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Pulmonary resection

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Pulmonary resection

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The 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.

The 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.

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Pulmonary resection

  1. 1. PULMONARY RESECTION Professor Abdulsalam Y Taha School of Medicine University of Sulaimani Iraq https://sulaimaniu.academia.edu/AbdulsalamTaha
  2. 2. Pertinent Anatomy 2 10/15/14
  3. 3. Anatomic resections of the lung (including pneumonectomy and lobectomy) are the standard operative techniques employed to treat both neoplastic and nonneoplastic diseases of the lung. Any surgeon who intends to operate on the pulmonary system must be keenly aware of the anatomy of the pulmonary vasculature, the bronchi, and the relation between the two. There is no substitute for this degree of familiarity. 3 10/15/14
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  9. 9. A broncho-pu , lmonary segment consists of a tertiary bronchus .the portion of lung it ventilates, an artery, and a vein 9 10/15/14
  10. 10. )The right side of the mediastinum is the ( blue side , dominated by the arch of the azygos vein, the SVC 10 .and the right atrium 10/15/14
  11. 11. ,The left side of the mediastinum is the red side , dominated by the arch and descending portion of the aorta 11 .the left common carotid and subclavian arteries 10/15/14
  12. 12. 12 10/15/14
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  15. 15. HISTORY Although the five patients operated on by Block (1883), Kronlein (1884) and Ruggi (1885) died following attempted partial resection of their tuberculous lungs, Tuffier successfully resected the apex of the right lung of a 25 years old man in 1891. The use of the individual ligation technique as proposed by Blades and Kent made pulmonary resection a safe procedure A in general. In 1933, both Graham and Rienhoff, independently performed successful pneumonectomy using this technique. The following decades have been refinements of surgical techniques and anaesthetic management in the field of thoracic surgery. The efforts of surgeons of the 1930s and 1940s culminated in the perfection of pulmonary resectional techniques currently practiced. In Iraq, pulmonary resection started in the treatment of pulmonary tuberculosis in early .115950s 10/15/14
  16. 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 it 16 10/15/14
  17. 17. Types of Pulmonary Resection Simple pneumonectomy* Radical pneumonectomy* Simple lobectomy* Radical lobectomy* Bilobectomy: performed in the right lung, * conserving either the upper or the lower lobe.(when a tumour extends across a lobar fissure, or invades bronchus intermedius, or ( endobronchial tumour or absent fissure Extended resection: when a lobectomy or * pneumonectomy is combined with enbloc .resection of involved contagious structures Segmentectomy* Wedge resection* Palliative resection* Sleeve lobectomy: when the primary tumour * encroaches upon the lobar orifice, precluding complete resection with margins .by standard lobectomy Radical resection refers to lobectomy or pneumonectomy combined with enbloc 17 .mediastinal lymphadenectomy 10/15/14
  18. 18. Thorough preoperative evaluation and preparation of the patient reduces the morbidity and mortality of thoracotomy and pulmonary resection. Pulmonary function tests and analysis of arterial blood gases help determine the feasibility of pulmonary resection. Postoperative pulmonary function is estimated by calculating the preoperative function and projected resection of pulmonary parenchyma. Patients are excluded from surgical therapy if estimated post-operative pulmonary function falls below .minimum acceptable values 18 10/15/14
  19. 19. Anaesthesia Although pulmonary resections can be performed with bilateral lung ventilation, careful hilar dissection is greatly facilitated by using unilateral lung ventilation. The advent of double-lumen endotracheal tubes and bronchial blockers has made it possible to isolate the ipsilateral lung and has made it easier for surgeons to carry out complex hilar dissections with the required precision. In patients with centrally located tumors, care must be taken with tube placement: inadvertent trauma to an endobronchial tumor during placement of a double-lumen tube can lead to significant bleeding and compromise of the airway. Bronchoscopic confirmation of tube position is recommended after the patient has .been positioned 19 10/15/14
  20. 20. INCISIONS Posterior lateral thoracotomy remains the standard incision for anatomic pulmonary resections; however, safe and complete resections can also be performed through a variety of smaller incisions, including posterior muscle-sparing, anterior muscle-sparing, and axillary thoracotomies. In most cases, the thorax is entered at the fifth intercostal space, an approach that affords excellent exposure of the hilar structures. The anterior muscle-sparing thoracotomy is generally placed at the fourth intercostal space because of the more caudal positioning of the anterior aspects of the ribs. Although a sternotomy may be employed to gain access to the upper lobes, it does not provide good exposure of the lower lobes 20 and the bronchi. 10/15/14
  21. 21. The 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 21 10/15/14
  22. 22. Traditionally, during a lobectomy, the arterial branches are divided first, followed by the venous branches. However, if conditions exist that limit exposure (e.g., a centrally placed tumor or significant inflammation and scarring(, the surgeon should start with the structures that provide the most accessible targets. Veins may be ligated first. Proponents of this approach believe that it may limit the escape of circulating tumor cells (an event that rarely, if ever, occurs(; opponents claim that initial vein ligation may lead to venous congestion and retention of blood that is subsequently lost with the specimen, though peribronchial venous channels will frequently prevent this result. 22 10/15/14
  23. 23. The bronchus may also be ligated first. However, there are two points that should be kept in mind if this is done. First, the distal limb of the bronchus (the specimen side( should be oversewn to prevent drainage of mucus into the chest. Second, after division of the bronchus, the lobe is much more mobile; therefore, to prevent avulsion of the pulmonary artery branches, care should be taken not to employ excessive torsion or traction. 23 10/15/14
  24. 24. The techniques used for dissection, ligation, and division of pulmonary arteries and their branches differ from those used for other vessels. Pulmonary vessels are low-pressure, high-flow, thin-walled, fragile structures. Accordingly, for rapid and safe dissection, a perivascular plane, known as the plane of Leriche, should be sought. This plane may be absent in the presence of long-standing granulomatous or tuberculous disease, after major chemotherapy, after thoracic radiotherapy, and in cases of reoperation. In these situations, proximal control of the main pulmonary artery and the two pulmonary veins may be necessary before the more peripheral arterial dissection can be started. Before any pulmonary vessel is divided, it should be controlled either with two separate suture ligatures proximal to the line of division or with vascular staples; stapling devices are especially useful for larger vessels. 24 10/15/14
  25. 25. Exposure of the bronchus should not involve stripping the bronchial surface of its adventitia. Aggressive dissection may compromise the vascular supply and lead to impaired healing and bronchial dehiscence. Overlying nodal tissues should be cleared, and major bronchial arteries should be clipped just proximal to the point of division. Bronchial closure has been greatly facilitated by the use of automatic staplers. 25 10/15/14
  26. 26. When bronchial length is limited, one may perform suture closure of the bronchial stump rather than attempt to force a stapler around the bonchus. Whenever there is a high risk of bronchial stump dehiscence (e.g., after chemotherapy, radiotherapy, or chemoradiotherapy; in patients for whom adjuvant therapy is planned; or after right pneumonectomy), a vascularized rotational tissue flap (e.g., from the pericardium, the pericardial fat pad, or intercostal muscle) should be used to reinforce 26 the bronchial closure. 10/15/14
  27. 27. Shown is the surgeon's view of the right interlobar fissure. The fissures have been completed, and the segmental arteries to the upper, middle, and lower lobes have been identified. The posterior ascending branch to the upper lobe most commonly varies with respect to size and origin. This vessel may be absent or diminutive and may arise from the superior segmental branch to the lower lobe. The posterior segmental vein draining into the superior pulmonary vein (not seen) is clearly visualized in the right upper lobe, lateral to the pulmonary .artery branches 27 Right Upper Lobectomy 10/15/14
  28. 28. Shown is the surgeon's view of the anterior right hilum. The apical venous branches of the superior pulmonary vein obscure the interlobar pulmonary artery and, to a lesser degree, the truncus anterior branch. Division of these venous branches during upper lobectomy improves exposure of the truncus anterior. The splitting of the main pulmonary artery into its two main branches may occur more proximally, and care should be taken to identify both branches before either one is divided. Another significant possible variation is a branch of the middle-lobe vein that arises from the intrapericardial portion of the superior .pulmonary vein 28 10/15/14
  29. 29. Shown is the surgeon's view of the posterior right hilum. The carina, the right mainstem bronchus, the right upper lobe, and the bronchus intermedius are easily seen. The interlobar sump node has been removed and the fissure completed, and the posterior ascending branch of the pulmonary artery is visible. Care should be taken not to injure this vessel during division of the fissure. It can be ligated via this approach if it cannot be adequately exposed from the fissure. Both the truncus anterior and the posterior ascending branch of the pulmonary artery lie directly anterior to the right upper-lobe bronchus, and care should be taken not to injure these vessels during bronchial encirclement. The bronchial arteries course along the medial and lateral edges of the bronchus .intermedius 29 10/15/14
  30. 30. Shown is the surgeon's view of the right middle-lobe bronchus. Gentle retraction of the basilar segmental artery to the lower lobe posteriorly allows clear visualization of the origin of the middle-lobe .bronchus 30 10/15/14
  31. 31. Shown is the surgeon's view of the right inferior pulmonary vein. For encirclement of this vein, dissection may also have to be performed on its anterior surface. The branch to the superior segment can be seen overlying the origin of the superior 31 segmental bronchus. 10/15/14
  32. 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 single oblique application of the stapler depends on the proximity of the middle-lobe bronchus to the superior 32 segmental and basilar bronchi. 10/15/14
  33. 33. Shown is the surgeon's view of the left interlobar fissure. The recurrent laryngeal nerve can be seen coursing lateral to the ligamentum arteriosum. The arterial branches supplying the left upper lobe between the apicoposterior segmental branch and the lingular branch can vary substantially in number and size. Another frequently encountered variation is a distal lingular branch that arises 33 . from a basilar segmental branch 10/15/14
  34. 34. Shown is the surgeon's view of the anterior left hilum. The apical branches of the superior pulmonary vein course anterior to the apicoposterior branches of the pulmonary artery. If additional vessel length is needed because of the presence of a central tumor, the pericardium may be entered and the vein divided at that location. 34 10/15/14
  35. 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. 36. Shown is the surgeon's view of the left . inferior pulmonary vein The left side, unlike the right side, affords only limited access to the subcarinal space. However, the length of the inferior pulmonary vein outside the pericardium is greater on the left .side than on the right 36 10/15/14
  37. 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 bronchus can 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-lobe bronchus arises from 37 the bronchus intermedius. 10/15/14
  38. 38. Shown is the surgeon's view of the posterior left hilum. The carina is located deep under the aortic arch. A left-side double-lumen tube or bronchial blocker may have to be withdrawn to afford better exposure of the proximal left mainstem bronchus. The orientation of the superior pulmonary vein and the pulmonary artery (anterior and 38 .superior to the bronchus, respectively) should be noted 10/15/14
  39. 39. Right pneumonectomy 39 10/15/14
  40. 40. Left pneumonectomy 40 10/15/14
  41. 41. Segmentectomy 41 10/15/14
  42. 42. RUL bronchoplasty 42 10/15/14
  43. 43. LUL bronchoplasty 43 10/15/14
  44. 44. LUL sleeve resection with bronchoplaty 44 10/15/14
  45. 45. LMB sleeve resection with bronchoplasty 45 10/15/14
  46. 46. LMB sleeve resection with bronchoplasty 46 10/15/14
  47. 47. LLL bronchoplasty 47 10/15/14
  48. 48. Pleural flap reinforcement of bronchial closure 48 10/15/14
  49. 49. Open bronchus technique for bronchial closure 49 10/15/14

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