1) A lobectomy is a type of lung surgery where one lobe of the lung is removed due to conditions like lung cancer, tuberculosis, or trauma. It aims to remove diseased portions while conserving more lung function than a pneumonectomy. 2) Indications for lobectomy include benign conditions like infectious diseases, developmental anomalies, and bleeding; and malignant conditions like non-small cell lung cancer, pulmonary metastases, and certain tumors. 3) Contraindications include poor lung function, recent heart issues, and large tumors over 6cm which make VATS technically challenging. Complications can include prolonged air leaks, pneumonia, and injuries to nearby structures.

1. JAMIA MILLIA ISLAMIA
CENTRE FOR PHYSIOTHERAPY AND REHABILITATION
SCIENCES
Lobectomy
SUBMITTED BY – MD ASIF
SUBMITTED TO- Dr. JAMAL ALI MOIZ
BPT 4TH YEAR

2. Introduction
Each of your lungs is made up of sections called lobes. . A lobectomy is a type
of lung cancer surgery in which one lobe of a lung is removed because it
contains malignant tumors.
A lobectomy is also occasionally performed for other conditions, such as
tuberculosis, severe COPD, or trauma that interrupts major blood vessels near
the lungs.
A lobectomy is done to remove a diseased or damaged portion of the lung, most
often due to lung cancer. Specifically, lobectomy is most commonly performed
for non-small cell lung cancers (NSCLC) in which the tumor is confined to a
single lobe.
This procedure is less invasive and conserves more lung function that
a pneumonectomy, a surgery that involves removing an entire lung. In contrast,
it is somewhat more extensive than a wedge resection, a surgery that removes
the tumor and a small amount of surrounding tissue.

3. Indications
Benign conditions
1. Infectious: Any chronic infectious process not controlled with antibiotics
therapy can benefit from surgical resection. Tuberculosis is the most common
reason for lobectomy worldwide.
Tuberculosis and its sequelae. Although antitubercular antibiotics remain the
standard treatment for the patient with tuberculosis, selected patients with
localized disease or its complication like a large cavity, localized bronchiectasis
can undergo lobectomy after optimal medical therapy.
They have high postoperative mortality and morbidity and require close follow
up.
2. Non-infectious
Developmental anomaly Congenital bronchial atresia, pulmonary
sequestration, bronchogenic cyst, congenital cystic adenomatous malformation.

4. Bleeding
Massive hemoptysis due to aspergilloma, cavity, AV malformation, and
bronchiectasis are controllable with lobectomy.
Lobectomy in trauma is indicated in hilar vessels or bronchi hilar injuries; the
associated mortality is up to 40%.
Malignant conditions
Lobectomy is the standard surgical approach for stage I-II non–small cell lung
cancer.
As lung cancer is most common in the right upper lobe, right upper lobectomy is
the most common procedure done for lung cancer.
Other less common neoplastic indications include mucoepidermoid tumors,
adenoid cystic tumors, and sarcomas.
Lobectomy may also be an option in a patient with localized pulmonary
metastasis

5. Contraindications
•The outcome of the procedure is largely dependent on patient selection.
Information about the patient's physiological ability to tolerate lobectomy will
help to risk-stratify the potential operative candidacy.
•Patients with forced expiratory volume in 1 second (FEV1) less than 800 cc or
diffusion capacity of carbon monoxide (DLCO) less than 40% are considered
high-risk patients. These patients are better served with sub-lobar resection or
nonoperative therapy.
•If possible, lobectomy should also be avoided in patients with recent myocardial
infarction and severe cardiovascular disease.
• VATS lobectomy should also be avoided in patients with a tumor larger than 6
cm due to technical challenges.

6. Equipment required
Conventional lobectomy procedures, a rib retractor is the mainstay surgical
tool. Long instrumental is essential to reach the hilar structures, and vascular
instrumental must be at hand due to the risk of major vessel injuries. Lung
parenchyma and hilar structures transection could be done by stapler or cut
incision with hand-sewn techniques repair.
Open Lobectomy
The essential equipment for open lobectomy is; rib spreader, scapula retractor,
periosteal elevator.
VATS Lobectomy
The basic equipment for VATS lobectomy is; video system, 10 mm 30-degree
video-thoracoscope, light source power, energy dissection devices (ultrasonic
dissector-coagulator or bipolar electrocautery devices), Long curved VATS
instruments with double articulation, vascular clips, curved-tipped endoscopic
staplers, plastic endobag, wound protectors for the utility port and 10 mm trocars.

7. Conventional Open Lobectomy
•Posterolateral thoracotomy is the conventional open approach. Its uses have
been decreasing over time; however, under complex conditions (both in lung
cancer and benign disease), it is preferred.
• Highlight complex conditions are; Centrally located tumors, tumors >6 cm,
endobronchial tumors, thick adhesions due to inflammatory processes, complex
congenital lung malformations.
•The hilum approach and hilum dissection sequence depend on the surgeon's
preference (posterior to anterior, anterior to posterior). For hilar division and
repair, staplers or hand-sewn techniques are the choices.

8. VATS Lobectomy
•Currently, the most common minimally invasive techniques are Duke,
Copenhagen, and uniportal VATS.
•The common ports between these techniques are;
o Anterior utility port incision,
o Anterior surgeon's position (patient abdomen),
o Anterior hilum approach (anterior mediastinum),
o Anterior to posterior hilum dissection sequence.
• The anterior utility port is a 5 cm length incision performed in the fourth or
fifth intercostal space between the anterior and middle axillary lines. It is
constant in the five types of lobectomy (right superior, right middle, right lower,
left superior, left lower lobectomies).
•Duke approach has two incisions, the utility port, and the camera port; the last
is a 5 to 10 mm counter-incision adjacent to the posterior vertex of the utility
port incision in the same intercostal space.

9. •The Copenhagen technique is a three portal approach, the anterior utility port
incision, the camera port incision 1 cm located at the top of the diaphragm in the
axillary anterior line and a 1.5 cm working port incision located at the same level of
the camera port straight down the line from the scapula.
•Uniportal VATS has only the anterior utility port incision.
•Initially, VATS lobectomy for lung cancer was indicated for early-stage disease.
After gaining experience and skill with VATS, some surgeons pioneered VATS
procedures for advanced cases, such as bronchoplasty, vascular sleev resections,
and chest wall resection
•VATS sleeve lobectomy is technically feasible and safe compared with
thoracotomy. VATS lobectomy was recommended as an acceptable procedure for
the treatment of clinical stage I NSCLC.
oIntraoperative blood loss,
oDuration of chest tube drainage, or length of hospital stay,
oWith a significant decrease in the duration of chest drainage,
oLength of hospital stay, post-thoracotomy pain
oFaster recovery time and return to work.

10. Hilum Approach, Hilum Dissection Sequence, and Fissure technique
Traditional lobectomy techniques describe division of pulmonary parenchyma
within the fissures for access to the pulmonary artery. This results in air leaks,
which may prolong chest tube drainage and hospitalization times. We describe a
technique for lobectomy in which all lung parenchyma is divided using a stapler.
The cornerstone of lobectomy is the individual dissection of the vein, arteries, and
airway for the lobe. Currently, the most popular is the anterior approach (anterior
mediastinum). the dissection sequence is anterior to posterior in a single
direction.
Fissure less technique is when the division of the pulmonary fissures with direct
stapling over the visceral pleura is performed lately in the surgery.
The fissure-last technique is when the fissure is open late in surgery to expose
arterial structures.
Fissure-first technique(tunnel technique)- the fissure is open first in surgery. It is a
consideration when the hilum dissection is complicated, and the vascular and
bronchial structures plane dissections are challenging to identify; however, the
fissure-less technique has been the recommended approach due to minor risk of
postoperative air leak.

11. The fissureless technique is a useful procedure for the treatment of patients with
dense fissures because it reduces the risk of prolonged postoperative air leakage
With this technique, it is very important to insert the stapler for division of the
bronchus smoothly and safely because injury to the pulmonary artery, behind the
bronchus, might cause catastrophic bleeding. We always try to dissect the
bronchus enough to ensure smooth stapling.
In conclusion, thoracoscopic fissureless left upper lobectomy is safe and feasible,
and is a useful technique for avoiding postoperative air leakage.
Procedures of fissure technique
oPreoperative imaging
oDetecting dense fissure
oDissecting dense fissure
oThe dense fissure was divided using staplers
oIntraoperative sealing test revealed no air leakage.

12. Clinical Significance
•Lobectomy surgery effectiveness depends on etiology and the surgical approach
(open lobectomy and VATS lobectomy).
•VATS has been the preferred approach due mainly to the results in postoperative
recovery. However, when VATS is not indicated, open lobectomy is performed to
improve patient transoperative safety.
•VATS lobectomy for infectious focal bronchiectasis or cavities can be performed
safely with low rates of mortality (0% to 1%) and morbidity (9% to 23%), the mean
length hospital stay is four days, also VATS lobectomy for congenital lung
diseases is feasible and effective in selected patients, with a conversion rate is
4%.
•NCCN (National Comprehensive Cancer Network) recommends VATS lobectomy
for lung cancer resection; research has shown VATS lobectomy to have minor
complications rates and better long-term survival compared to open thoracotomy
lobectomy for NSCLC.

13. Complications
Lobectomy complications incidence depends on etiology, patient diagnosis,
and resected lobe.
Complications after lobectomy usually occur in the early postoperative period
(within 48 hours), unlike pneumonectomy, which presents late complications
due to the risk of pleural fluid infection.
A National Cancer Database review found that lobectomy mortality is 2.6%,
and morbidity is 10% to 50%, mortality and comorbidity risks increases in
patients over 75 years old.
The main postoperative lobectomy complications are
oProlonged air leak (15% to 18%),
oSubcutaneous emphysema,
oPneumonia/mucus plugging/atelectasis (6%),
oPleural empyema (1% to 3%),
oPersistent space (9.5%) atrial fibrillation (33%),
oRight middle lobe torsion (0.09 to 0.4%),
oHemorrhage (2.9%), chylothorax (0.7% to 2%),
oPhrenic nerve injury and
oRecurrent laryngeal nerve injury, wound infection, tumor embolization
(less than 1%) and very rarely bronchopleural fistula.

14. Reference
Video-assisted thoracoscopic surgery lobectomy for non-small cell lung
cancer
Mingyon Mun1 · Masayuki Nakao1 · Yosuke Matsuura1 · Junji Ichinose1 · Ken
Nakagawa1 · Sakae Okumura1
MMCTS Thoracoscopic fissureless left upper lobectomy for the patient with a
dense fissure
Lobectomy
Gerardo Rea; Mohan Rudrappa.
Fissureless Lobectomy
R. Thomas Temes, MD, Christopher D. Willms, MD, Santiago A. Endara, MD,
and
Jorge A. Wernly, MD