general surgery

1. Lung resections

2. 2 10/15/14
Anatomic resections of the lung (including
pneumonectomy and lobectomy)
are the standard operative techniques employed
to treat both neoplastic and
nonneoplastic diseases of the lung.one must be
keenly aware of the anatomy of the
vasculature, the bronchi, and the relation between
the two. There is no
substitute for this degree of familiarity.

6. The right side of the mediastinum is the ( blue side)
, dominated by the arch of the azygos vein, the SVC
.and the right atrium 10/15/14
10

7. The left side of the mediastinum is the red side
, dominated by the arch and descending portion of the aorta
.the left common carotid and subclavian arteries 10/15/14
11

10. Indications ofpulmonary resection
• Congenital:
al lobaf a lobe.
• Traumatic:
• severely lacerated lobe.
• Inflammatory
• destroyed lobe or lung.
• Neoplasticr in end stage lung diseases.

11. Types of Pulmonary Resection
Simple pneumonectomy*
Radical pneumonectomy*
Simple lobectomy*
Radical lobectomy*
Bilobectomy: performed in the right lung,*
conserving either the upper or the lower
lobe.(when a tumour extends across a lobar
fissure, or invades bronchus intermedius, or
( endobronchial tumour or absent fissure
Extended resection: when a lobectomy or*
pneumonectomy is combined with enbloc
.resection of involved contagious structures
Segmentectomy*
Wedge resection*
Palliative resection*
Sleeve lobectomy: when the primary tumour*
encroaches upon the lobar orifice,
precluding complete resection with margins
.by standard lobectomy
Radical resection refers to lobectomy or
pneumonectomy combined with enbloc
.mediastinal lymphadenectomy

12. Wedge resection

13. segmentectomy

14. lobectomy

15. pneumonectomy
This is the surgical removal of the
entire lung, a radical pneumonectomy
includes excision of the mediastinal
glands with dissection from the chest
wall or pericardium.part of the chest
wall may have to be removed
Indications-
carcinoma,bronchiectesis,tuberculosis
Incisions-usually is ;posterior lateral
thoracotomy

16. 16 10/15/14
Thorough preoperative evaluation and
preparation of the patient reduces the morbidity
and mortality of thoracotomy and pulmonary
resection. Pulmonary function tests and analysis
of arterial blood gases help determine the
feasibility of pulmonary resection. Postoperative
pulmonary function is estimated by calculating
the preoperative function and projected
resection of pulmonary parenchyma. Patients
are excluded from surgical therapy if estimated
post-operative pulmonary function falls below
.minimum acceptable values

17. 17 10/15/14
Anaesthesia
Although pulmonary resections can be performed with
bilateral lung ventilation, careful hilar dissection is
greatly facilitated by using unilateral lung ventilation.
The advent of double-lumen endotracheal tubes and
bronchial blockers has made it possible to isolate the
ipsilateral lung and has made it easier for surgeons to
carry out complex hilar dissections with the required
precision. In patients with centrally located tumors, care
must be taken with tube placement: inadvertent trauma
to an endobronchial tumor during placement of a
double-lumen tube can lead to significant bleeding and
compromise of the airway. Bronchoscopic confirmation
of tube position is recommended after the patient has
.been positioned

18. INCISIONS
Posterior lateral thoracotomy remains the standard
incision for anatomic pulmonary resections;
however, safe and complete resections can also
be performed through a variety of smaller
incisions, including posterior muscle-sparing,
anterior muscle-sparing, and axillary
thoracotomies. In most cases, the thorax is
entered at the fifth intercostal space, an approach
that affords excellent exposure of the hilar
structures. The anterior muscle-sparing
thoracotomy is generally placed at the fourth
intercostal space because of the more caudal
positioning of the anterior aspects of the ribs.
Although a sternotomy may be employed to gain
access to the upper lobes, it does not provide good
exposure of the lower lobes and the bronchi. 10/15/14
20

20. 20 10/15/14
Traditionally, during a lobectomy, the arterial
branches are divided first, followed by the venous
branches. However, if conditions exist that limit
exposure (e.g., a centrally placed tumor or
significant inflammation and scarring(, the
surgeon should start with the structures that
provide the most accessible targets. Veins may
be ligated first. Proponents of this approach
believe that it may limit the escape of circulating
tumor cells (an event that rarely, if ever, occurs(;
opponents claim that initial vein ligation may lead
to venous congestion and retention of blood that
is subsequently lost with the specimen, though
peribronchial venous channels will frequently
prevent this result.

21. 21 10/15/14
The bronchus may also be ligated first.
However, there are two points that should
be kept in mind if this is done. First, the
distal limb of the bronchus (the specimen
side( should be oversewn to prevent
drainage of mucus into the chest. Second,
after division of the bronchus, the lobe is
much more mobile; therefore, to prevent
avulsion of the pulmonary artery branches,
care should be taken not to employ
excessive torsion or traction.

22. 22 10/15/14
Exposure of the bronchus should not
involve stripping the bronchial surface of its
adventitia. Aggressive dissection may
compromise the vascular supply and lead
to impaired healing and bronchial
dehiscence. Overlying nodal tissues should
be cleared, and major bronchial arteries
should be clipped just proximal to the point
of division. Bronchial closure has been
greatly facilitated by the use of automatic
staplers.

23. • When bronchial length is limited, one may
perform suture closure of the bronchial stump
rather than attempt to force a stapler around the
bonchus Whenever there is a high risk of
bronchial stump dehiscence (e.g., after
chemotherapy, radiotherapy, or
chemoradiotherapy; in patients for whom
adjuvant therapy is planned; or after right
pneumonectomy), a vascularized rotational
tissue flap (e.g., from the pericardium, the
pericardial fat pad, or intercostal muscle) should
be used to reinforce the bronchial closure

24. VATS

25. Complications of pulmonary
resection
 Early (30 days complications):
 Acute postoperative respiratory failure, due to
 Pain (postoperative analgesia; local + general, is mandatory).
 Atelectasis & Pneumonia (chest physiotherapy, IV antibiotics, ?
bronchoscopy).
 Pulmonary oedema (restriction of IV fluids, diuretics, chest
physiotherapy).
 ARDS .
 Cardiac arrhythmia (AF in patients > 60 ys).
 Bleeding.
 DVT, pulmonary embolism,
 Infections: empyema, wound infection and dehiscence.
 persistent air leak (visceral, disruption of bronchial stump
causing bronchopleural fistula),

26. Complications of pulmonary
resection
Late:
 chronic pain,
 chronic respiratory
failure,
 post-pneumonectomy
syndrome

27. THANK YOU