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32. Trans-Sternal Thymectomy
Geoffrey T. Lam, MD, and Jessica S. Donington, MD
NYU School of Medicine, New York, NY
Essential Operative Steps
1. Lines and monitoring
2. General endotracheal anesthesia with double-lumen tube: preferable but not essential
3. Bronchoscopy: to confirm placement of double-lumen tube
4. Median sternotomy
5. Thymectomy
6. Preservation of phrenic nerve
7. Chest tube placement
8. Sternotomy closure
Potential Complications and Pitfalls
1. Straying off midline during sternotomy
2. Injury to innominate vein
3. Injury to phrenic nerve
4. Failure to remove the entire thymus
5. Inadequate hemostasis prior to sternotomy closure
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. mediastinal mass, thymoma, thymic carcinoma]
Postoperative Diagnosis: Same
Procedure(s) Performed: Trans-sternal thymectomy, fiberoptic bronchoscopy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Specimens: [BLANK]
Drains: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [THYMOMA/THYMIC CARCINOMA]. Preoperative
imaging revealed [FINDINGS].
Description of Procedure: Informed consent for surgery was obtained from the patient, including a discussion of risks,
benefits and alternatives, and the form was documented in the chart. The patient was taken to the operating room on [DATE]
and placed on the operating room table in supine position. Anesthesia inserted appropriate intravascular access and
hemodynamic monitoring lines. Preoperative IV antibiotics were administered. A time out was called to identify the correct
patient, procedure and anatomic location. Following the induction of teneral endotracheal anesthesia, the patient was intubated
with a double-lumen endotracheal tube. Bronchoscopy was performed. Proper placement of the endotracheal tube was
confirmed. The airways were examined. Normal endobronchial anatomy was noted. There were no endobronchial
abnormalities. The patient was left in the supine position, a transverse shoulder roll was placed, and the arms were tucked. A
lower Bair Hugger was applied and all pressure points were padded. The neck and chest were prepped and draped in sterile
fashion.
The endotracheal tube was disconnected from the ventilator. A median sternotomy was performed. Mechanical ventilation
was resumed. Hemostasis of the sternum was obtained, and a sternotomy retractor was placed. The [RIGHT/LEFT] side
was approached first. The ipsilateral lung was isolated, the sternal table was elevated and the pleural space was widely
opened. Dissection was started inferiorly and care taken to identify and preserve the phrenic nerve. Small thymic branches
were doubly clipped with medium clips and divided using Bovie electrocautery. The mass was elevated off the pericardium
[THE PERICARDIUM WAS RESECTED EN BLO C IF ADHERENT] and dissection continued over the pericardial
surface, superiorly up to the level of the innominate vein and laterally out to the phrenic nerve. Attention was turned to the
superior horn, which was dissected free, clipped superiorly and brought inferiorly to the level of the innominate vein. Prior to
beginning dissection on the contralateral side, a 28-French straight chest tube was placed into the pleural space via a separate
lateral stab incision, directed anteriorly and superiorly and secured to the skin using #1 silk. Anesthesia then switched the lung
isolation. The sternal table was elevated and the contralateral pleural space was opened widely. The dissection was started
inferiorly and carried in a superior direction, taking care to identify and preserve the phrenic nerve. All thymic tissue and
mediastinal fat between the phrenic nerves was dissected free up to the level of the innominate vein. The second superior horn
was dissected free and clipped at its highest point and then dissected inferiorly down to the level of the innominate vein. The
thymus was dissected off the innominate vein, and the draining vein was identified, clipped and divided. The thymus was
passed off the field.
Hemostasis was achieved using Bovie electrocautery. A 28-French straight chest tube was placed into the contralateral
pleural space via a separate lateral stab incision, directed anteriorly and superiorly and secured to the skin using #1 silk. The
lung was reinflated and the patient left on two-lung ventilation. The sternum was reapproximated using [NUMBER] #5
stainless steel wires. The sternotomy incision was closed in layers, using #0 PDS for the fascia, #2-0 PDS for the deep dermal
layer and a running #3-0 Monocryl subcuticular stitch for the skin. Sterile dry dressings were applied. The chest tubes were
connected to Pleur-Evac drainage.
The patient tolerated the procedure well. The patient was extubated in the operating room and transferred in stable condition
to the recovery room. At the end of the case, the sponge, needle and instrument counts were correct x2.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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33. Open Lobectomies
Erin Gillaspie, MD and K. Robert Shen, MD
Mayo Clinic, Rochester, MN
Note: There are a variety of surgical options for managing the pulmonary vasculature and the bronchus. Different methods are
described throughout the chapter.
Right Upper Lobectomy
Essential Operative Steps
1. Place an arterial line and Foley catheter.
2. General endotracheal anesthesia and thoracic epidural catheter.
3. Flexible bronchoscopy to assess airway for secretions, pus, blood, bronchial anatomical abnormalities and
endobronchial lesions.
4. Exchange single lumen for dual lumen tube or place bronchial blocker.
5. Confirm tube positioning with bronchoscopy.
6. Place patient in lateral decubitus positioning with table flexed cephalad to xiphoid process.
7. Perform muscle sparing postero-lateral thoracotomy dividing the latissimus dorsi but sparing the serratus anterior
muscle which is reflected anteriorly. Chest is entered in the 4
th
or 5
th
intercostal space.
8. Divide inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open mediastinal pleural circumferentially around the hilum.
10. Open fissure to expose the pulmonary artery at the junction of the major and minor fissure.
11. Transect superior pulmonary vein after verifying that there is a separate inferior pulmonary vein.
12. Transect the truncus anterior artery and posterior ascending artery.
13. Transect bronchus after test clamping the right upper lobe and having the anesthesia team reinflate the right lung to
verify that the bronchi to the middle and lower lobes have unobstructed flow.
14. Complete fissure posteriorly and complete parenchymal division anteriorly.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4, 7, 8, 9 as well as
peribronchial nodes around the bronchus of the right upper lobe.
16. Test bronchial stump for pneumostasis.
17. Check for hemostasis.
18. Tack right middle lobe to lower lobe to prevent middle lobe torsion.
19. Place chest tubes.
20. Close thoracotomy.
Potential Complications and Pitfalls
1. Traditionally, the pulmonary vein is transected first. However, if exposure is difficult, the artery or bronchus may be
transected initially to provide adequate exposure to complete the lobectomy safely.
2. If the bronchus is divided first, the vein and artery are at risk for injury due to the lack the structural support of the
bronchus; special care must be taken.
3. Prior to dividing any venous branches, verification of a separate inferior pulmonary vein is mandatory
4. The right upper lobe artery anatomy is variable. The posterior ascending artery typically originates from the main PA
just opposite to the middle lobe artery. It may also originate from the superior segment to the right lower lobe.
5. The venous anatomy is also variable. The middle lobe vein may be a tributary of either (or both) the superior or
inferior pulmonary vein. Special attention must be taken when performing a middle lobectomy to assure that the
middle lobe vein isn’t sacrificed.
6. Removal of the “sump node” (level 11R node), which resides between the right upper lobe bronchus and bronchus
intermedius, is helpful to expose the posterior ascending artery.
7. Avoid devascularization of the whole bronchus as this impairs healing and results in higher rates of broncho-pleural
fistula formation.
Template Dictation
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
Procedure(s) Performed: Right upper lobectomy
Attending Surgeon: [BLANK]
Assistant Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented with [DURATION] history of [COMPLAINT].
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. Pulmonary functions tests demonstrated
patient to be a candidate for lobectomy.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were confirmed. The patient was transferred to the operating room table and placed in supine position. General
endotracheal anesthesia was induced. Flexible bronchoscopy was performed. There were no secretions, pus, blood,
bronchial anatomical abnormalities, or endobronchial lesions. The single lumen tube was exchanged for a dual lumen
endotracheal tube. Tube position was verified with bronchoscopy. A radial arterial line and additional peripheral IVs were
placed.
The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A time out
was performed. All members of the surgical team were present and were in agreement.
The right lung was isolated. A serratus-sparing right posterolateral thoracotomy was performed. The chest was entered. The
[FIFTH/SIXTH] rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior
pulmonary vein. A station 9 lymph node was sampled. The lung and pleura were examined; the lesion was identified in the
upper lobe. The lung was retracted posteriorly and the mediastinal pleural opened circumferentially around the hilum. The
sump node (station 11R) was removed. The horizontal fissure was opened using electrocautery and completed with the GIA
stapler to expose the underlying pulmonary artery. The superior pulmonary vein was identified and the apical, anterior and
posterior branches were skeletonized, ligated proximally and distally with [TIE/SUTURE/STAPLE] and divided. The
truncus anterior and posterior ascending branches of the pulmonary artery were skeletonized, ligated proximally and distally
with [TIE/SUTURE/STAPLE] and divided. The upper lobe was retracted superiorly and posteriorly to identify the right
upper lobe bronchus. The bronchus was exposed circumferentially with lymphatic tissue being swept up towards the
specimen. The upper lobe bronchus was occluded just distal to the takeoff from the mainstem bronchus with a curved clamp.
The middle and lower lobe expanded, thereby confirming unobstructed flow. The bronchus was transected and over-sewn
with #3-0 PDS [SUTURE MATERIAL]. The upper was sent to Pathology. Frozen sections demonstrated negative bronchial
margins
Mediastinal lymph nodes from stations 2R, 4R, 7, 8, 9, 10R, and 11R were sampled during the dissection.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure and the stump was found to be
pneumostatic. The right middle lobe was sutured to the right lower lobe to prevent torsion. The chest was re-evaluated for
bleeding and excellent hemostasis was assured.
Two 28 french chest tubes were placed in the pleural cavity and sutured into place.
The lung was allowed to re-expand under direct vision.
The ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with
running suture. The latissimus dorsi was closed in two layers with running suture. The subcutaneous tissue and skin were
closed in running fashion.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Right Middle Lobectomy
Essential Operative Steps
1. Place an arterial line and Foley catheter.
2. General endotracheal anesthesia and thoracic epidural catheter.
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3. Flexible bronchoscopy to assess airway for secretions, pus, blood, bronchial anatomical abnormalities and
endobronchial lesions.
4. Exchange single lumen for dual lumen tube or place bronchial blocker.
5. Confirm tube positioning with bronchoscopy.
6. Place patient in lateral decubitus positioning with table flexed cephalad to xiphoid process.
7. Perform a muscle sparing posterolateral thoracotomy, dividing the latissimus dorsi but sparing the serratus anterior
muscle, which is reflected anteriorly. Chest is entered in the 4
th
or 5
th
intercostal space.
8. Divide inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open mediastinal pleural circumferentially around the hilum.
10. Open horizontal fissure.
11. Transect venous branch to the middle lobe.
12. Transect artery (or arteries). There may be one or two middle lobe arterial branches.
13. Transect the bronchus after test clamping the right middle lobe and having the anesthesia team reinflate the right lung
to verify that the bronchi to the upper and lower lobes have unobstructed flow.
14. Complete the horizontal and oblique fissures.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4R, 7, 8, 9 as well as
peribronchial nodes around the bronchus of the right middle lobe.
16. Test bronchial stump for pneumostasis.
17. Check for hemostasis.
18. Place chest tubes.
19. Close thoracotomy.
Potential Complications and Pitfalls
1. There may be one or two arterial branches to the middle lobe. The posterior ascending branch to the RUL should not
be confused with a second branch.
2. Venous anatomy is variable. The middle lobe vein can be a tributary of the superior or inferior pulmonary vein and at
times both.
3. Avoid devascularization of the whole bronchus as this impairs healing and results in higher rates of broncho-pleural
fistula formation.
Template Dictation
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
Procedure(s) Performed: Right middle lobectomy
Attending Surgeon: [BLANK]
Assistant Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented with [DURATION] history of [COMPLAINT].
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. The patient’s pulmonary function tests
indicate that a lobectomy could be safely performed.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were confirmed. The patient was transferred to the operating room table and placed in supine position. General
endotracheal anesthesia was induced. Flexible bronchoscopy was performed. There were no secretions, pus, blood,
bronchial anatomical abnormalities, or endobronchial lesions. The single lumen tube was exchanged for a dual lumen
endotracheal tube. Tube position was verified with bronchoscopy. A radial arterial line and additional peripheral IVs were
placed.
The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A time out
was performed. All members of the surgical team were present and were in agreement.
The right lung was isolated. A serratus-sparing right posterolateral thoracotomy was performed. The chest was entered. The
[FIFTH/SIXTH] rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior
pulmonary vein. A station 9 lymph node was sampled. The lung and pleura were examined; the lesion was identified in the
upper lobe. The lung was retracted posteriorly and the mediastinal pleural was opened circumferentially around the hilum.
The horizontal fissure was opened and completed with a GIA stapler to expose underlying pulmonary artery branches. The
lung was rotated posteriorly and middle lobe vein identified from its takeoff from the [SUPERIOR/INFERIOR] pulmonary
vein. The vein was skeletonized and transected with vascular load stapler. The [ONE/TWO] arterial branches to the right
middle lobe were identified, skeletonized and divided with a vascular load stapler. The oblique fissure was completed using
serial applications of GIA stapler. Finally, the middle lobe was rotated superiorly to expose the right middle lobe bronchus at
the origin of the bronchus intermedius. The bronchus was exposed circumferentially. All lymphatic tissue was swept up
towards the specimen. A 4.8 mm TA stapler applied to the right middle lobe bronchus. The lung allowed to re-inflate.
Unobstructed airflow to the right upper and lower lobes was confirmed. The bronchus was transected, and the specimen was
removed from the chest. Frozen sections demonstrated negative bronchial margins.
Station 2R, 4R, 7, 8, 9 and 10R lymph nodes were sampled.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure, and the stump was found to be
pneumostatic. The chest was irrigated. Hemostasis was assured.
Two 28 French chest tubes were placed in the pleural cavity.
The lung was allowed to re-expand.
The ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with
running suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed
in a running fashion.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Right Lower Lobectomy
Essential Operative Steps
1. Place an arterial line and Foley catheter.
2. General endotracheal anesthesia and thoracic epidural catheter.
3. Flexible bronchoscopy to assess airway for secretions, pus, blood, bronchial anatomical abnormalities and
endobronchial lesions.
4. Exchange single lumen for dual lumen tube or place bronchial blocker
5. Confirm tube positioning with bronchoscopy.
6. Place patient in lateral decubitus positioning with table flexed cephalad to xiphoid process.
7. Perform muscle sparing posterolateral thoracotomy, dividing the latissimus dorsi and sparing the serratus anterior
muscle, which is reflected anteriorly. The chest is entered in the 4
th
or 5
th
intercostal space.
8. Divide the inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open mediastinal pleural circumferentially around the hilum.
10. Open the fissure.
11. Transect inferior pulmonary vein after verifying that there is a separate superior pulmonary vein.
12. Transect superior segmental artery and basial arterial branches.
13. Transect the bronchus after test clamping the right lower lobe and having the anesthesia team reinflate the right lung
to verify that the bronchi to the right upper and middle lobes have unobstructed flow.
14. Complete the fissure posteriorly and complete parenchymal division anteriorly.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4R, 7, 8, 9, and 10R as
well as peribronchial nodes around the bronchus of the right lower lobe.
16. Test bronchial stump for pneumostasis.
17. Check for hemostasis.
18. Place chest tubes.
19. Close thoracotomy.
Potential Complications and Pitfalls
1. The right middle lobe bronchus is at risk when completing the fissure between the right middle lobe and lower lobe
posteriorly. Care needs to be taken to ensure that the right middle lobe bronchus is not inadvertently divided or
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narrowed during this step.
2. Furthermore, when preparing the divide the bronchus to the right lower lobe, it is critical to ensure that the bronchus
to the right middle lobe is not kinked or narrowed by the stapler since it comes off the bronchus at close to a 90
degree angle just proximal to the take-off for the right lower lobe.
3. Avoid devascularization of the whole bronchus as this impairs healing and results in higher rates of broncho-pleural
fistula formation.
Template Dictation
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
Procedure(s) Performed: Right lower lobectomy
Attending Surgeon: [BLANK]
Assistant Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented with [DURATION] history of [COMPLAINT].
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. The patient’s pulmonary function tests
indicate that a lobectomy could be safely performed.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were confirmed. The patient was transferred to the operating room table and placed in supine position. General
endotracheal anesthesia was induced. Flexible bronchoscopy was performed. There were no secretions, pus, blood,
bronchial anatomical abnormalities, or endobronchial lesions. The single lumen tube was exchanged for a dual lumen
endotracheal tube. Tube position was verified with bronchoscopy. A radial arterial line and additional peripheral IVs were
placed.
The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A time out
was performed. All members of the surgical team were present and were in agreement.
The right lung was isolated. A serratus-sparing right posterolateral thoracotomy was performed. The chest was entered. The
sixth rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein. A
station 9 lymph node was sampled. The lung and pleura were examined; the lesion was identified in the upper lobe. The lung
was retracted posteriorly and the mediastinal pleural was opened circumferentially around the hilum. The oblique fissure was
opened using electrocautery and completed with serial GIA stapler application. The inferior pulmonary vein was encircled as
it exits the pericardium and divided using a vascular load stapler. The superior and basilar segmental arterial branches to the
right lower lobe were identified, encircled and ligated with a vascular load stapler. The lower lobe was rotated anteriorly;
the bronchus intermedius was identified. The branch to the right middle lobe and right lower lobe were identified and the
lower lobe branch exposed circumferentially with lymphatic tissue being swept up towards the specimen. A 4.8 mm TA
stapler applied to the right lower lobe bronchus. The remaining was lung allowed to re-inflate to confirm unobstructed
airflow. The stapler was fired, the bronchus was transected, and the specimen was removed from the chest.
Mediastinal lymph nodes from stations 4R, 7, 8, 9, and 10R and 11R were sampled.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure, and the stump was found to be
pneumostatic. Chest was irrigated. Hemostasis was assured.
Two 28 french chest tubes were placed in the pleural cavity.
The lung was reinsufflated under direct vision.
Ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with running
suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed in a
running fashion.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Left Upper Lobectomy
Essential Operative Steps
1. Place an arterial line and Foley catheter
2. General endotracheal anesthesia and thoracic epidural catheter.
3. Flexible bronchoscopy to assess airway for secretions, pus, blood, bronchial anatomical abnormalities and
endobronchial lesions.
4. Exchange single lumen for dual lumen tube or place bronchial blocker. Generally, a left-sided double lumen
endotracheal tube is used for most situations because it is considered technically easier to place. However, in some
circumstances, such as a left pneumonectomy or a left sleeve lobectomy, a right-sided double lumen tube may be
preferable and should be discussed with the anesthesia team.
5. Confirm endotracheal tube positioning with bronchoscopy.
6. Place patient in lateral decubitus positioning with table flexed cephalad to xiphoid process.
7. Perform muscle sparing postero-lateral thoracotomy, dividing the latissimus dorsi and sparing the serratus anterior
muscle, which is reflected anteriorly. The chest is entered in the 4
th
or 5
th
intercostal space.
8. Divide the inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open the mediastinal pleural circumferentially around the hilum.
10. Open the fissure anteriorly and posteriorly.
11. Transect the superior pulmonary vein after verifying that there is a separate inferior pulmonary vein.
12. Transect apico-anterior, posterior and lingular arterial branches.
13. Transect bronchus after test clamping the left upper lobe and having the anesthesia team reinflate the left lung to
verify that the bronchus to the lower lobe has unobstructed flow.
14. Complete the fissure.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4L, 5, 6, 7, 8, 9, 10L as
well as peribronchial nodes around the bronchus of the left upper lobe.
16. Test bronchial stump for pneumostasis.
17. Check for hemostasis.
18. Place chest tubes.
19. Close thoracotomy.
Potential Complications and Pitfalls
1. The left upper-lobe pulmonary artery anatomy is the most variable among the lobes. Usually, there are three
branches– apico-anterior, posterior and lingular. A left upper lobectomy is the most technically challenging
lobectomy in part due to this variability in the segmental arterial anatomy. In addition, the segmental arteries are quite
small, and easily injured. In particular the most proximal segmental artery needs to be handled with care since an
inadvertent injury can rapidly propagate into a left main pulmonary artery tear and be very difficult to control.
2. Avoid devascularization of the whole bronchus as this impairs healing and results in higher rates of broncho-pleural
fistula formation.
Template Dictation
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
Procedure(s) Performed: Left upper lobectomy
Attending Surgeon: [BLANK]
Assistant Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented with [DURATION] history of [COMPLAINT].
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. The patient’s pulmonary function tests
indicate that a lobectomy could be safely performed.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were confirmed. The patient was transferred to the operating room table and placed in the supine position. General
endotracheal anesthesia was induced, and the patient was intubated with a single lumen endotracheal tube. Flexible
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bronchoscopy was performed. There were no secretions, pus, blood, bronchial anatomical abnormalities, or endobronchial
lesions. The single lumen tube was exchanged for a dual lumen endotracheal tube. Tube position was verified with
bronchoscopy. A radial arterial line and additional peripheral IVs were placed.
The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A time out
was performed. All members of the surgical team were present and were in agreement.
The left lung was isolated. A serratus-sparing left posterolateral thoracotomy was performed. The chest was entered. The
sixth rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein.
The lung was retracted posteriorly and the mediastinal pleural opened circumferentially around the hilum. The fissure was
opened using sharp dissection and electrocautery. The fissure was completed with serial GIA stapler applications. The
superior pulmonary vein was encircled, ligated with [TIE/SUTURE], and divided. The left upper lobe pulmonary artery
branches were identified, skeletonized, individually ligated proximally and distally with [TIE/SUTURE] and divided. The
upper lobe was retracted anteriorly to identify the left upper lobe bronchus. The bronchus was exposed circumferentially. All
lymphatic tissue was swept upwards. A curved clamp was applied to the bronchus, and the lower lobe was allowed to
reinflate, thereby confirming unobstructed flow. The bronchus was transected and over-sewn with [SUTURE MATERIAL].
Mediastinal lymph node stations 4L, 5, 6, 7, 9, 10L and 11L were sampled.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure, and the stump was found to be
pneumostatic. The chest was irrigated. Hemostasis was assured.
Two 28 French chest tubes were placed in the pleural cavity.
Lung was allowed to re-expand.
Ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with running
suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed in
running fashion.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Left Lower Lobectomy
Essential Operative Steps
1. Place an arterial line and Foley catheter.
2. General endotracheal anesthesia and thoracic epidural catheter.
3. Flexible bronchoscopy to assess airway for secretions, pus, blood, bronchial anatomical abnormalities and
endobronchial lesions.
4. Exchange single lumen for dual lumen tube or place bronchial blocker. Generally, a left-sided double lumen
endotracheal tube is used for most situations because it is considered technically easier to place. However, in some
circumstances, such as a left pneumonectomy or a left sleeve lobectomy, a right sided double lumen tube may be
preferable and should be considered or discussed with the anesthesia team.
5. Confirm tube positioning with bronchoscopy.
6. Place patient in lateral decubitus positioning with table flexed cephalad to xiphoid process.
7. Perform muscle sparing postero-lateral thoracotomy dividing the latissimus dorsi but sparing the serratus anterior
muscle which is reflected anteriorly. Chest is entered in the 5
th
intercostal space.
8. Divide inferior pulmonary ligament up to the inferior pulmonary vein.
9. Open mediastinal pleural circumferentially around the hilum.
10. Open fissure anteriorly and posteriorly.
11. Transect inferior pulmonary vein after verifying that there is a separate superior pulmonary vein.
12. Transect superior segmental (one or two branches) and basilar segmental arterial branches.
13. Transect bronchus after test clamping the left lower lobe and having the anesthesia team reinflate the left lung to
verify that the bronchus to the upper lobe has unobstructed flow.
14. Complete the fissure.
15. Perform thoracic lymphadenectomy with sampling or removal of lymph nodes from stations 4, 5, 6, 7, 8, 9 as well as
peribronchial nodes around the bronchus of the left lower lobe.
16. Test bronchial stump for pneumostasis.
17. Check for hemostasis.
18. Place chest tubes.
19. Close thoracotomy.
Potential Complications and Pitfalls
1. Must be careful not to compromise the pulmonary artery branch to the lingula, which originates just proximally to the
lower lobe branches.
2. Avoid devascularization of the whole bronchus as this impairs healing and results in higher rates of broncho-pleural
fistula formation.
Template Dictation
Preoperative Diagnosis: [INDICATION]
Postoperative Diagnosis: Same
Procedure(s) Performed: Left lower lobectomy
Attending Surgeon: [BLANK]
Assistant Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [GENERAL ENDOTRACHEAL, THORACIC EPIDURAL]
Indication(s) for Procedure: [AGE] year old [GENDER] who presented with [DURATION] history of [COMPLAINT].
Workup included [CXR, CT, PET] which demonstrated [WORKUP FINDINGS]. The patient’s pulmonary function tests
indicate that a lobectomy could be safely performed.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were confirmed. The patient was transferred to the operating room table and placed in the supine position. General
endotracheal anesthesia was induced, and the patient was intubated with a single lumen endotracheal tube. Flexible
bronchoscopy was performed. There were no secretions, pus, blood, bronchial anatomical abnormalities, or endobronchial
lesions. The single lumen tube was exchanged for a dual lumen endotracheal tube. Tube position was verified with
bronchoscopy. A radial arterial line and additional peripheral IVs were placed.
The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A time out
was performed. All members of the surgical team were present and were in agreement.
The left lung was isolated. A serratus-sparing left posterolateral thoracotomy was performed. The chest was entered. The
sixth rib was shingled posteriorly. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein.
The lung was retracted posteriorly and the mediastinal pleural opened circumferentially around the hilum. The fissure was
opened using sharp dissection and electrocautery. The fissure was completed with serial GIA stapler applications. The
inferior pulmonary vein was isolated and divided with a vascular load stapler. The left lower lobe pulmonary artery branches
were identified, skeletonized and ligated with a vascular load stapler. The lower lobe was retracted anteriorly to identify the
lower lobe bronchus. The bronchus was exposed circumferentially; all lymphatic tissue was swept up towards the specimen.
A 4.8 mm TA stapler was applied to the bronchus, and the remaining lung was allowed to re-inflate. The stapler was fired, the
bronchus transected sharply and the specimen removed from the chest.
Mediastinal lymph node stations 4L, 5, 6, 7, 9, 10L and 11L were sampled.
The bronchial stump was submerged under water, the lung was inflated to 40 cm water pressure, and the stump was found to be
pneumostatic. The chest was irrigated. Hemostasis was assured.
Two 28 French chest tubes were placed in the pleural cavity.
The lung was re-expanded under direct vision.
Ribs were re-approximated with figure of 8 peri-costal sutures. The serratus anterior layer was re-approximated with running
suture. The latissimus dorsi was closed in two layers with running suture. Subcutaneous tissue and skin were closed in
running fashion.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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