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Lobectomy


Medical editor Steinar Solberg MD
Thoracic Surgeon

Oslo University Hospital
Norway

General

Commonly, at least one lobe is surgically removed. In patients with reduced lung function, a more limited resection is carried out (wedge or segment resection). If the tumor includes more than one lobe, or is situated centrally, a bilobectomy or pneumonectomy may be necessary.

A pneumonectomy is a greater burden to the patient than a (bi)lobectomy and is therefore avoided unless it is the only way to remove all cancer tissue.

Indication

  • Lung cancer

Contraindications

  • Metastatic disease
  • Spreading to mediastinal lymph nodes
  • Invasion toward the heart and other central structures
  • Severe reduced lung function
  • Other risk factors/diseases

Goal

  • Complete removal of cancer tissue

Equipment

  • Thoracic tray with a large and small self retaining retractor
  • Equipment for stapling lung tissue, vessels, and bronchi
  • Possibly tissue glue or tissue tape to close air leakages from the lung surface after the operation

Preparation

Information should be given by the surgeon about the nature and risks of the operation. It is recommended that the patient's closest relative is present during the preoperative information meeting.

  • The procedure is carried out under general anesthesia and with selective ventilation of the two lungs. This is to stop ventilation of the operated lung so it can be collapsed to lie still. Good surgical access is essential.
  • Most patients will have an epidural catheter before the operation for postoperative pain relief.
  • The patient lies on his/her side.

Implementation

Thoracotomy

The most common surgical entrance to the pleural cavities is through a lateral thoracotomy. An anterolateral incision is the most common surgical entrance, because it minimizes division of muscle tissue.

  • The skin over the area is incised and the soft tissue is split or mobilized.

The entrance to the pleural cavity is usually through 5-7 intercostal spaces depending on the location of the tumor.  

  • The ribs are retracted after the intercostal muscles are split. This gives good access to the pleural cavity and the lung. 
  • The pulmonary ligament is divided up to the lower pulmonary vein, whether a (bi)lobectomy or pneumonectomy is performed.
  • The pleura is opened around the entire lung hilum.
  • The lung lobes are examined to assess how well-defined the lobes are and where they can be separated from each other.

Lobectomy/bilobectomy

Only one lobe is usually removed when the tumor is confined to single lobe. In some cases, the anatomy and/or pathology are such that two lobes must be removed.

  • After the pulmonary ligament is split and the hilum is opened, the lobe fissure is cut to isolate the involved lobe from the rest of the lung tissue.
  • The pulmonary artery (with oxygen-poor blood) and pulmonary veins (with oxygen-rich blood) of the involved lobe are clamped and divided.
  • The bronchus to the involved lobe is dissected and the remaining end is closed.

Pneumonectomy

The incision is the same as for a lobectomy. A pneumonectomy is often more simple and expedient than a lobectomy. 

  • Veins, arteries, and the bronchus are dissected and cut centrally. There are fewer small branches to be divided and it is often unnecessary to open lobe fissures.
  • After the lung/lobe is removed, the operation field is always checked for air leakage and bleeding. 
  • Lymph nodes and lymph node-containing tissue should be resected after the lung is removed.
  • All tissue that is removed is sent to pathology for assessment.

Drain/closure of thoracotomy

After a (bi)lobectomy, two drains are routinely installed. One is placed basally to collect fluid and the other is placed over the top of the lungs to drain air.

  • The drains are connected to active suction equivalent to a column of water of 10–20 cm.
  • After a pneumonectomy, only one drain is installed which should not have active suction.
  • The ribs which are separated are pulled together with thick, absorbable sutures.
  • The muscles as well as the subcutis are adapted with absorbable sutures. Finally, the skin is sutured.

Follow-up

The patient is monitored at the postoperative unit for the first 24 hours. An X-ray check is performed. Heart rhythm and blood gases are monitored. 

  • The drain is usually removed 2-4 days after the operation.
  • The patient may return home after 4-7 days.

The patient is followed-up locally by a lung specialist or general practitioner. When additional treatment with chemotherapy or radiation therapy is needed the patient will be followed up by an oncologist.


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