1) A 12-year-old boy was admitted to the hospital with chronic cough, shortness of breath, and wheezing since birth and was diagnosed with bilateral bronchiectasis. 2) CT scans showed severe consolidation and cavitation in his right lower lobe and lingula. He was treated unsuccessfully with antibiotics, bronchodilators, and bronchoscopies. 3) He underwent a right middle and lower pulmonary bilobectomy. The procedure involved removing the middle and lower lobes of his right lung due to severe cystic bronchiectasis that was resistant to medical treatment.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
Right Middle and Lower
Pulmonary Bilobectomy for
Bronchiectasis
Prof. Abdulsalam Y Taha
College of Medicine
University of Sulaimani
2022
1

2. The Case
 A 12-years old boy was admitted to
Sulaymaniyah Teaching Hospital,
Sulaymaniyah, Iraq on 5th of Jan 2010
because of chronic productive cough
associated with shortness of breath (SOB)
and wheeze since birth.
 He had been thoroughly investigated by
repeated CXRs and chest CT scans as well
as sputum cultures and PFTs and received
a diagnosis of bilateral bronchiectasis.
2

3. 3

4. 4

5. 5

6. 6

7. CT scan of the chest showed a severe consolidation
and cavitation in RLL and to a lesser extent in part
of the lingula.
7

8. 8

9.  He used to be treated by antibiotics,
expectorants and bronchodilators with
mild to moderate response. He had 2
sessions of rigid bronchoscopy under
general anesthesia (GA) for
bronchopulmonary toilet.
 During bronchoscopy, a copious amount
of thick yellowish pus in both sides of
the bronchial tree was seen mainly in
the right side. Aspiration of large
amount of pus was done followed by
irrigation by normal saline. A sample of
pus was obtained for AFB and for C&S
tests. The recovery was smooth.
9

10. 10

11. 11

12. 12

13. Preoperative Treatment
 Culture and sensitivity test of
the bronchial wash revealed a
growth of pseudomonas
sensitive to Rifampicin and
Amikacin but no growth of AFB.
Accordingly, the patient
received rifampicin and
amikacin for 1 week and was
prepared for surgery.
13

14. Operative Notes
1. Under GA via a single lumen endotracheal tube in a lateral position.
2. Right posterolateral thoracotomy via 5th intercostal space was
done.
3. Findings: the middle and lower lobes were shrunken with severe
cystic bronchiectasis. The right upper lobe was healthy.
4. A decision was made to carry out bilobectomy.
5. There were severe chronic inflammatory changes with multiple LNs
densely adherent to pulmonary artery branches as well as the bronchi.
6. The right main PA was isolated for proximal control.
7. Bilobectomy was done in the standard method with very tedious
dissection. The middle lobe vein was found draining to inferior
pulmonary vein. The inferior pulmonary vein was isolated, proximally
controlled by a vascular clamp. Then it was divided and sutured in 2
layers of 3-0 and 4-0 polypropylene.
8. Hemostasis was secured.
9. Two chest tubes were placed.
10. The chest wall was closed in layers. 14

15. The Right Lower and Middle Lobes Specimens
15

16. The early postoperative CXR showed full
expansion of RUL. The recovery was smooth.
16

17. comment
 Bronchiectasis is characterized radiologically by
permanent dilation of the bronchi, and clinically by a
syndrome of cough, sputum production and recurrent
respiratory infections [1].
 Surgery is now rarely employed in bronchiectasis,
although in highly localised bronchiectasis with
symptoms that cannot be controlled by maximal
medical therapy, referral for lobectomy or
segmentectomy may be considered [1].
 Bilobectomy is a form of pulmonary resection in which
either the right middle and lower lobes or the right
middle and upper pulmonary lobes are removed
together.
17

18. Bibliography
[1] Chalmers JD, Aliberti S, Blasi F.
Management of bronchiectasis in
adults. European Respiratory
Journal. 2015 May 1;45(5):1446-62.
18