MMCTS
(June 28, 2005). doi:10.1510/mmcts.2004.000083
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Extrapericardial pneumonectomy
Jeroen Hendriks,
Patrick Lauwers and
Paul Van Schil*
University Hospital Antwerp, Department of Thoracic and Vascular Surgery, Wilrijkstraat 10, B-2650 Edegem, Belgium
* Corresponding author: * Tel.: +32-3-821 37 85; fax: +32-3-821 43 96. E-mail: paul.van.schil{at}uza.be and jeroen.hendriks{at}uza.be
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Summary
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Presentation of the technique of extrapericardial left and right standard pneumonectomy. After insertion of a disposable double-lumen endotracheal tube, the patient is positioned in lateral decubitus and a lateral thoracotomy is performed. One-lung ventilation is started after a thorough identification is performed followed by systematic nodal dissection. Centrally, the pulmonary artery and veins are encircled, cut on clamps and sewed. Alternatively, the vessels can be stapled. Next, the bronchus is dissected toward the trachea and transected by stapling or interrupted sutures as close to the trachea as possible. When there is a high risk of bronchopleural fistula, as after induction chemotherapy or radiotherapy, the bronchial stump is covered with viable tissue (as azygos vein, pericardial fat, intercostal muscle or pleural flap, omentum, or muscle flaps from the thoracic wall).
Key Words: Pneumonectomy • Thoracotomy • Lung cancer
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Introduction
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History
The first successful one-stage pneumonectomy was performed by Graham and Singer in 1933 for a patient with a bronchogenic carcinoma [1]. Rienhoff first described the technique of individual ligation of the pulmonary vessels and suturing of the bronchus [2]. By the 1940s pneumonectomy was the standard operation for resectable lung cancer, and from the early 1950s lobectomy became the procedure of choice for the treatment of peripheral lung cancer limited to one lobe, as initially discussed some years before by Churchill [3]. Other important landmarks were the technique of individual ligation of the vessels and bronchial suture by Overholt in 1939 [4], the technique of rhythmic insufflation anaesthesia by Crafoord in 1940 [5], and the technique of closure of the bronchus by Rienhoff in 1942 [6]. The first report of covering the bronchial stump to prevent bronchopleural fistula was presented by Brewer in 1953 [7].
Anatomy
The left hilum is bounded anteriorly by the left phrenic nerve which courses more anteriorly than on the right (Schematic 1), posteriorly by the aorta, oesophagus and left vagus nerve (Schematic 2), superiorly by the aortic arch, and inferiorly by the pericardium (Video 1). The left vagus nerve runs closer to the lung than its right-sided counterpart.
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Schematic 1 The left hilar anatomy, anterior view (reproduced from Ref. [14] with permission from Lippincott Williams & Wilkins).
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Schematic 2 The left hilar anatomy, posterior view (reproduced from Ref. [14] with permission from Lippincott Williams & Wilkins).
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Video 1 The superior border of the left hilum consists of the aortic arch, while the inferior border is lined by the diaphragm and pericardium.
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The right hilum is bounded anteriorly by the right atrium, vena cava and by the phrenic nerve (Schematic 3); it relates posteriorly to the azygos vein, oesophagus and vagus nerve (Schematic 4). Superiorly it is bounded by the arch of the azygos vein and the tracheobronchial lymph nodes (Video 2).
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Schematic 3 The right hilar anatomy, anterior view (reproduced from Ref. [14] with permission from Lippincott Williams & Wilkins).
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Schematic 4 The right hilar anatomy, posterior view (reproduced from Ref. [14] with permission from Lippincott Williams & Wilkins).
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Video 2 The superior border of the right hilum is depicted by the arch of the azygos vein and tracheobronchial lymph nodes.
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Surgical technique
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After incision of the pleura, the lung is retracted posteriorly and the pericardial reflections are divided to expose the most anterior part of the hilar structures. Once the vessels have been identified, they are cleared circumferentially by finger dissection and forceps. The inferior pulmonary vein is exposed by retracting the lung upward and anteriorly, followed by division of the inferior pulmonary ligament by coagulation or ligation. Next, the anterior and posterior pleura are incised upward. For the extrapericardial pulmonary artery, which is longer at the left side, encircling takes place by passing a forceps against the tip of the finger (Video 3). At the left side, the bronchial wall can be used posteriorly as a guide when passing the finger around the pulmonary artery. On the right side, exposure of the pulmonary artery can be facilitated with prior passing of a vessel loop around or ligation of the superior pulmonary vein (Video 4). When all vessels are encircled, section of the vessels can start.
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Video 3 The left pulmonary artery is cleared from surrounding tissue and encircled by passing a forceps against the tip of the finger.
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Video 4 The left superior pulmonary vein is separated from its surrounding tissue and encircled by passing a forceps against the tip of the finger.
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There is no proven therapeutical or oncologic advantage of a pulmonary vein first approach compared to a pulmonary artery first division although malignant cells have been found in the venous effluent. This is explained by the fact that pulmonary artery blood flow stops almost immediately after clamping of the pulmonary veins. Section of the pulmonary veins and artery (Video 5) is performed by clamps and sutures with polypropylene 4/0 or 5/0, but techniques with stapling devices are also described.
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Video 5 The left pulmonary artery is already sectioned. The video demonstrates the surgeon closing the proximal part of the pulmonary artery with a running suture with prolene 4/0 (MMCTSLink 50). Next, a non-absorbable Mersuture suture (MMCTSLink 36) is placed before removing the pulmonary artery clamp.
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After the vessels have been secured, bronchial dissection is started. Exposure of the main stem bronchus can be performed by a combination of anterior and posterior exposure. The superior tracheobronchial and paratracheal lymph nodes may be removed before or after section of the bronchus. The bronchial arteries are usually ligated at the level of the proposed transection. At present, most surgeons will close the bronchus by a stapling device (4.8 mm staples) (Video 6). In order to avoid creating a blind pouch, the instrument is applied across the origin of the main bronchus from the trachea, at a right angle to the long axis of the bronchus. In this way, the membranous portion of the bronchial wall is apposed to the cartilaginous portion. While the bronchus is clamped distally, it is transected with a scalpel along the edge of the stapler (MMCTSLink 48), and the stump is cleansed with an antiseptic poviiodine solution. For tumours centrally located in the main bronchus slay transection and manual suture of the bronchial stump are preferred after frozen section analysis of the bronchial margin. The suture line is tested underwater for air leak with positive pressure applied by the anaesthesiologist. A valsalva manoeuvre with about 30 cm H2O static airway pressure is usually sufficient (Video 7). Metallic clips can be applied to direct postoperative radiotherapy in case of doubtful margins. The bronchus can be covered with additional tissue such as the azygos vein on the right side or pericardial fat on the left side (Video 8). Omentum and/or muscle flaps are preserved for the bronchial stump at risk, in case of empyema and preoperative chemotherapy combined with high-dose radiotherapy.
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Video 6 The left main bronchus is cleared from its surrounding tissue and bronchial arteries. In this video the left main bronchus is cut after placing a stapling device proximally and a bronchus clamp distally. After firing the stapling device, the bronchus is sectioned just distally from the stapling device.
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Video 7 A view of the thoracic cavity with sectioned pulmonary veins, artery and bronchus is shown from the anterior side of the patient. The cavity is filled with saline and tested for air leaks with a valsalva manoeuvre with about 30 cm H2O static pressure.
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Video 8 After excluding an air leak, clips for postoperative radiotherapy are placed around the hilum and the bronchial stump is covered with pericardial fat.
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Before or after removing the lung, a lymph node dissection is performed involving the superior tracheobronchial and paratracheal lymph nodes, the subcarinal nodes, the nodes along the pulmonary ligament, the oesophagus, and the anterior mediastinal lymph nodes. These lymph nodes correlate with stations 2, 3, 4, 7, 8, 9 and 10 on the right side, and with stations 4, 5 (Video 9), 6, 7 (Video 10), 8 (Video 11), 9 (Video 12) and 10 (Videos 13 and 14) on the left side according to the lymph node mapping by Mountain et al. [8] (Schematics 5 and 6).
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Video 9 Lymph node station 5 between the aortic arch and the pulmonary artery is removed.
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Video 10 Lymph node station 7 is removed. In this video lymph node station 7 was removed before sectioning the bronchus which is retracted anteriorly. Therefore, a posterior view between the left main bronchus and the descending aorta is presented.
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Video 11 Lymph node station 8 is removed. This station is located along the oesophagus. In this video the node is dissected from the posterior side with the lung retracted anteriorly.
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Video 12 After dividing the inferior pulmonary ligament, lymph node station 9 is dissected from the inferior pulmonary vein close to the left lower lobe.
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Video 13 Lymph node 10 anterior is found at the anterior aspect of the left main bronchus.
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Video 14 Lymph node 10 posterior is found at the posterior aspect of the left main bronchus. It is in close connection with the bronchus and must not be confused with lymph node station 5 located more cranial between the pulmonary artery and the descending aorta.
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Schematic 5 Regional lymph nodes, stations 1 to 14 (reproduced from Ref. [14] with permission from Lippincott Williams & Wilkins).
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Schematic 6 Regional lymph nodes, stations 5 and 6 (reproduced from Ref. [14] with permission from Lippincott Williams & Wilkins).
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Although not an absolute indication, we leave a chest tube in the hemithorax to obtain pressure control in the postpneumonectomy space and to detect any significant blood loss during the first posteroperative hours. This tube is connected to a commercially available ‘pneumonectomy’ balanced drainage system (MMCTSLink 49) maintaining the pressure between –15 and +1 cm H2O (Video 15). The tube is removed within 24 h. Other surgeons do not use a chest drain because of the risk of introducing microorganisms via this route, and prefer close clinical follow-up of the patients in the immediate postoperative period.
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Video 15 A thoracic drain is placed into the thoracic cavity. Next the chest tube is fixed with Mersuture and a purse string suture is placed for removal of the drain after 24–48 h. This chest tube is connected to a commercially available balanced drainage system.
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Results
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According to specific risk stratification the perioperative death rate after pneumonectomy for lung cancer varies from 0 to 25% [9]. Several risk factors have been demonstrated like age, pulmonary function, induction chemo- or chemoradiotherapy, failure to extubate and excess fluid administration postoperatively. Especially a right-sided pneumonectomy is associated with a higher mortality, even in the absence of induction chemotherapy [10]. Complications after a pneumonectomy involve mainly cardiac and respiratory problems like cardiac arrhythmia, myocardial infarction, pneumonia, pulmonary embolus, respiratory failure, bronchopleural fistula and empyema [11,12]. Although a pneumonectomy is reserved for primary tumour involving the main stem bronchus or the pulmonary artery proximally or when it extends clearly across the fissure, the long-term survival is only slightly lower for a pneumonectomy compared to lesser resection [11], also depending on the specific stage. It is possible that part of this survival difference can be explained by the higher operative mortality and late complications of pneumonectomy. In some cases bronchial or pulmonary artery sleeve resection provides an alternative to pneumonectomy and gives good long-term results when a complete resection can be obtained [13].
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Acknowledgements
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We thank Kurt Kerkhofs, Frank Van Coppenolle and Vic Jauniaux of the Audiovisual Centre of the University of Antwerp for their help in making this video presentation.
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References
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- Graham EA, Singer JJ. Successful removal of an entire lung for carcinoma of the bronchus. JAMA 1933;101:1371.
- Rienhoff WFJr, Pneumonectomy. A preliminary report of the operative technique in two successful cases. Bulletin of the Johns Hopkins Hospital 1933;53:390.
- Churchill ED, Discussion on papers on cancer of the lung. J Thorac Cardiovasc Surg 1934;4:192.
- Overholt R, Pneumonectomy for malignant and suppurative disease of the lung. J Thorac Cardiovasc Surg 1939;9:17.
- Crafoord C, Pulmonary ventilation and anesthesia in major chest surgery. J Thorac Cardiovasc Surg 1940;9:237–253.
- Rienhoff WFJr, Gannon J, Sherman I. Closure of the bronchus following total pneumonectomy. Experimental and clinical observations. Ann Surg 1942;116:481.[Medline]
- Brewer LA3rd, King EL, Lilly LJ, Bai AF. Bronchial closure in pulmonary resection: a clinical and experimental study using a pedicled pericardial fat graft reinforcement. J Thorac Cardiovasc Surg 1953;26:507–532.
- Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest 1997;111:1718–1723.[Abstract/Free Full Text]
- Romano P, Mark D. Patient mortality and hospital characteristics related to in-hospital mortality after lung resection. Chest 1992;101:1332–1337.[Abstract/Free Full Text]
- Darling GE, Abdurahman A, Yi QL, Johnston M, Waddell TK, Pierre A, Keshavjee S, Ginsberg R. Risk of a right pneumonectomy: role of bronchopleural fistula. Ann Thorac Surg 2005;79:433–437.[Abstract/Free Full Text]
- Watanabe S, Asamura H, Suzuki K, Tsuchiya R. Recent results of postoperative mortality for surgical resection in lung cancer. Ann Thorac Surg 2004;78:999–1002.[Abstract/Free Full Text]
- De Decker K, Jorens PG, Van Schil P. Cardiac complications after noncardiac thoracic surgery: an evidence-based current review. Ann Thorac Surg 2003;75:1340–1348.[Abstract/Free Full Text]
- Deslauriers J, Grégoire J, Jacques LF, Piraux M, Guojin L, Lacasse Y. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences. Ann Thorac Surg 2004;77:1152–1156.[Abstract/Free Full Text]
- Shields T, editor. General Thoracic Surgery, 6th edition, Lippincott Williams & Wilkins, 2005.
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Summary
Introduction