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DESCRIPTIONThe 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.
- 1. PULMONARY RESECTIONProfessorAbdulsalam Y TahaSchool of MedicineUniversity of SulaimaniIraqhttps://sulaimaniu.academia.edu/AbdulsalamTaha
2. Pertinent Anatomy2 10/15/14 3. Anatomic resections of the lung (includingpneumonectomy and lobectomy)are the standard operative techniques employedto treat both neoplastic andnonneoplastic diseases of the lung. Any surgeonwho intends to operate onthe pulmonary system must be keenly aware ofthe anatomy of the pulmonaryvasculature, the bronchi, and the relation betweenthe two. There is nosubstitute for this degree of familiarity.3 10/15/14 4. 4 10/15/14 5. 5 10/15/14 6. 6 10/15/14 7. 7 10/15/14 8. 8 10/15/14 9. A broncho-pu , lmonary segment consists of a tertiary bronchus.the portion of lung it ventilates, an artery, and a vein9 10/15/14 10. )The right side of the mediastinum is the ( blue side, dominated by the arch of the azygos vein, the SVC10 .and the right atrium 10/15/14 11. ,The left side of the mediastinum is the red side, dominated by the arch and descending portion of the aorta11 .the left common carotid and subclavian arteries 10/15/14 12. 12 10/15/14 13. 13 10/15/14 14. 14 10/15/14 15. HISTORYAlthough the five patients operated on by Block (1883),Kronlein (1884) and Ruggi (1885) died following attemptedpartial resection of their tuberculous lungs, Tuffiersuccessfully resected the apex of the right lung of a 25years old man in 1891. The use of the individual ligationtechnique as proposed by Blades and Kent madepulmonary resection a safe procedure Ain general. In 1933,both Graham and Rienhoff, independently performedsuccessful pneumonectomy using this technique. Thefollowing decades have been refinements of surgicaltechniques and anaesthetic management in the field ofthoracic surgery. The efforts of surgeons of the 1930s and1940s culminated in the perfection of pulmonary resectionaltechniques currently practiced. In Iraq, pulmonary resectionstarted in the treatment of pulmonary tuberculosis in early.115950s 10/15/14 16. :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 it16 10/15/14 17. Types of Pulmonary ResectionSimple pneumonectomy*Radical pneumonectomy*Simple lobectomy*Radical lobectomy*Bilobectomy: performed in the right lung, *conserving either the upper or the lowerlobe.(when a tumour extends across a lobarfissure, or invades bronchus intermedius, or( endobronchial tumour or absent fissureExtended resection: when a lobectomy or *pneumonectomy is combined with enbloc.resection of involved contagious structuresSegmentectomy*Wedge resection*Palliative resection*Sleeve lobectomy: when the primary tumour *encroaches upon the lobar orifice,precluding complete resection with margins.by standard lobectomyRadical resection refers to lobectomy orpneumonectomy combined with enbloc17 .mediastinal lymphadenectomy 10/15/14 18. Thorough preoperative evaluation andpreparation of the patient reduces the morbidityand mortality of thoracotomy and pulmonaryresection. Pulmonary function tests and analysisof arterial blood gases help determine thefeasibility of pulmonary resection. Postoperativepulmonary function is estimated by calculatingthe preoperative function and projectedresection of pulmonary parenchyma. Patientsare excluded from surgical therapy if estimatedpost-operative pulmonary function falls below.minimum acceptable values18 10/15/14 19. AnaesthesiaAlthough pulmonary resections can be performed withbilateral lung ventilation, careful hilar dissection isgreatly facilitated by using unilateral lung ventilation.The advent of double-lumen endotracheal tubes andbronchial blockers has made it possible to isolate theipsilateral lung and has made it easier for surgeons tocarry out complex hilar dissections with the requiredprecision. In patients with centrally located tumors, caremust be taken with tube placement: inadvertent traumato an endobronchial tumor during placement of adouble-lumen tube can lead to significant bleeding andcompromise of the airway. Bronchoscopic confirmationof tube position is recommended after the patient has.been positioned19 10/15/14 20. INCISIONSPosterior lateral thoracotomy remains the standardincision for anatomic pulmonary resections;however, safe and complete resections can alsobe performed through a variety of smallerincisions, including posterior muscle-sparing,anterior muscle-sparing, and axillarythoracotomies. In most cases, the thorax isentered at the fifth intercostal space, an approachthat affords excellent exposure of the hilarstructures. The anterior muscle-sparingthoracotomy is generally placed at the fourthintercostal space because of the more caudalpositioning of the anterior aspects of the ribs.Although a sternotomy may be employed to gainaccess to the upper lobes, it does not provide goodexposure of the lower lobes 20 and the bronchi. 10/15/14 21. The technique of pulmonary resection haddramatically changed from mass ligation ofpulmonary hilum to individual ligation of hilarstructures and recently to video-assistedthoracoscopic pulmonary resection. However,the safe performance of lung resectionrequires a perfect knowledge of hilar anatomyand a technique with which the surgeon is.familiar21 10/15/14 22. Traditionally, during a lobectomy, the arterialbranches are divided first, followed by the venousbranches. However, if conditions exist that limitexposure (e.g., a centrally placed tumor orsignificant inflammation and scarring(, thesurgeon should start with the structures thatprovide the most accessible targets. Veins maybe ligated first. Proponents of this approachbelieve that it may limit the escape of circulatingtumor cells (an event that rarely, if ever, occurs(;opponents claim that initial vein ligation may leadto venous congestion and retention of blood thatis subsequently lost with the specimen, thoughperibronchial venous channels will frequentlyprevent this result.22 10/15/14 23. The bronchus may also be ligated first.However, there are two points that shouldbe kept in mind if this is done. First, thedistal limb of the bronchus (the specimenside( should be oversewn to preventdrainage of mucus into the chest. Second,after division of the bronchus, the lobe ismuch more mobile; therefore, to preventavulsion of the pulmonary artery branches,care should be taken not to employexcessive torsion or traction.23 10/15/14 24. The techniques used for dissection, ligation, anddivision of pulmonary arteries and their branchesdiffer from those used for other vessels. Pulmonaryvessels are low-pressure, high-flow, thin-walled,fragile structures. Accordingly, for rapid and safedissection, a perivascular plane, known as the planeof Leriche, should be sought. This plane may beabsent in the presence of long-standinggranulomatous or tuberculous disease, after majorchemotherapy, after thoracic radiotherapy, and incases of reoperation. In these situations, proximalcontrol of the main pulmonary artery and the twopulmonary veins may be necessary before the moreperipheral arterial dissection can be started. Beforeany pulmonary vessel is divided, it should becontrolled either with two separate suture ligaturesproximal to the line of division or with vascularstaples; stapling devices are especially useful forlarger vessels.24 10/15/14 25. Exposure of the bronchus should notinvolve stripping the bronchial surface of itsadventitia. Aggressive dissection maycompromise the vascular supply and leadto impaired healing and bronchialdehiscence. Overlying nodal tissues shouldbe cleared, and major bronchial arteriesshould be clipped just proximal to the pointof division. Bronchial closure has beengreatly facilitated by the use of automaticstaplers.25 10/15/14 26. When bronchial length is limited, onemay perform suture closure of thebronchial stump rather than attempt toforce a stapler around the bonchus.Whenever there is a high risk ofbronchial stump dehiscence (e.g., afterchemotherapy, radiotherapy, orchemoradiotherapy; in patients forwhom adjuvant therapy is planned; orafter right pneumonectomy), avascularized rotational tissue flap (e.g.,from the pericardium, the pericardial fatpad, or intercostal muscle) should beused to reinforce 26 the bronchial closure. 10/15/14 27. Shown is the surgeon's view of theright interlobar fissure. Thefissures have been completed, andthe segmental arteries to theupper, middle, and lower lobeshave been identified. The posteriorascending branch to the upperlobe most commonly varies withrespect to size and origin. Thisvessel may be absent or diminutiveand may arise from the superiorsegmental branch to the lowerlobe. The posterior segmental veindraining into the superiorpulmonary vein (not seen) isclearly visualized in the right upperlobe, lateral to the pulmonary.artery branches27 Right Upper Lobectomy 10/15/14 28. Shown is the surgeon's view ofthe anterior right hilum. Theapical venous branches of thesuperior pulmonary veinobscure the interlobarpulmonary artery and, to alesser degree, the truncusanterior branch. Division ofthese venous branches duringupper lobectomy improvesexposure of the truncusanterior. The splitting of themain pulmonary artery into itstwo main branches may occurmore proximally, and careshould be taken to identify bothbranches before either one isdivided. Another significantpossible variation is a branchof the middle-lobe vein thatarises from the intrapericardialportion of the superior.pulmonary vein28 10/15/14 29. Shown is the surgeon's view of theposterior right hilum. The carina, theright mainstem bronchus, the right upperlobe, and the bronchus intermedius areeasily seen. The interlobar sump nodehas been removed and the fissurecompleted, and the posterior ascendingbranch of the pulmonary artery is visible.Care should be taken not to injure thisvessel during division of the fissure. Itcan be ligated via this approach if itcannot be adequately exposed from thefissure. Both the truncus anterior and theposterior ascending branch of thepulmonary artery lie directly anterior tothe right upper-lobe bronchus, and careshould be taken not to injure thesevessels during bronchial encirclement.The bronchial arteries course along themedial and lateral edges of the bronchus.intermedius29 10/15/14 30. Shown is thesurgeon's viewof the rightmiddle-lobebronchus.Gentleretraction ofthe basilarsegmentalartery to thelower lobeposteriorlyallows clearvisualization ofthe origin of themiddle-lobe.bronchus30 10/15/14 31. Shown is the surgeon's view of the right inferior pulmonary vein.For encirclement of this vein, dissection may also have to beperformed on its anterior surface. The branch to the superiorsegment can be seen overlying the origin of the superior31 segmental bronchus. 10/15/14 32. 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 bronchusto the superior 32 segmental and basilar bronchi. 10/15/14 33. Shown is the surgeon's view of the left interlobar fissure. The recurrent laryngeal nerve can beseen coursing lateral to the ligamentum arteriosum. The arterial branches supplying the leftupper lobe between the apicoposterior segmental branch and the lingular branch can varysubstantially in number and size. Another frequently encountered variation is a distal lingularbranch that arises 33 . from a basilar segmental branch 10/15/14 34. Shown is the surgeon'sview of the anterior lefthilum.The apical branches ofthe superior pulmonaryveincourse anterior to theapicoposterior branchesof thepulmonary artery. Ifadditional vessel lengthis neededbecause of thepresence of a centraltumor, thepericardium may beentered and the veindivided at that location.34 10/15/14 35. Shown is the surgeon's view of the left fissure after division . of the upper-lobe arteries.C3a5re should be taken not to injure the pulmonary artery inadvertently when applying1 0a/1 s5t/a1p4ler 36. Shown is the surgeon's view of the left . inferior pulmonary veinThe left side, unlike the right side, affords only limited accessto the subcarinal space. However, the length of the inferiorpulmonary vein outside the pericardium is greater on the left.side than on the right 36 10/15/14 37. 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 bronchuscan 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-lobebronchus arises from 37 the bronchus intermedius. 10/15/14 38. Shown is the surgeon's view of the posterior left hilum. The carina islocated deep under the aortic arch. A left-side double-lumen tube orbronchial blocker may have to be withdrawn to afford better exposureof the proximal left mainstem bronchus. The orientation of thesuperior pulmonary vein and the pulmonary artery (anterior and38 .superior to the bronchus, respectively) should be noted 10/15/14 39. Right pneumonectomy39 10/15/14 40. Left pneumonectomy40 10/15/14 41. Segmentectomy41 10/15/14 42. RUL bronchoplasty42 10/15/14 43. LUL bronchoplasty43 10/15/14 44. LUL sleeveresection withbronchoplaty44 10/15/14 45. LMB sleeveresection withbronchoplasty45 10/15/14 46. LMB sleeveresection withbronchoplasty46 10/15/14 47. LLL bronchoplasty47 10/15/14 48. Pleural flap reinforcementof bronchial closure48 10/15/14 49. Open bronchus techniquefor bronchial closure49 10/15/14