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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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124 Right-sided pulmonary resections
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DIVISION OF THE SUPERIOR PULMONARY VEIN
The superior pulmonary vein will be easily exposed by
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incising the pleura. The lower border is free from other
major organs. On the other hand, the upper border of the
vein adjacent to the mediastinum crosses the right pulmonary artery. Before dissecting the upper border, the soft
tissue and lymph nodes located in front of the superior vein
should be dissected until the anterior adventitia of the vein
is completely exposed. If the dissection of the vein is performed along with the adventitia, no damage to the pulmonary artery on the hilar lymph nodes will occur.
Recently, the superior pulmonary vein has almost always
been divided with a stapler. However, in the case of a
tumor invading or located in the hilum, a conventional
suture and/or ligature are needed. Before ligation of the
superior vein, each branch should be tied independently.
This step is required to avoid the peripheral branches, when
tied together, covering the right pulmonary artery and
obscure the peripheral dissection of the superior branch of
the pulmonary artery. This cautionary procedure is much
more important when performing a lobectomy than in that
of pneumonectomy.
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Operation 125
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DIVISION OF THE RIGHT PULMONARY ARTERY
The right pulmonary artery and superior vena cava are
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connected by a fibrous membrane at the bifurcation of
the upper and lower branches of the pulmonary artery. This
membrane is a part of the pericardium. Division of this
membrane makes central dissection of the front of the right
pulmonary artery easy. Because the posterior wall of the
right pulmonary artery is covered by a fibrous portion of
the pericardium attaching the trachea and both main
bronchi, this fibrous portion should be divided from the
bronchus to expose the artery completely. This dissection
totally around the artery is very important to prevent the
ligature from slipping off from the stump of the artery.
When the stapler to divide the pulmonary artery is used,
misfiring should be avoided. Therefore, a vascular clamp
should be placed on the pulmonary artery before it is
divided. After the artery is cut, the central stump should be
dissected from neighboring structures until the stump is
free from tension to avoid slipping of the ligature or tearing
near the staples.
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126 Right-sided pulmonary resections
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DISSECTION OF THE UPPER MEDIASTINUM
To expose the upper mediastinum, the medi-
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astinal pleura is opened longitudinally from the
azygos vein to the apex of the thorax as described by
Cahan. The mediastinal pleura will be cut horizontally at the apex. The azygos vein should be divided
when the upper mediastinal lymph nodes are
swollen. To preserve the recurrent nerve, the vagal
nerve should be taped and pulled toward the front at
the border of the azygos and be stripped naked
upward. The recurrent nerve is easily detected when
the vagal nerve is pulled anteriorly. After the recurrent nerve is stripped, the right brachiocephalic
artery is exposed toward the ascending aorta. Then,
the superior vena cava is exposed from the upper
mediastinal fat tissue including the lymph nodes at
the azygos vein to both brachiocephalic veins. A
mediastinal venous branch draining into the superior vena cava should be carefully ligated. When the
bifurcation of both brachiocephalic veins is exposed,
the inferior thyroid vein should be identified. Next,
exposure of the tracheal wall should be started near
the recurrent nerve and ended at the fibrous membrane detaching the tracheal carina and covering the
pulmonary artery. After grasping the superior mediastinal lymph nodes with Allis or Babcok forceps
and pulling them anteriorly, the upper mediastinal
fat tissue including the lymph nodes will be
detached from the pericardium covering the ascending aorta to the right pulmonary artery. The upper
mediastinal lymph nodes will then be dissected as a
compartment.
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Operation 127
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DIVISION OF THE RIGHT MAIN BRONCHUS
If there is enough length between the surgical margin of
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the bronchus and the tumor margin, mechanical closure
with a stapler will be applied as described by Sweet. In the case
of a short neck of the right main bronchus, the Overholt
method will be applied with a stapler or with a manual pro-
cedure. Covering of the stump of the bronchus with a pericardial fat pad or with an intercostal muscle should be applied
in cases of preoperative chemotherapy and/or radiotherapy.
In the case of intense chemoradiotherapy, omentopexy
should be applied.
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Upper lobectomy
A lung cancer located at the right upper lobe is the most common, although the reason is not clear. Therefore, right upper
lobectomy with systematic nodal dissection is the most typical procedure for lung cancer surgery.
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DIVISION OF THE SUPERIOR PULMONARY VEIN
The upper lobe of the right lung should be
10a,b
hilum of the lung. After opening of the pleura of the hilum,
the superior pulmonary vein is stripped, and the upper lobe
vein will be ligated or stapled. When the vein is ligated, the
pulled posteriorly to expose the anterior
branches of the vein should be ligated at the peripheral cut
end to develop the surface of the upper pulmonary artery for
safe management. When the stapler is applied, the stapler
compresses the vein and separates the branches of vein.
Therefore, stapler management of the pulmonary vein is
safe.
10a
10b
DIVISION OF THE SUPERIOR PULMONARY
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ARTERY
To strip the pulmonary artery, the
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fibrous membrane connecting the
pulmonary artery to the superior vena cava
should be divided with an electronic cautery
or scissor. After division of this membrane,
the right main pulmonary artery can be easily
stripped peripherally, and the lymph nodes
located. The bifurcation of the superior and
intermediate pulmonary arteries is also dissected from the pulmonary artery. The superior pulmonary artery will be stapled and then
the intermediate pulmonary artery will be
stripped toward the periphery to detect the
ascending artery or arteries. In most of the
cases, the ascending arteries will be divided at
this point. However, in cases with large hilar
or intrapulmonary nodes, the ascending arteries will be cut after incomplete separation of
the upper and middle lobes. After division of
the right upper lobe pulmonary artery branch,
the front wall of the right main, upper lobe
and intermediate bronchi should be stripped,
and bronchial arteries should be ligated.
Operation 129
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DISSECTION OF THE UPPER MEDIASTINUM
The upper mediastinal nodal dissection should be performed
in a similar way to the description in the section on pneumonectomy above. After the upper mediastinal dissection,
the back wall of the right main, upper lobe and intermediate
bronchi should be stripped, and the bronchial arteries ligated.
The lung parenchyma around the upper lobe bronchus
should be dissected from the upper lobe bronchus and the
lymph nodes located at the second carina. After those lymph
nodes are carefully stripped, the posterior wall of the intermediate pulmonary artery can be exposed.
130 Right-sided pulmonary resections
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DIVISION OF THE INTERLOBAR SPACE
The major fissure separates the upper and middle
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from each other. However, separation of the minor fissure
between the upper and middle lobes is incomplete in most
cases. Therefore, even in cases of upper lobectomy, separation of the major fissure should be performed first at the
point of crossing of both fissures. Separation of the major fissure will continue to expose the intermediate pulmonary
lobes and the lower lobe, which are well separated
artery or the lymph node attaching to the artery. The tunnels
extend from the interlobar space to the posterior and anterior
hilum beside the pulmonary artery. Staplers should be
applied to divide the interlobar incomplete separation.
Incomplete separation between the upper and lower lobes
usually is thin; therefore, a stapler can be easily applied to separate the lobes. On the other hand, when the tissue is a thick
division between the upper and middle lobes, staplers should
be applied in multiple dissections.
DISSECTION OF THE INTERLOBAR LYMPH NODES
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After dividing the interlobar space, the interlobar
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from the intermediate bronchus.
lymph nodes will be exposed and should be dissected
Operation 131
DIVISION OF THE UPPER LOBE BRONCHUS
The entrance of the upper lobe bronchus is extrapulmonary.
Therefore, the upper lobe bronchus has a cartilaginous portion and a membranous portion. Two major procedures exist
to close the bronchial stump, the Sweet procedure and the
Overholt procedure. The Sweet procedure should not be
applied in cases of a short neck of the bronchus, because a
deformity of the residual main and intermediate bronchi will
be made. The Overholt procedure is a good method to close a
short neck of the upper lobe bronchial stump.
Lower lobectomy
The lower mediastinal and subcarinal lymph node dissection
and ligature of the inferior pulmonary vein should be per-
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formed in a similar manner to a pneumonectomy. After those
procedures, most of the division of the interlobar space, division of the pulmonary artery, dissection of the interlobar
lymph nodes, and division of the lower lobe bronchus are
carried out through the interlobar space. Lymphatic flow
from the lower lobe drains to the interlobar and hilar lymph
nodes around the middle lobe, the upper lobe, the intermediate and main bronchi, and finally to the upper mediastinal
lymph nodes. Therefore, those lymph nodes should be dissected completely as an
DIVISION OF THE INTERLOBAR SPACE
Most patients will have almost a complete separation between
the middle and lower lobes. However, the interlobar space
between the upper and lower lobes is separated incompletely.
en bloc dissection.
132 Right-sided pulmonary resections
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Therefore, the interlobar space between the middle and lower
lobes should be divided first by using electric cautery. In cases
with incomplete separation, the interlobar space should be
dissected near the crossing of three lobes until the lymph
nodes located beside the pulmonary artery are exposed. A
DIVISION OF THE PULMONARY ARTERY
The lymph nodes beside the pulmonary artery
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toward the lower lobe. The adventitia of the pulmonary
artery should be cleared by using a scissor or electric cautery.
The superior segmental artery is divided separately from the
should be dissected from the pulmonary artery
tunnel is thus establised from the interlobar space to the anterior hilum near the root of both pulmonary veins. A stapler
should be used through the tunnel to divide the space. A similar tunnel should be made from the interlobar space to the
posterior hilum between the upper and intermediate bronchi.
other basal arteries. The basal segmental artery is divided
with a stapler. When the basal artery is ligated, the existence
of a branch of the middle lobe artery from the anterior segmental artery of the lower lobe should be visualized. This
branch of the anterior segmental artery should be ligated at
the periphery.
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Operation 133
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DISSECTION OF THE INTERLOBAR LYMPH NODES
Lymph nodes located around the lower lobe bronchus, the
interbronchi between the lower lobe and the middle lobe
bronchi, and the interbronchi between the intermediate and
the upper lobe bronchi should be dissected toward the lower
lobe. In cases with metastases of these lymph nodes, the intrapulmonary lymph nodes in the middle and upper lobes
DIVISION OF THE LOWER LOBE BRONCHUS
Because the origin of the superior segmental
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the middle lobe bronchus, the resection line of the lower lobe
bronchus should be set diagonally. Attention should be paid
bronchus is almost at the same level as the origin of
should be dissected completely, or bilobectomy should be
performed.
An upper mediastinal lymph node dissection should be
performed routinely even though the possibility of cure for
patients with lower lobe lung cancer metastasizing to the
upper mediastinum is extremely rare. Therefore, hilar and
interlobar lymph node dissection is much more important
than upper mediastinal dissection.
to prevent stricture of the middle lobe bronchus by closure of
the bronchial stump. Therefore, in the case of a short surgical
margin from the edge of the cancer, conversion to a bilobectomy of the middle and lower lobes should be done to obtain
an adequate surgical margin.
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