How I do a Lung Resection

 
  1. 1.Lateral decubitus position

  2. 2.Double lumen endo-tracheal tube

  3. 3.Incision - postero-lateral

  4. 4.Divide adhesions - before spreading the ribs and before deflating the lung

  5. 5.Fissure - get started before deflating the lung

  6. 6.Deflate the lung - if it won’t deflate get another pair of hands and make sure the incision is big enough

  7. 7.Divide Inferior Pulmonary Ligament - encircle IPV at this stage and take IPV node [determines IPV operability]

  8. 8.Continue this plane of dissection along the pleura in front of the aorta (in front of the oesophagus/vertebral column on the right)

  9. 9.Retract vagus (this retracts the oesophagus and exposes the subcarinal nodes - divide bronchial arteries and vagal branches to the lung

  10. 10.Subcarinal dissection - retract vagus/oesophagus and dissect posterior surface of pericardium. [Determines bronchial operability]

  11. 11.Dissect visceral pleura from back of main bronchus, with a mixture of sharp dissection and blunt dissection with a pledget. When you reach lymph nodes the PA branches in the fissure are not far away.

  12. 12.Expose main PA [determines PA operability]

    1. 1.on the left dissect AP window nodes (beware of the recurrent laryngeal node),

    2. 2.there is a constant vagal branch overlying the left PA which must be divided and ligated (do not diathermy). This exposes the PA superiorly.

    3. 3.on the right dissect pleura below the azygous, divide bronchials and remove the tracheo-bronchial nodes, dissect the plane between the SVC and PA

    4. 4.enter the adventitia and divide it on either side

    5. 5.blunt digital dissection only, pushing adventitia away from the vessel

    6. 6.after passing a finger around the PA guide a Craaford around it and emcircle it with a sloop

    7. 7.if the anaesthetist keeps having to inflate the lung because of the shunt, clamp the PA with a Sitinsky

    8. 8.on the left side continue the dissection of the posterior PA into the fissure to define its posterior extent

  13. 13.Anterior pleura - encircle superior vein by dissecting off the adventitia at this stage [determines SPV operability] allows definition of the front end of the fissure (beware of the phrenic)

  14. 14.Fissure - nodes indicate you are getting close to the PA. Stay close to the surface of the nodes and you won’t hit anything.

  15. 15.Enter adventitia and bluntly dissect (posteriorly on the left, anteriorly on the right, avoiding RML branches), beware of "trivial" branches

  16. 16.Having defined the PA branches use a Roberts to define the plane of the fissure - go back towards the bronchus and feel the tip with the left hand. (In upper lobectomy it is often easier to take the SPV first)

  17. 17.Double ligate PA branches

  18. 18.Ligate and transfix vein or double ligate at "Y" division

  19. 19.Sweep bronchial nodal tissue back towards resected lung

  20. 20.Apply stapler

  21. 21.Check that the other lobes expand

  22. 22.Fire stapler

  23. 23.Cut distal to stapler

  24. 24.Test stump to 40 cm H20 (35 for a lobe)

  25. 25.Complete node dissection - paratracheal in particular

  26. 26.Haemostasis

  27. 27.Suture RML to prevent rotation

  28. 28.Place 28 Fr apical and 32 Fr basal drains - suture to apical pleura and diaphragm respectively if necessary

  29. 29.If no epidural in situ, place extrapleural cannula for Marcaine(0.25% at 5ml per hour)

  30. 30.Closure

    1. 1.4 pericostal (1 Vicryl on blunt needle)

    2. 2.Serratus fascia (0 Vicryl)

    3. 3.Latissimus dorsi (0 Vicryl)

    4. 4.Subcutaneous (2/0 Vicryl)

    5. 5.Subcuticular (undyed 2/0 Vicryl)

  31. 31.Make sure drains are working after the patient has been placed on the bed and before he leaves theatre.

  32. 32.Check CXR, heart rhythm and rate, Sa02 , pain relief in recovery ward before starting next case