Pulmonary surgery

Indications

• Malignancy: primary bronchial carcinoma, bronchial carcinoid etc

• Inflammatory: lung abscess, tuberculosis, bronchiectasis etc

• Trauma: stab wounds, gun shot wounds

• Degenerative: large lung bullae

• Congenital: arterio-venous fistula, lobar emphysema

1. Pneumonectomy

• Entire lung is removed

• Radical pneumonectomy: mediastinal lymph nodes and part of chest wall may also be
removed

• Cavity filled by protein rich fluid and fibrin

• Cavity size reduced by lateral shift of trachea and heart, upwaed shift of diaphragm,
reduction of intercostal spaces on the operated side

• Occasionally scoliosis may develop

• Any of the five lobes maybe removed

• Right side: middle and lower lobes are removed together

• Sleeve lobectomy: tumor in the upper lobe protrudes into main bronchus- cuff of main
bronchus removed along with lobe
3. Segmental resection

• Bronchopulmonary segment removed with its segmental artery and bronchus

• Indicated for Tb

4. Wedge Resection

• Non anatomical resection

• Diagnosis in open lung biopsy

• Treatment of well localized peripheral carcinomas in patients with reduced lung function
Pre- Operative Investigations

1. Bronchoscopy

• Two separate techniques:

a. Via flexible fibre optic instrument in a conscious patient: allows to see further into
subsegmental bronchi

b. Via rigid instrument in a patient under general anaesthetic: better assessment of

• Small transverse incision made 1cm above the suprasternal notch

• Strap muscles are separated and paratracheal fascia entered

• Not all lymph node groups in the mediastinum can be reached by this technique

• Anterior mediastinotomy: mediastinoscope is passed through the 2nd or 3rd intercostal space
and biopsy taken.
3. CT Scan

• Thorax and upper abdomen to include adrenals

• Identifying metastatic deposits in the liver or adrenals

• Detect enlarged mediastinal lymph nodes

• Confirmed with mediastinoscopy or mediastinotomy

• Clinical assessment alone may be sufficient

• Respiratory function tests are helpful in borderline cases

• If FEV1/FVC ratio is <40% of the predicted value or PaO2 >40mmHg: surgery

• Ventilation-perfusion scans may also be helpful

• Postero-lateral incision: divides lower fibres of trapezius, latissimus dorsi, serratus anterior
and the external and internal intercostal muscles

• High posterior extension of the incision divides rhomboid major and the erector spinae
group

• Antero-lateral thoracotomy: standard approach

1. Closed drainage

• Tube with end and side holes is introduced into the thorax via an intercostal space

• Connected to a closed bottle via a transparent tube which ends under water

• A second short tube left unconnected maintains atmospheric pressure within the bottle

• Simple one way valve

• If short tube connected to suction apparatus- air pressure in bottle reduced below atm
pressure

• Allows for easy measurement of blood loss

• Fluid level ceases to swing: lung fully expanded or tube blocked

• If connected to suction: no swing

• Drainage bottle to be kept at a lower level than that of the patient’s chest

• Drains should not be clamped

• After pnemonectomy: ICD rarely used

• Other lung resections: one at the apex of pleural cavity and other at the base used
2. Open drainage

• Tube in the pleural cavity connects directly with air

• Only safe when pleural cavity has become rigid and immovable

• Drain chronic empyema

Early (0-2 weeks)

Local complications

• Haemorrhage

• Atelectasis

• Wound infection

• Surgical emphysema

• Pleural effusion

• Empyema
• Broncho-pleural fistula

• Nerve damage: eg: recurrent laryngeal nerve, phrenic nerve

General complications

• Ventilator insufficiency

• Atrial fibrillation

• Myocardial infarction

• Pulmonary embolism/ DVT

• Cerebrovascular accident
Late complications

Local

• Thoracotomy wound pain

• Recurrence of carcinoma

• Chest wall deformity

• Restricted arm movement

General

• Distant spread of carcinoma

• Breakdown of the bronchial stump

• Occurs around 10th postoperative day

• Recognized by dyspnea, an irritating cough and possible expectoration of dark fluid

• Associated empyema inevitable

• Patient should be sat up or turned on to the operated side to prevent spill-over of infected
fluid into the remaining lung
Thoracotomy (excluding pneumonectomy)

Pre-operative period

• Overall assessment of the patient

Objectives

1. Maintain full joint range and adequate circulation

2. Maintain correct posture

3. Maintain adequate ventilation

4. General mobility is encouraged

5. Teach effective coughing

6. Remove excessive secretions

Following surgery and before each treatment PT should check:

• Type of operation Drug chart

• Incision Fluid chart

• Chest X-ray Oxygen therapy

• Temperature Drains- amount of fluid drained

• Pulse rate - whether or not there is air leak

• Respiratory rate - whether on or off suction

• Blood pressure - if suction off- whether or not drain is

swinging
Post operative problem list

1. Pain

2. Intercostal drains in situ

3. Decreased air entry

4. Retained secretions

5. Decreased movement

6. Decreased mobility

7. Poor posture
Post operative treatment plan

• Ensure patient has adequate analgesia

• Ensure patency of draining tubes- milking

• Deep inspiratory breathing exercises

• Full range active/ assisted arm exercises

• Early mobilization

• Trunk, shoulder girdle exercises and postural correction

Day of surgery

• Oxygen therapy

• Full range active/ assisted shoulder movements

• Breathing exercises

• Splinted coughing
Day 1

• Side lying: unaffected sided

• Sit out of bed- pillows should be used

• Encourage to practise breathing, coughing, limb and shoulder girdle exercises and correct
his posture regularly during the day

Day 2

• Chest PT 2-3 times

• Sitting on firm chair

• Trunk exercises
• Mobilization

• Stair climbing

Day 3 to Discharge

• Assess on a day to day basis

• Postural exercises and general activities should be progressed

• Follow up not necessary until shoulder has been a particular problem

Pre-operative

• Explain simple details of surgery

• Instruct not to lie on good side for at least 10days post surgery

• Huffing technique should be taught

Post operative problem list

• Pain

• Decreased air entry

• Retained secretions
• Decreased shoulder movement on the affected side

• Decreased mobility

• Poor posture

• Decreased exercise tolerance

Post operative treatment plan

• Ensure patient has adequate analgesia

• Deep breathing exercises

• Full range active/assisted exercises

• Active leg, foot and ankle exercises

Post operative regime

• Oxygen therapy

• Should not cough

• Check if there is any deficit between the apex and the radial pulse

• Side lying position