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MMCTS
(June 28, 2005). doi:10.1510/mmcts.2004.000059 Copyright © 2005 European Association for Cardio-thoracic Surgery Procedure Lobectomy of the right lower lobe for lung cancerUniversity Hospital of Antwerp, Department of Thoracic and Vascular Surgery, Wilrijkstraat 10, B-2650 Edegem, Belgium * Corresponding author: * Tel.: +32-3-8214 36; fax: +32-3-8214 396. E-mail: paul.van.schil{at}uza.be
Lobectomy is the treatment of choice for primary non-small cell lung cancer (NSCLC), provided that the patient is fit enough to undergo surgery, the primary tumour is confined to one lobe and there are no distant metastases. Other indications for lobectomy include metastatic disease (with multiple nodules in one lobe or central localisation of metastasis), centrally located benign tumours (such as hamartoma), extensive infectious diseases (such as lung abcess, bronchiectasis), and congenital anomalies (such as congenital cystic adenomatoid malformation-CCAM). A lobectomy of the right lower lobe for squamous cell carcinoma is presented in a 66-year old patient. As there was proven involvement of the mediastinal lymph nodes (stage IIIa–N2), induction chemotherapy consisting of four cycles of gemcitabin and cisplatinum was given. Control CT-scan and FDG-PET scan showed no mediastinal involvement anymore. He was scheduled for surgical treatment. Through a right anterolateral muscle-sparing thoracotomy, lobectomy of the lower lobe with a mediastinal lymphadenectomy was done. Apart from atrial fibrillation, the postoperative course was uneventful.
Key Words: Lobectomy • Lung cancer • Lung resection • Tumour
The surgical technique of lobectomy of the lower lobe, is described in several textbooks of general thoracic surgery [1,2].
Preoperative assessment Pulmonary function testing, besides a thorough cardiac evaluation, indicates the operative risk of the procedure. To reduce the postoperative respiratory complication rate, physiotherapy is started at least one or two days beforehand. CT-scan of the thorax showed a good response of the tumour to induction chemotherapy (Photo 1). Spirometry showed mild chronic obstructive pulmonary disease (FVC 3.09 litres, FEV1 2.11 litres, FEV1/FVC 68%, DLCO 57%).
Positioning of the patient The patient is under general anaesthesia, with double-lumen intubation. An epidural catheter for maximum pain control in the postoperative period is inserted. The patient is positioned in a stable left lateral decubitus position, with a roll under the left axilla (caudal and parallel to the arm) to protect the neurovascular structures crossing the axilla. The right arm is supported by a pillow or additional roll, and is flexed at the elbow. The pelvis is supported posteriorly, and a strip of tape is applied for stabilisation of the patient. The left leg is flexed, while the right leg is nearly completely in extension; this leg is supported by a pillow at the level of the calf. The right hemithorax is desinfected and draped (Photo 2).
Anterolateral thoracotomy The incision starts at the level of the inframammary fold, and extends laterally to a point 2–3 centimetres below the inferior angle of the scapula. After division of the subcutaneous tissues, skin flaps are created to facilitate closure at the end of the procedure. The latissimus dorsi muscle is retracted posteriorly (muscle-sparing thoracotomy). Division of the serratus anterior muscle, just above its insertion. The sixth rib is identified; after installation of single lung ventilation, the intercostal muscles and the parietal pleura are divided just above the sixth rib (Video 1).
Exploration of the thoracic cavity In order to evaluate resectability of the tumour, the thoracic cavity is inspected. Any abnormality of the pericardium, parietal pleura, mediastinum (including the mediastinal lymph nodes) or diaphragm is noticed. In the presence of pleural fluid, this is aspirated for cytologic examination. The tumour is localised; the decision to perform lobectomy or pneumonectomy depends on the relation of the primary tumour to the fissures and other lobes. In case of doubt, frozen section analysis should be done.
Mobilisation of the lung Mobilisation of the lung requires division of the pulmonary ligament (Video 2); the inferior pulmonary vein is localised and completely exposed (Video 2).
Exposure of the vessels in the hilum and in the fissure After incision of the mediastinal pleura, the pulmonary artery and the superior pulmonary vein are localised. As abnormalities in anatomy are frequently seen, complete visualisation of the vessels is important. The lower pulmonary vein and the pulmonary artery are encircled by a vessel loop (Video 3). The last step in the dissection is exposure of the vessels in the major fissure. To open the fissure, sharp dissection is preferred (Videos 3 and 4). If too many adhesions between lower and upper lobe or between lower and middle lobe are encountered, these can be divided by a linear stapler. The segmental arterial branches to the lower lobe (basilar artery and superior segmental artery) are identified (Videos 4 and 5, and Schematic 1).
Division of the superior segmental artery After identification of the arterial divisions to the lower lobe (basilar artery and superior segmental artery), these vessels are divided (Videos 5 and 6). In this patient, the superior segmental artery is divided first. The proximal stump is closed with a non-absorbable monofilament running suture (polypropylene 5/0); an additional ligature of non-absorbable polyfilament (Mersilene® 2/0 MMCTSLink 36) is placed. The distal stump is ligated with polyfilament suture material (Mersilene 2/0) or transected with a polyfilament suture (polyglactin 2/0) (Video 6).
Division of the major fissure To allow resection of the lower lobe, the major fissure has also to be divided anteriorly. A linear stapling device is used to accomplish transection between the lower and middle lobe (Video 7 and Schematic 2).
Division of the major fissure pulmonary artery (basilar artery) The main branch of the pulmonary artery to the lower lobe (basilar artery) is divided between clamps. As for the superior segmental artery, the proximal stump is closed with a non-absorbable monofilament running suture (polypropylene 5/0); an additional ligature of non-absorbable polyfilament (Mersilene® 2/0, MMCTSLink 36) is placed. The distal stump is ligated with polyfilament suture material (Mersilene 2/0) or transected with a polyfilament suture (polyglactin 2/0) (Video 8, Schematic 3).
Division of the lower pulmonary vein Consecutively, the inferior pulmonary vein is divided between clamps. The proximal stump is closed with a non-absorbable monofilament running suture (polypropylene 4/0) and an additional ligature, as for the arterial segmental branches (Video 9). Some surgeons prefer to use a vascular stapling device, instead of suturing of the pulmonary artery and vein.
Section of the bronchus The bronchus to the lower lobe is identified and dissected. Surrounding bronchial arteries are ligated, in order to prevent postoperative bleeding. Lymph nodes are resected for histologic examination. For closure of the bronchus, we use a stapler unless there is proximal involvement. In these cases manual suturing is preferred. Attention is paid to the length of the bronchial stump. The bronchus should be transected as close to its origin as possible, to prevent bronchopleural fistula formation. After closure of the stapler, but before firing, the right lung is re-inflated, to control the exact positioning of the stapler (Video 10). Instead of mechanical stapling, the bronchus can also be closed by manual suturing; however, while doing a running suture (non-resorbable monofilament suture), the risk of spillage of bronchial secretions into the pleural cavity exists.
Lymphadenectomy During the several steps of the dissection of the lower lobe, the different lymph node stations are biopsied. While mobilising the lower lobe (incision of inferior pulmonary ligament, dissection of the inferior pulmonary vein), lymph node IX is sampled. Lymph node VIII is resected while opening the posterior mediastinal pleura (Video 11). The interlobar lymph nodes (XI, and X more anteriorly in the hilum) are resected at the moment of dissection of the pulmonary artery in the fissure (Video 5). A mediastinal lymphadenectomy is performed at the termination of the lobectomy (Video 12). For this purpose the parietal pleura is incised at the right paratracheal site, below (for lymph node IV) and above (for lymph node II) the level of the azygos vein.
Completion of the procedure With warm saline solution in the thoracic cavity, the right lung is partially re-inflated to check for air leakage. At the end of the procedure, two thoracic drains are left behind, to evacuate residual air and blood. A 32-French chest tube is placed anteriorly, in apical position; a 36-French tube is positioned more posteriorly in the costophrenic sinus. Both drains come out through separate skin incisions; fixation is provided by purse string suture. The tubes are connected to a chest drainage unit consisting of a collecting chamber and an underwater seal. To prevent torsion around their axis, the middle and upper lobes are fixed to the parietal pleura or the mediastinum (Video 13).
Closure of the chest After securing hemostasis, four or five resorbable sutures (polyglactin 2) are placed. The serratus anterior muscle is approximated (polyglactin 1). The anterior border of the latissimus dorsi muscle is sewn (polyglactin 1), with a closed suction drainage underneath. Subcutaneous tissues and skin are closed by a running suture (Video 14).
Surgery is the treatment of choice for primary non-small cell lung cancer (NSCLC), provided that the patient is fit enough to undergo resection. Although initially pneumonectomy was considered to be the golden standard, it was shown that lobectomy is an oncologically valid treatment if the tumour is confined to one lobe. To evaluate resectability of NSCLC, complete staging is mandatory. This includes screening for distant metastases (brain, bone, adrenals, liver) and for mediastinal lymph node involvement. Pulmonary function testing, besides a thorough cardiac evaluation, indicates the operative risk of the procedure. Lung diffusion for carbon monoxide seems to be one of the best tests in predicting respiratory complications [3,4]. After induction chemotherapy for stage IIIa disease, pulmonary function tests are altered; a higher complication rate is to be expected [5]. The possible complications of lobectomy can be divided in three categories: pulmonary (atelectasis, pneumonia, empyema, prolonged air leak), cardiovascular (arrhythmia, myocardial infarction, bleeding), and others (wound infection, ...) [6,7]. The risk of developing a bronchopleural fistula, one of the most feared complications, occurs in about 0.5% of the patients [8]. Mortality rates after lobectomy are about 0.5%. Morbidity and mortality rates are higher in patients aged over 70 [9]. Long-term survival rates depend on the pathological stage of disease. Five-year survival rates are 57–67%, 39–55% and 25% for stages I, II and IIIa, respectively [10,11]. Due to multimodality treatment for selected cases, a better prognosis can be offered [12]. We can conclude that, in experienced hands, lobectomy for primary NSCLC is a safe procedure with good results concerning the immediate postoperative course (morbidity, mortality); to obtain long-term survival, combination with chemotherapy (multimodality treatment) depending on the clinical and pathological stage is mandatory.
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