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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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144 Left-sided pulmonary resections
s
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When performing a left upper lobe sleeve
4f–i
vein are ligated and divided as they are in a standard left
upper lobectomy. The pulmonary artery is then mobilized
and retracted away from the upper lobe bronchus. A sleeve
resection of the main bronchus is accomplished by dividing it
resection, the arteries and superior pulmonary
Section left
main bronchu
Section LLL
on each side of the take off of the upper lobe bronchus. A circumferential anastomosis is then carried out between the
proximal mainstem bronchus and lower lobe bronchus using
interrupted 3-0 polyglycolic sutures. If necessary, the repair
can be buttressed through the use of parietal pleura or intercostal muscle.
4f
4h
Main bronchus
Tumor
Lower lobe
4g
4i
Operation 145
UL bronchus
LL bronchus divided
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Lingula branch
Basal trunk
LOWER LOBECTOMY
The procedure is similar to that of left upper
5a
the assistant reclining the upper lobe superiorly and anteriorly. The visceral pleura is then opened, and both branches of
the PA going to the lower lobe (basal and apical branches) are
identified, dissected, and ligated. Before ligating the basal
artery, it is important to clearly identify the arterial branch of
the PA going to the lingula so that it can be preserved.
5b–e
identified and stapled. At this stage, both anterior and posterior portions of the fissure are divided, and the lower lobe
bronchus is freed right up to the origin of the upper lobe
lobectomy. The interlobar fissure is first exposed with
The inferior pulmonary ligament is then
mobilized and the inferior pulmonary vein
LUL
LLL
5a
where it is stapled and divided. For proximal endobronchial
lesions of the lower lobe, a sleeve resection can be done by
reattaching the upper lobe to the main stem bronchus.
However, this type of bronchoplasty is seldom done.
Apical branch
(superior segment)
5b
LLL
Inferior vein
Main bronchus
5c
Upper lobe
Tumor
5d
5e
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LEFT LOBECTOMY WITH CHEST WALL RESECTION
Occasionally, lung cancer locally invades the chest wall which
must then be resected en bloc with the involved lobe. If this
type of resection has been anticipated through the review of
the CT scan or because the patient presents with chest pain,
the pleural space is entered one or two intercostal spaces
below the area where the tumor is invading the ribs. The chest
wall dissection and resection is then done prior to exposure of
the hilum or suturing of blood vessels. Ribs should be divided
at least 5 cm away from the margins of the tumor. It is also
recommended to remove one rib below and one rib above the
site of involvement. This technique is facilitated by lifting the
scapula away from the ribs. When the chest wall is completely
freed, it falls down into the pleural space along with the rest of
the lung, and the lobectomy can be carried out in the fashion
previously described. The chest wall is only repaired when the
scapula does not cover the defect, and in such cases, a prosthetic mesh is used.
Intraoperative maneuvers useful to decrease
complications after lobectomy
One of the most common complication of lobectomies is a
persistent air leak (> 7 days) with or without residual space.
This problem is commonly due to incomplete lung reexpansion; and indeed, air leaks tend to be minimal when the lung
is completely reexpanded because the parenchyma is in contact with the parietal pleural where it creates an inflammatory
reaction which tends to seal the air leak.
When full reexpansion appears possible, prolonged air
leaks can be prevented by careful suturing of parenchymal
tears or by the use of staples, reinforced staples, or biological
glues over suture lines and fissures. When full reexpansion
does not appear possible, for example after combined left
lower lobectomy and lingulectomy, one can reduce the
“boundaries” of the pleural space through the use of a pleural
tent (after upper lobectomy) or pneumoperitoneum after left
lower lobectomy. This latter technique has never been popularized but can at times be very useful. A small catheter is
inserted intraoperatively through the diaphragm into the
peritoneal cavity. This catheter is brought out through a separate skin incision adjacent to the chest tube, and it is
attached to a three-way stopcock. If a residual space is present
despite proper pleural space drainage, air can be injected into
the peritoneal cavity in order to elevate the hemidiaphragm
and help collapse this space.
Although phrenic crush techniques are no longer used, the
hemidiaphragm can be raised by injecting a local anesthetic
agent such as marcaine in the fatty tissues located around the
phrenic nerve above the diaphragm. In the majority of cases,
this technique will create a temporary paralysis of the
diaphragm which may be useful to collapse a potential
residual space.
Pneumonectomy
STANDARD PNEUMONECTOMY
With the lung retracted posteriorly and inferiorly,
6a
identified. During this dissection, care must be taken not to
injure the phrenic or the vagus nerves. If necessary, the ligamentum arteriosum can be divided in order to increase the
length of the main artery available for dissection and division.
In order to get around this artery one can use a Leahey clamp
or finger dissection. Once freed, the artery is stapled proximally, clamped distally, and divided.
the mediastinal pleura is opened and the left main PA
Phrenic nerve
Recurrent
nerve
Vagus
nerve
6a
The superior pulmonary vein is then identi-
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6b–f
and divided. Sometimes, it is easier to divide the superior vein
first in order to gain access to the main PA. The inferior vein
is then located at the base of the hilum after division of the
inferior pulmonary ligament and it is mobilized, stapled, and
divided. An umbilical tape is then passed around the left main
bronchus which is freed posteriorly and anteriorly up to the
carina where the stapler is applied and the bronchus divided.
During this dissection, great care must be taken not to injure
the esophagus which is located immediately behind the
bronchus. Sometimes we ask the anesthetist to withdraw the
double-lumen tube in the trachea in order to increase the
mobility of the carina. We seldom recover the left main
bronchus because its stump retracts underneath the aortic
arch which acts as autologous tissue. This situation is different than on the right side where the pneumonectomy stump
is free in the pleural space.
fied in the anterior hilum when it is stapled
Operation 147
6b
6c
6e
On occasion, it may be advantageous to divide the bronchus
before ligating the pulmonary blood vessels (bronchus-first
technique). If this technique is done, one has to be careful in
freeing the bronchus which is very close to the superior vein
6d
6f
(anteriorly), the pulmonary artery (superior border), and the
lower vein (lower border). Dividing the bronchus first is particularly helpful to gain access to the superior vein and main PA
in cases of completion pneumonectomies.
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INTRAPERICARDIAL PNEUMONECTOMY
The opening of the pericardium greatly facilitates access
7
to the main pulmonary blood vessels especially when the
tumor is centrally located and/or is very large. The pericardium is usually opened anterior to the phrenic nerve, and
the incision is carried upwards to the aorta. The PA is mobilized first and, to improve access, the pericardial incision is
carried right up to its reflection over the PA. This maneuver
will lead the operator directly to the adventitia of the artery
which can be opened, and the PA is fully mobilized and stapled. Once the artery has been secured, the access to the pulmonary veins becomes much easier.
In cases of intrapericardial pneumonectomy, we try to divide
only one of the two pulmonary veins within the pericardium
in the hope to prevent postpneumonectomy cardiac herniation (the vein which is divided extrapericardially will anchor
the heart and prevent its herniation). Once the lung has been
removed, it is also important to close the pericardium in
order to prevent herniation of the heart which is fatal in the
majority of cases. This goal is accomplished with interrupted
nonabsorbable sutures.
Segmental resections of the left lung
The most commonly resected segments of the left lung are the
lingula and apical segment of the lower lobe. Indications for
Anterior edge of peritoneum
Inferior vein
Superior vein
Posterior edge of peritoneum
Ligamentum arteriosum
Aorta
Vagus nerve
Recurrent nerve
7
this type of operation include lung cancer in compromised
individuals and bronchiectasis or tuberculosis limited to one
segment.
The principles involved in the resection of pulmonary segments are similar to those used for lobectomy, although the
surgery is done in two rather than three phases. The first step
is the identification of the artery and bronchus (bronchovascular pedicle), while the second step consists of retrograde
dissection starting at the hilum and following the plane of the
intersegmental vein which must stay with the remaining lung.
Most surgeons now use staplers to divide the intersegmental
plane rather than the more classic finger dissection while the
anesthetist inflates the lung.
The lingula is made of two segments (superior
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8a,b
together. In principle, lingulectomy is an easy operation. The
interlobar fissure is opened, and the arterial branch to the lingula (the most distal branch) is first identified and ligated.
The bronchus is then identified and stapled, and the segment
is removed. The venous drainage is through a common trunk
which is the lower part of the superior vein. This trunk is easily mobilized and divided.
and inferior), which are usually resected
8a
LUL
LLL
Division of arterial branch
to lingula
Operation 149
Division of bronchus lingula
Superior
trunk
Lingula
LUL
Main bronchus
LLL
8c
LLL
LUL
Pulmonary branch
to apical segment
8b
The surgical pedicle to the apical segment is also
8c,d
The artery is first mobilized from the fissure, ligated, and
divided. The bronchus can also be reached through the fissure, divided, and closed (manually or with stapler). For this
segment, no clear venous branch can be identified, so that on
freeing the segment from the basal segments, each collateral
or secondary vein is freed, clipped, and divided.
made up of a bronchus and an arterial branch.
Bronchus to apical segment
8d
150 Left-sided pulmonary resections
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POSTOPERATIVE CARE
Tube drainage
After lobectomy or segmentectomy, one or two chest tubes
are left in the pleural space. If two tubes are used, one is
placed anteriorly and at the apex, and the second one is positioned inferiorly and posteriorly. The chest tubes are connected to an active suction system usually with –20 cm of
water suction. They are removed when there is no longer an
air leak and when the amount of fluid drainage is below
200 ml/24 hours.
Most surgeons do not drain pneumonectomy spaces
because drainage through a water seal system can lead to an
extreme mediastinal shift and overexpansion of the remaining lung. Instead of drainage, we recommend aspirating
1000–1200 ml of air from the space in order to position the
mediastinum as much as possible in the midline. Other
options are to leave a chest tube which is removed when the
patient is turned over onto his or her back or is clamped until
the following morning. Possible indications to leave a draining chest tube are a high risk of postoperative hemorrhage or
bronchopleural fistula. Balanced drainage systems are currently used by only a handful of surgeons.
Analgesia
The methods used to control postoperative pain have
changed considerably over the years, but their purpose has
remained the same. They must provide proper analgesia so
that the patient can have more efficient breathing and coughing. To do so, a proper balance must be reached between too
much analgesia which will sedate the patient and not enough
which will make the patient uncooperative.
The most commonly used technique is that of epidural analgesia with the drugs being administered at the lumbar or thoracic levels. For most patients, this method provides good pain
control although side-effects such as nausea, itching, urinary
retention, and even drowsiness are common. The epidural
catheter is inserted prior to operation and left for 3–4 days
postoperatively. When the catheter is removed, the patient is
started on narcotics given subcutaneously or by mouth.
Drug management
All patients are given heparin subcutaneously as a prophylaxis against deep vein thrombosis. Patients are also given
antibiotics for 2–3 days after operation. Oxygen is given to
titrate saturation at 92% or higher. Although bronchodilation drugs can be added, the best way to improve respiratory
efficacy is through active physiotherapy and use of incentive
spirometry which are started the evening of the operation. If
mucous and sputum retention do occur, we do not hesitate to
perform bedside bronchoscopy or even insert a minitracheotomy for the sole purpose of suctioning. After left-sided
resections, it is not uncommon to have vocal cord paralysis
because of accidental or deliberate trauma to the recurrent
nerve. Unfortunately, no early solution exists for this problem, and one must be aware that these patients are more likely
to have respiratory and coughing difficulties.
Although arrhythmias are a common problem after pneumonectomy (incidence of 15–20%), it is generally not recommended to use prophylactic antiarrhythmic medication prior
to surgery.
OUTCOME
Early
The accepted mortality rate for left pneumonectomy is in the
range of 5–6%, and most causes of death are respiratory.
These problems include infectious complications, pulmonary
embolism, and postpneumonectomy edema. Fatal cardiovascular events are relatively uncommon. Risk factors for mortality after pneumonectomy include age of the patient,
preoperative cardiopulmonary compromise, extent of resection, and associated comorbidities such as diabetes.
For lobectomy, whether upper, lower, or associated with
sleeve resection, the operative mortality is in the neighborhood of 2.5–3%. Common complications include prolonged
air leaks, arrhythmias, and respiratory events. Bronchopleural fistulae (BPF) are uncommon if bronchial closure is
handled with care. The incidence is less than 3% after pneumonectomy and less than 1% after lobectomy. Once the diagnosis is made, BPF can be treated in a variety of ways. BPF are
seldom a cause of death although they usually are associated
with prolonged morbidity.
Late
In lung cancer, long-term results reflect the stage of disease
rather than the extent of operation. Since pneumonectomies
are done for higher stages of disease, 5-year survival results are
worse than what is seen after lobectomy and are in the range
of 20–25%. By comparison, 5-year survival after sleeve resections of the left lung is approximately 50%. The use of adjuvant treatments either as induction or postoperatively has not
changed those results. In most series, patients with squamous
cell carcinoma do better than those with adenocarcinomas.
In general, operation on the left lung can be done quite
safely if the operating surgeon follows a methodical approach
for the mobilization of bronchovascular pedicles. As a whole,
they are technically easier than similar procedures on the
right side, and they are better tolerated. Indeed, the incidence
of major morbidity or mortality is less after left pneumonectomy than after right pneumonectomy. Special attention
must be given to preserve the recurrent nerve which is much
more accessible to trauma on the left side than on the right
side.
Further reading 151
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FURTHER READING
Bechard D, Wetstein L. Assessment of exercise oxygen consumption as
preoperative criterion for lung resection. Annals of Thoracic Surgery
1987; 44: 344–9.
Dales RE, Stark RM, Sankaranakayanan R. Computed tomography to
stage lung cancer. Approaching a controversy using a meta-analysis.
American Review of Respiratory Disease 1990; 141: 1096–101.
Klemperer J, Ginsberg RJ. Morbidity and mortality after
pneumonectomy. Chest Surgery Clinics of North America 1999; 9:
515–25.
Ratto GB, Piaconza G, Fiola C. Chest wall involvement by lung cancer:
computed tomographic detection and results of operation. Annals of
Thoracic Surgery 1991; 51: 182–8.
Tronc F, Grégoire J, Rouleau J, et al. Long-term results of sleeve
lobectomy for lung cancer. European Journal of Cardiothoracic
Surgery 2000; 17: 550–6.
Weisbrod GL. Transthoracic needle biopsy. World Journal of Surgery
1993; 17: 705–11.
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Tracheal resection
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PETER GOLDSTRAW FRCS
Consultant Thoracic Surgeon, Royal Brompton Hospital, London; Professor of Thoracic Surgery, Imperial College, London, UK
16
HISTORY
Early attempts at tracheal resection were timid, limited to 2
cm or less of the trachea and frequently less than circumferential. More extensive resections were attempted, exploring
the use of various prostheses and homograft techniques. The
results with such techniques were poor, adversely affected by
failure of healing and granulation tissue ingrowth. The modern era of tracheal surgery began when Dr H.C. Grillo and
colleagues undertook a series of cadaveric studies to establish
the length of trachea that could be safely resected with endto-end anastomosis. These studies were confirmed by surgical
series in which he and Dr F.G. Pearson developed and
expanded surgical techniques. These pioneers established the
general principles of this surgery; the length of trachea that
could be safely resected, and the ancillary measures required
allowing tension-free anastomosis. Although some have tried
to extend these limits by developing newer prosthetic materials, these have not proven to be safe.
PRINCIPLES
Segmental resection of the trachea is appropriate for benign
or malignant conditions affecting the trachea from the
cricoid cartilage to the carina. Below this level carinal resection and reconstruction is possible. Such conditions include
fibrous stricture following intubation or tracheostomy,
benign tumors of the airways such as carcinoid tumors and
malignant tumors, chiefly squamous carcinoma and adenoid
cystic carcinoma. To be suitable for resection the disease
process has to be limited to a length of trachea that can be
safely resected, and the patient must be sufficiently fit to tolerate such surgery safely. As a general rule 50% of the trachea
can be resected and repaired by end-to-end anastomosis. This
length may be slightly greater in a young child and slightly less
in an older person. As one approaches these limits various
release procedures are helpful to enable end-to-end anastomosis without undue tension.
A cervical approach allows resection of airway pathology
affecting the distal larynx, the cervical trachea, and all but the
distal 2–3 cm of the intrathoracic trachea. If this segment is
involved then a thoracic approach is to be preferred, allowing
carinal reconstruction, if necessary. The approach used will
be influenced somewhat by the pathology. The length of airway to be resected can be more reliably determined for
benign pathology. The margins of resection for malignant
disease are less predictable and the surgeon will have to plan
to allow for wider resection if necessary.
The choice of relieving procedure will, to some extent, also
be influenced by the incision used.
In planning the surgical approach consideration must be
given to the alternatives available to allow continued ventilation during resection and reconstruction. The use of cardiopulmonary bypass has been tried in the past but has been
rendered obsolete by alternatives that do not require
heparinization.
Prophylactic antibiotics should be given for any operation
on the airway, and anaerobic cover is added if there is severe
obstruction or necrotic tumor.
As the surgeon will understandably restrict the length of
resection to the minimum, the use of frozen section examination is recommended when undertaking airway resection for
tumors, especially adenoid cystic carcinoma with its propensity for microscopic intramural extension.
For patients who are unfit for surgery, or whose disease is
too extensive to permit resection, there are many alternative
techniques. The appropriate technique will vary depending
upon the site, length, and pathology of the stricture, and
include radiotherapy and a wide range of surgical procedures
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