When bringing a patient round to the recovery room after a thoracotomy, I am often reminded of a Formula 1 driver taking a corner. Michael Schumacher knows that if he sets his car up correctly going into a corner, with the correct braking, correct speed and correct line, the car takes the corner by itself with very little further intervention from himself ... and pity help anyone who tries to encroach on his setup!

Similarly, if you set up a patient with the drains on the right place, the fluids and electrolytes right, correct analgesia, the bronchodilators right, there will be little further intervention required. The patient has a more stable postop course and you get to have a decent night’s sleep.

Before closing the chest ...

Air leaks

Attention to major leaks at the end of surgery will prevent persistent air leak, pleural space problems and empyema. The emphysematous lungs of smokers will start to leak from all your suture holes so there does come a time when you have to accept residual small air leaks and close up. Oversew leaking staple lines and parenchymal leaks with Teflon buttressed sutures. Consider tissue sealants - one cannot tell in the operating theatre who is going to have a persistent air leak so you have decide all cases or no cases. I do consider sealants in VATS lobectomies as they are often heading home when the drains are still in, keeping them back.

Getting the lung to re-inflate completely and fill the space is what resolves all air leaks and space problems, including major lobar bronchial dehiscence. I routinely release the inferior pulmonary ligament to allow the residual lobe to rotate into the apex.  Some surgeons believe that this increases the risk of torsion of the residual lung. All torsions I have seen have been associated with haemorrhage which may have been the cause. I have seen far more space problems resulting from failure to divide the ligament.

Bleeding

It is unlikely that a major pulmonary vessel will be bleeding, though obviously all major vessels should be checked before closure. Lung parenchyma will also stop bleeding fairly quickly, even if air leak persists. Systematically check the inferior pulmonary ligament, bronchial vessels, node dissection sites and the thoracotomy wound itself as these are the commonest sites requiring re-opening for bleeding. Bleeding may only start after the patient wakes up and the blood pressure rises.

Lobar torsion

Lobar torsion does occur and it can happen with any lobe that is left on a narrow pedicle. The lobe most likely to tort is the middle lobe. I routinely suture or staple the middle lobe to the residual lobe. This is mainly for medicolegal purposes because the middle lobe frequently has some consolidation on postop Xrays and one is always open to criticism if you have made no effort to prevent torsion (and recorded it in the op note!)

Drains

Placing the drains in the right position will overcome a multitude of sins. Theoretically, if the lung is sealed with a tight staple line or with tissue sealant, all air is evacuated by inflating the lung and the incisions closed while positive pressure is maintained, no drains would be required. However it is rare that all the above are achieved, except in a straightforward thoracoscopic lung biopsy.

Again, theoretically, only one drain is required, a good apical drain. The lung acts as a “balloon in a box” and with a few good coughs, the balloon will fill the box and evacuate all air and blood. Unfortunately in the immediate postoperative period the patient is likely to be drowsy and in some pain and will therefore have an ineffective cough. Usually they cannot cough blood out of the apical drain. I usually place a basal drain for the first 24 hours or so. After that, a good cough will evacuate blood through the apical drain.

Pain relief

The surgeon and anaesthetist together should have decided on a pain relief strategy. If there is an epidural the surgeon should add a phrenic nerve block to prevent shoulder tip pain. If no epidural is placed, an extrapleural, paravertebral infusion or intercostal blocks should be administered.

In Recovery ...

Electrolytes - get baseline K+(>4.5mmol/l) and Mg++ (>1mmol/l) and replace to normal thoracic levels

Bleeding - it is hard to give useful advice on what bleeding to tolerate. Most lung procedures will drain about 200-300cc in the first hour or two, after which bleeding will settle to 50cc per hour. Any bleeding over and above this is abnormal and should be investigated with a view to re-exploration

Suction - if needed make sure it is attached correctly and the settings on the gauge are correct or that there is bubbling through the suction control column of a multichamber bottle. (I routinely apply suction for 24 hours as again the patients usually have an ineffective cough in the immediate postop period) 

Secretions - smokers and COPD patients will have trouble clearing secretions. Placement of a prophylactic minitracheostomy (cricoidotomy) will prevent sputum retention in most of these.

Pain relief - anaesthetist should have epidural/PCAS in place. Check these and add the following as indicated

1. •Paracetamol
   

2. •NSAID - over 60 years of age all will require cover with PPI. Caution should be applied if patient has a peptic history
   

Nitrate patches - patients with symptomatic angina may benefit from a nitrate patch (as long as BP is maintained)

Thromboprophylaxis - check regime is written on drug chart as per protocol.

Arrythmias - ensure that B blockers have not been stopped. Change to appropriate IV if necessary.

Chest Xray - ensure

1. •drains are in correct place
   

2. •CVC and other cannulae in correct place
   

3. •no haemothorax
   

4. •no pneumothorax
   

5. •contralateral lung has no atelectasis or pneumothorax