Post on 14-Jun-2015
description
PULMONARY RESECTION
Professor
Abdulsalam Y Taha
School of Medicine
University of Sulaimani
Iraq https://sulaimaniu.academia.edu/AbdulsalamTaha
Pertinent Anatomy
04/13/232
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. Any surgeon who intends to operate on
the pulmonary system must be keenly aware of the anatomy of the pulmonary
vasculature, the bronchi, and the relation between the two. There is no
substitute for this degree of familiarity.
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A broncho-pulmonary segment consists of a tertiary bronchus, the portion of lung it ventilates, an artery, and a vein.
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The right side of the mediastinum is the ( blue side)dominated by the arch of the azygos vein, the SVC ,
and the right atrium. 04/13/2310
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. 04/13/2311
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A
HISTORYAlthough the five patients operated on by Block (1883), Kronlein (1884) and Ruggi (1885) died following attempted partial resection of their tuberculous lungs, Tuffier successfully resected the apex of the right lung of a 25 years old man in 1891. The use of the individual ligation technique as proposed by Blades and Kent made pulmonary resection a safe procedure in general. In 1933, both Graham and Rienhoff, independently performed successful pneumonectomy using this technique. The following decades have been refinements of surgical techniques and anaesthetic management in the field of thoracic surgery. The efforts of surgeons of the 1930s and 1940s culminated in the perfection of pulmonary resectional techniques currently practiced. In Iraq, pulmonary resection started in the treatment of pulmonary tuberculosis in early 1950s.
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Indications:
*Primary and secondary lung malignancies. *Benign tumours.
* Suppurative diseases(Broncheictasis, lung abscess and tuberculosis).
* Parasitic infestation( pulmonary hydatid cyst).* Fungal infections( aspergillosis).
*Pulmonary sequestration. *Pulmonary arterio-venous fistula. *Infantile lobar emphysema(ILE).
* Chest trauma Any pulmonary procedure can change into pulmonary resection, therefore every thoracic surgeon should master it.
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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. 04/13/2317
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.
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AnaesthesiaAlthough 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.04/13/2319
INCISIONSPosterior 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. 04/13/2320
The technique of pulmonary resection had dramatically changed from mass ligation of pulmonary hilum to individual ligation of hilar structures and recently to video-assisted thoracoscopic pulmonary resection. However, the safe performance of lung resection requires a perfect knowledge of hilar anatomy and a technique with which the surgeon is familiar.
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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.
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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.
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The techniques used for dissection, ligation, and division of pulmonary arteries and their branches differ from those used for other vessels. Pulmonary vessels are low-pressure, high-flow, thin-walled, fragile structures. Accordingly, for rapid and safe dissection, a perivascular plane, known as the plane of Leriche, should be sought. This plane may be absent in the presence of long-standing granulomatous or tuberculous disease, after major chemotherapy, after thoracic radiotherapy, and in cases of reoperation. In these situations, proximal control of the main pulmonary artery and the two pulmonary veins may be necessary before the more peripheral arterial dissection can be started. Before any pulmonary vessel is divided, it should be controlled either with two separate suture ligatures proximal to the line of division or with vascular staples; stapling devices are especially useful for larger vessels.
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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.
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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.
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Shown is the surgeon's view of the right interlobar fissure. The
fissures have been completed, and the segmental arteries to the
upper, middle, and lower lobes have been identified. The posterior
ascending branch to the upper lobe most commonly varies with respect to size and origin. This
vessel may be absent or diminutive and may arise from the superior segmental branch to the lower
lobe. The posterior segmental vein draining into the superior
pulmonary vein (not seen) is clearly visualized in the right upper
lobe, lateral to the pulmonary artery branches.
Right Upper Lobectomy 04/13/2327
Shown is the surgeon's view of the anterior right hilum. The apical venous branches of the superior pulmonary vein obscure the interlobar pulmonary artery and, to a lesser degree, the truncus anterior branch. Division of these venous branches during upper lobectomy improves exposure of the truncus anterior. The splitting of the main pulmonary artery into its two main branches may occur more proximally, and care should be taken to identify both branches before either one is divided. Another significant possible variation is a branch of the middle-lobe vein that arises from the intrapericardial portion of the superior pulmonary vein.
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Shown is the surgeon's view of the posterior right hilum. The carina, the right mainstem bronchus, the right upper lobe, and the bronchus intermedius are easily seen. The interlobar sump node has been removed and the fissure completed, and the posterior ascending branch of the pulmonary artery is visible. Care should be taken not to injure this vessel during division of the fissure. It can be ligated via this approach if it cannot be adequately exposed from the fissure. Both the truncus anterior and the posterior ascending branch of the pulmonary artery lie directly anterior to the right upper-lobe bronchus, and care should be taken not to injure these vessels during bronchial encirclement. The bronchial arteries course along the medial and lateral edges of the bronchus intermedius.
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Shown is the surgeon's view of the right middle-lobe bronchus. Gentle retraction of the basilar
segmental artery to the lower lobe posteriorly allows clear visualization of the origin of the middle-lobe bronchus.
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Shown is the surgeon's view of the right inferior pulmonary vein. For encirclement of this vein, dissection may also have to be performed on its anterior surface. The branch to the superior
segment can be seen overlying the origin of the superior segmental bronchus. 04/13/2331
Shown is the surgeon's view of the right fissure after division of the lower-lobe vessels. The decision whether to divide the bronchi separately or to transect them with a singleoblique application of the stapler depends on the proximity of the middle-lobe bronchus
to the superior segmental and basilar bronchi. 04/13/2332
Shown is the surgeon's view of the left interlobar fissure. The recurrent laryngeal nerve can be seen coursing lateral to the ligamentum arteriosum. The arterial branches supplying the left upper lobe between the apicoposterior segmental branch and the lingular branch can vary
substantially in number and size. Another frequently encountered variation is a distal lingular branch that arises from a basilar segmental branch. 04/13/2333
Shown is the surgeon's view of the anterior left hilum. The apical branches of the superior pulmonary vein course anterior to the apicoposterior branches of the pulmonary artery. If additional vessel length is needed because of the presence of a central tumor, the pericardium may be entered and the vein divided at that location.
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Shown is the surgeon's view of the left fissure after division of the upper-lobe arteries .Care should be taken not to injure the pulmonary artery inadvertently when applying a stapler. 04/13/2335
Shown is the surgeon's view of the left inferior pulmonary vein .The left side, unlike the right side, affords only limited access
to the subcarinal space. However, the length of the inferior pulmonary vein outside the pericardium is greater on the left
side than on the right.04/13/2336
Shown is the surgeon's view of the left fissure after division of the lower-lobe vessels. In this procedure, a single oblique transection of the entire left lower-lobe bronchus
can be employed without any concern that a proximal bronchus will be compromised; this step would not be feasible in a right lower lobectomy, in that the right middle-lobe
bronchus arises from the bronchus intermedius. 04/13/2337
Shown is the surgeon's view of the posterior left hilum. The carina is located deep under the aortic arch. A left-side double-lumen tube or
bronchial blocker may have to be withdrawn to afford better exposure of the proximal left mainstem bronchus. The orientation of the superior pulmonary vein and the pulmonary artery (anterior and
superior to the bronchus, respectively) should be noted. 04/13/2338
Right pneumonectomy
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Left pneumonectomy
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Segmentectomy
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RUL bronchoplasty
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LUL bronchoplasty
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LUL sleeveresection withbronchoplaty
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LMB sleeve resection with
bronchoplasty
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LMB sleeveresection with
bronchoplasty
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LLL bronchoplasty
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Pleural flap reinforcement of bronchial closure
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Open bronchus technique for bronchial closure
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