:

1. Correct site marking: The site mark should match the pre-op clinic correspondence, consent, operation list, CT and chest x-ray (CXR) imaging and should also be confirmed with the patient. This is to help prevent ‘wrong site surgery’ which is a Never Event. ‘Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers’ (National Health Services Improvements 2018, p. 4).

2. Appropriate preoperative investigations: For example, spirometry is usually required for all thoracic surgery. For more major surgery, such as anatomical lung resection, a full set of pulmonary function tests should be carried out (Lim, Baldwin & Beckles 2010). High-risk patients, with borderline WHO performance status and pulmonary function tests, may require further investigations in the form of 6-minute walk test, shuttle walk test, stair-climbing test and cardiopulmonary exercise testing to fully evaluate the risk stratification for patients undergoing major surgery. All test results should be filed and documented in the patients’ notes and be accessible to all clinicians involved in their care. This group of patients will usually require anaesthetic assessment for fitness, prior to surgery. Stopping smoking prior to surgery also has a significant impact on postoperative recovery and pulmonary rehabilitation/optimisation. Nutritional supplements and correction of any anaemia should be considered.

3. Imaging: All current CT and positron emission tomography (PET) scans must be available and checked. All scans must be within three months of the operation date. This is important, as a disease such as lung cancer may have progressed and may no longer be amenable to surgical resection. The patient will then require further investigations and possible referral to oncology for alternative treatment.

4. Biopsies and tissue samples: Another crucial aspect in thoracic surgery is obtaining samples and tissue biobsies, ensuring they are labelled and handled accurately and sent to the laboratories safely. It is not uncommon to require a frozen section and it is important that these patients are identified before surgery and that the histopathology laboratory is informed in advance. This means that a pathologist is alerted and able to provide the report in a timely manner. In addition, before the surgeons scrub for the surgery, they should prepare the forms, labelling them urgent, completing the patient’s clinical details and all relevant information to ensure that the laboratory can carry out the tests quickly and accurately

6. Drains: Usually a single pleural drain is used in relevant thoracic surgery; however, more than one drain will occasionally be required. If using more than one, it is good practice to label them and leave clear instructions with the recovery and/or ward staff about suction on the drains and duration.

7. Finally: The WHO Surgical Safety Checklist should be completed and a debrief carried out, to discuss any problems and their resolution during the surgery with the whole operating team. The operating notes should be written up and any electronic data completed. If a CXR is required, it needs to be ordered and checked to ensure there are no problems (such as a pneumothorax or any fluid collection).

Diagnostic procedures

Thoracic surgeons perform a variety of interventions to help establish the diagnosis, including staging lung cancer tests to aid in optimum patient management. One of the most potentially helpful diagnostic tools is bronchoscopy, which is used to procure tissues or secretions from the tracheobronchial tree or adjacent structures. Specimens are usually described as washings, brushings, biopsies or needle aspirations. Although respiratory physicians perform some of these, thoracic surgeons carry out a different set of diagnostic procedures as listed below.

Endoscopic procedures

Bronchoscopy

This is an optical tool for the visual inspection of the airways. It is an important part of routine thoracic surgical intervention.

• Photography available

• Laser/brachytherapy can also be performed.

Disadvantages/Risks:

• Small channel

• Risk of breakdown.

Rigid bronchoscopy

Rigid bronchoscopy, an essential skill for thoracic surgeons, is almost always performed under general anaesthetic and is an important diagnostic and therapeutic tool for thoracic surgeons. Adult rigid scopes used to come with variable internal diameters of 6, 7 or 8mm and they are 40cm in length. Modern scopes can be used with telescopic lenses and illumination is supplied by a halogen light source.

Advantages/Indications:

• Clear view of major airways to obtain tissue and perform interventions (e.g. removal of foreign bodies, dilation of strictures and placement of stents)

• Managing massive haemoptysis

• Relieving tracheal obstruction

• Performing laser bronchoscopy

• Insertion of endobronchial valves and coild for emphysema.

Disadvantages/Risks:

• Risk of injury to gums and dislodgement of teeth

• Requires general anaesthesia

• Risk of hypoventilation and airway bleeding.

The endoscopic examination

For this procedure the patient is usually positioned supine on the operating table. While taking care of the patient’s eyes, lips and teeth, the first phase of diagnostic rigid bronchoscopy is visualisation of the larynx and the vocal cords. Gently lifting the epiglottis will bring the vocal cords into view and their mobility can be assessed. Rotating the scope 90 degrees, the tip is passed between vocal cords to visualise the tracheal rings. With flexible bronchoscopy, all lobar and segmental bronchi must be examined carefully and systematically. The carina can be identified as a sharp vertical ridge at the end of the trachea. Always examine the normal side first to prevent spillage of infection or malignant contamination.

The right main bronchus is short and in line with the trachea. The right upper lobe bronchus comes off just distal to the carina, at 90 degrees, and trifurcates into the apical, anterior and posterior segmental bronchi. The bronchus intermedius is a continuation of the right main bronchus and it trifurcates into the middle lobe (medial and lateral segments), common basal trunk and apical lower lobe segment.

In almost all bronchoscopic procedures, the samples/specimens are obtained for cytological and histopathological examination and it is vitally important to handle these specimens very carefully, making sure all the specimens are counted and recorded in the theatre books and sent to the laboratories in appropriately labelled containers.

Endobronchial ultrasound-guided transbronchial needle aspirate

This is similar to the above, but not described here as this procedure is usually performed by respiratory physicians.

Mediastinal procedures

Mediastinoscopy

This used to be one of the most common operations performed by thoracic surgeons and was the gold standard for diagnosis/staging the mediastinum but is now only used selectively, due to CT, PET scans and prevalent use of diagnostic bronchoscopy and endobronchial ultrasound.

Indications:

• Primary lung cancer staging (mediastinal adenopathy)

• Central tumours

• High radioactive tracer uptake in the tumours/nodal tissue on PET scan

• Biopsy of mediastinal masses.

Caution to be exercised in the following conditions:

• Huge cervical goitre

• Extensive calcification or aneurysm of the innominate artery

• Superior vena cava obstruction

• Permanent tracheostomy after laryngectomy and radiation.

Procedure

A 3cm transverse skin incision is centred between the anterior borders of the sternocleidomastoid muscles, 2cm above the jugular notch, and carried through the platysma. The avascular space between the strap muscles is opened vertically by blunt dissection; and palpation of the trachea aids in guiding to the plane. Using the middle finger, a tunnel is created in the pre-tracheal space and the scope is passed in front of the tracheal rings. If in doubt, needle aspiration may help differentiate between the nodes and vessels. Lymph nodes stations 2 (upper paratracheal), 4 (lower paratracheal) and 7 (subcarinal) can be sampled when staging lung cancer. For mediastinal conditions, biopsies can be taken from the mass.

Bleeding is usually minor and requires no treatment. To assess haemostasis, the scope is withdrawn slowly and the space is filled with a swab for 1–2 minutes. Usually no drain is required and the wound is closed in layers.

Anterior mediastinotomy

Also known as a parasternal mediastinotomy (Chamberlain procedure), this is a means of accessing the masses and nodes not reached by cervical mediastinoscopy in the subaortic region (stations 5 and 6). This approach can also be used on the right side and offers access to the upper hilum (station 10), the lung, and pleura on both sides. In addition to diagnosing and staging of lung cancer, an anterior mediastinotomy can be used to biopsy many anterior mediastinal masses. VATS can be used as an alternative approach.

Procedure

The patient is positioned supine and selective lung ventilation through a double-lumen endotracheal under general anaesthesia may be helpful. Adequate exposure into the mediastinum is achieved via a 4–6cm transverse incision made just lateral to the sternum at the second or third costal space. The mediastinum is then entered through the posterior perichondrium. The internal mammary artery and vein are retracted and spared. The mediastinal pleural reflection is separated bluntly from the posterior table of the sternum and retracted laterally. Finger dissection opens the loose areolar tissue and extends inward until the aorta, pulmonary artery, and intervening space are noted. Enlarged nodes can be sampled directly or through the mediastinoscope using the technique described above. If the pleura was not entered, drainage is usually not required.

Video-assisted thoracoscopy as a diagnostic tool

The use of VATS as a diagnostic tool for pleural diseases, solitary pulmonary nodules and interstitial lung diseases has now been well accepted in mainstream thoracic surgery. The surgeon is very dependent on their assistant during VATS procedures and an able, knowledgeable assistant is crucial for the safe conduct of the operation. The assistant learns how to hold and manoeuvre the camera, keeping the working station in the centre of the screen and anticipating the next step to facilitate the smooth running of the procedure. Rotating the lens can give superior views but the camera must be kept vertical.

The patient is placed in a full lateral decubitus position and the table flexed to widen the rib spaces on the operative side. Under general anaesthesia, selective single-lung ventilation is achieved using either a double-lumen endotracheal tube (ETT) or a bronchial blocker via ETT (depending on the anaesthetist’s preference).

The procedure can be performed with one or several ports, depending on the procedure and experience/preference of the surgeon. For general exploration, three ports (placed in a triangular fashion) are used, one for the camera and two for operating instruments. The first 10mm port entry for the camera should be made by blunt dissection, using a finger to avoid iatrogenic injury to the lung in case of adhesions. This is usually sited in the mid-axillary to anterior axillary line, at the 7th or 8th intercostal space. The other two instrument ports are inserted under video guidance. Five- or 10-mm thoracoscopes are used with a 0- or 30-degree lens and a three-chip 3D video camera.

Pre-warming the thoracoscope in a sterile hot-water bath effectively prevents fogging of the lens. For generalised lung and pleural problems, at least two to three biopsy samples are taken from different places. Most surgeons take a full-thickness pleural biopsy when dissecting for the first port entry.

Common indications for diagnostic VATS

Pleural disease:

• Pleural effusions/masses

• Identification of source of haemothorax/chylothorax

• Pleural space infections/empyema and localisation of broncho-pleural or pleuro-peritoneal fistulae.

Pulmonary disease:

• Diffuse interstitial disease/pulmonary infiltrates

• Solitary pulmonary nodules

• Lung cancer staging and assessment of operability.

Mediastinal disease:

• Mediastinal cystic and solid mass lesions and lymphadenopathy.

Thoracic therapeutic procedures

Tracheobronchoscopic procedures

An airway intervention is a highly specialised thoracic surgical procedure practised by experienced thoracic surgeons. The endobronchial management takes a secondary palliative position for acutely unwell patients with inoperable tracheobronchial tumours.

The operative details of endoscopic procedures are beyond the scope of this book but essentially surgeons need to follow the same principles as those elaborated in the endoscopic diagnostic procedures. Ensure that fluoroscopy is available for bronchoscopic balloon dilatation procedures.

Thoracic incisions

Positioning, preparation and prophylaxis

Most general thoracic surgical procedures are done with patients in the right or left lateral decubitus position with the spine parallel and close to the edge of the table. Pressure points are protected with padded foam pads to avoid positioning injuries due to nerve stretching or compression at pressure points. In addition to mechanically supporting the chest wall, a roll should be placed under the dependent chest wall to take pressure off the shoulder and brachial plexus. One or two pillows should be placed between the legs. The dependent areas e.g. tibial tuberosity, lateral malleolus should also be padded.

Various manoeuvres are available to hold the patient in an appropriate lateral position. These include placing a sandbag under the operating table mattress, and positioning rolled sheets front and back, and beanbags. Padded straps or adhesive tape placed under surgical towels at the hip and the calf are also used. The dependent arm is flexed at the elbow and padded. The superior arm can be flexed similarly and appropriately padded, obtaining the so-called praying position, or it can be extended on a padded arm holder. Finally, the operating table is flexed (or an inflatable bag/gel bag can be used) to spread the intercostal space.

Intermittent pneumatic compression devices can be applied prior to induction of anaesthesia, as they are a useful adjunct, helping to prevent the development of a deep vein thrombosis. Antibiotic prophylaxis should be given prior to skin incision and a dose as necessary to maintain adequate levels throughout the operation. A forced-air patient warming device helps to keep patients normothermic.

Posterolateral thoracotomy

This incision (with serratus anterior muscle-sparing) is probably the most common incision used for open thoracic surgery. The posterolateral thoracotomy incision is made with the patient in the lateral decubitus position. The variable-length skin incision is placed to provide access to the appropriate intercostal space (ICS), most commonly the 5th ICS through the bed of the unresected 6th rib. The classic incision starts in front of the anterior axillary line, curves two fingerbreadths under the tip of the scapula, and extends vertically on a line halfway between the posterior midline, over the vertebral column and the medial edge of the scapula. The advantage of this approach is superb exposure to the operative site; and the disadvantage is the time expended because of the extent of the incision.

The lung is then deflated, and the intercostal muscle is carefully incised down to the parietal pleura, using the electrocautery or periosteal elevator. If the lung does not drop away freely, adhesions should be suspected that may need to be released carefully. A Tuffier, Rienhoff or Finochietto-type rib spreader can be placed to open the ribs spaces slowly and in stages to minimise the chance of a rib fracture.

Closure of the incision is carried out after inserting one or two chest drains through a separate stab incision, inferior to the skin incision in the anterior and midaxillary lines. Tunnelling the drain tract reduces the risk of surgical emphysema. At the end of the operation the bridge or bean bag or gel roll is taken off to aid rib approximation and two or three pericostal sutures of heavy absorbable material (such as no 1 Vicryl) are used to bring them back in position. Then both the musculofascial planes are closed with a running absorbable no. 0 Vicryl suture. The subcutaneous tissues are closed with a size 2-0 running suture of the same material and the skin, with a 3/0 Monocryl in a subcuticular fashion.

All closures of incisions described in this chapter will use the above technique unless otherwise stated.

Axillary thoracotomy

This is a good muscle-sparing incision for uncomplicated, straightforward pulmonary operations, which provides access to the apex of the lung and is also used for first rib resections. It is not recommended for complex operations as it provides less exposure. The main advantages are the speed of opening and closing and the reduced blood loss from minimal muscle transection.

Anterior thoracotomy

The patient can be positioned supine, or with a roll placed under the back, and the incision is usually made in the 4th ICS. This incision can be altered in order to place it in the inframammary crease in women, for cosmetic reasons. Thoracic surgeons limit its use and it is mostly employed for lung transplant.

Thoracoabdominal incision

This incision is commonly used for open thoracoabdominal aortic operations and oesophageal operations. It provides an extended exposure both to the thorax and abdomen for these difficult operations. It is less commonly used for routine thoracic surgery.

Median sternotomy

Clamshell incision (bilateral transverse thoracosternotomy)

The patient is positioned supine and the transverse incision is usually made over both 4th ICSs. The pectoral major muscle is lifted off the rib and the sternum and is then transected with an oscillating saw, after ligating both the internal mammary vascular bundles. The retractors are used on each side to get the maximum exposure. This incision is primarily used for bilateral lung transplantation; it is less commonly used for bilateral general thoracic surgical procedures such as the resection of bilateral metastatic lesions to the lungs and large anterior mediastinal masses. Heavy polyglycolic acid pericostal sutures are used to approximate the ribs, and figure-of-eight stainless- steel wires are used to close the sternum.

Lung resections

Lung resections encompass a variety of operative procedures that could be grouped as anatomical and non-anatomical lung resections. A wedge resection or an excision biopsy are non-anatomical lung resections. Anatomical resections may be subgrouped to include segmentectomy, simple lobectomy, complex lobectomy (sleeve lobectomy, double-sleeve resection, bronchoplasty and pneumonectomy. A brief account of these common operations follows below.

Lobectomy

A lobectomy is the most common operation and remains the definitive procedure of choice for early- stage non-small-cell lung cancer. It is an anatomical resection that ensures removal of the regional lymph nodes that course along the lobar bronchus, and thus provides the best staging information and local control. Most thoracic units in the UK are now performing VATS lobectomies in addition to open lobectomies, and the operative strategies can overlap. The VATS type is frequently performed through an anterior approach; and the posterior approach is used for the open cases. Bronchoscopy is routinely performed to evaluate the anatomy, suction the secretions and assess the resection in case of endobronchial tumours.

Once the chest is opened, confirmation of the location and assessment for the resectability of the tumour is sought before committing to any structural division. The hilar and mediastinal lymph node dissection/sampling is an essential part of the operation for lung cancer surgery and should be performed either at the start, during dissection or at the completion of lobectomy (Goldstraw et al. 2015).