The document discusses various surgical interventions for pulmonary tuberculosis, highlighting indications and contraindications for procedures such as lobectomy, segmentectomy, and physiological lung exclusion. It emphasizes the challenges presented by complications like hemoptysis and empyema and outlines the importance of preoperative assessments and precautions. Furthermore, it introduces physiological lung exclusion as a viable alternative for managing cases where traditional resection is impractical due to extensive fibrosis or vascular adhesions.

2. SURGERY FOR PULMONARY
TUBERCULOSIS
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3. INDICATIONS
 COMPLICATIONS OF PULM.
TUBERCULOSIS - Empyema with BPF or No
BPF -
Hemoptysis - Massive or Recurrent -
Destroyrd Lung (always prone to infection)
- Bronchial Stenosis
-Bronchiectasis - Persistent cavity
( AFB –ve) with secondary
Infection - Cavity with
Aspergiloma ( Hemoptysis)
 DIAGNOSTIC DIALEMA -
Tuberculoma versus Bronchogenic
Carcinoma

4. INDICATIONS
 Mediastinal Lymphadenopathy
 Chest wall Involvement – Cold Abcess
 Pericardial Involvement- Ch
constrictive pericarditis, effusion with
tamponade
 Spinal TB- Pott’s Paraplegia
 Cavity with Multi Drug Resistent AFB
 Persistant Cavity - Sputum +ve (after
3 months ATT)

5. CONTRAINDICATIONS
 B/L Disease
 Active Disease - Sputum +ve ?
 Presence of Bronchial tuberculosis
 Poor P F T
 Uncontolled Severe Systemic Disease
(Diabetes mellitus, CAD, Renal failure ,
wide spread malignancy present)

6. INVESTIGATIONS
 Sputum for AFB
 FOB Bronchoscopy
 Pulm. Function Tests
 HIV, HBS , Tests
 Hemograms- ESR
 Radiological Investigations
 RFT, LFT, ECG,

7. INVESTIGATIONS
Chest x-ray Bronchogram

8. Aspergilloma

9. Left upper lobe active TB

10. Large cavity left upper lobe

11. SURGICAL PROCEDURES
 COLLAPSE THERAPY
-Thoracoplasty- Standard or Plombage
-Artificial Pneumothorax or
Pneumomediastinum
-Phrenic Crush
 Cavernostomy or Monaldi’s peration

12. SURGICAL PROCEDURES
 RESECTIONAL PROCEDURES
*LOBECTOMY * SEGMENTECTOMY
*PNEUMONECTOMY
*PLEUROPNEMONECTOMY
 OTHER OPERATIONS
*DECORTICATION *CLOSURE OF BPF
*RIB RESECTION / ELOESEIER FLAP
 PHYSIOLOGICAL LUNG
EXCLUSION

13. COLLAPSE THERAPY
 Only treatment available prior to advent
of Anti TB drugs
 Forlanini 1882 observed that collapse of
a lobe or lung lead to healing of
tubercular lesion in that part
 Artificial Pneumothorax
 Phrenic Paralysis
 Pneumoperitoneum

14. COLLAPSE THERAPY
 Extrapleural Paravertebral
Thoracoplasty - Decrneville 1885
Friedrich & Bauer -1907
 John Alexander- Staged this procedure
Published book ‘Collapse therapy for
Pulm tuberculosis’ in 1937
 IInnddiiccaattiioonnss for - B/L Pulm TB
-Pt not fit for lung resection
-Presence of MDRTB -
Post resectional empyema or BPF

15. RESECTIONAL PROCEDURES
 Tuffier 1891–Resection of Apex of lung
 Freidlander 1934 – Lobectomy
 Blades , Kent , Churchll 1940 -
Individual Ligation of vessels for
lobectomy
 Churchill, Belsey 1939 – Segmental
resection
 J Maxwell Chamberlane popularized it

16. IMPORTANT
PRECAUTIONS
 Arrange adequate amount of blood
 Double lumen endotracheal tube essential
 Position of Patient PLT
ALT Face Down
 Resectional Surgery for Pulm TB is
difficult -Careful mobilisation of lung
Marked vascular adhesions with chest wall
Calcification in pleura , Marked blood loss,
Difficult hilar vessels control

17. COMPLICATIONS
 B P F -Causes +ve sputum,MDRTB,
Diabetes,Rt pneumonectomy ,Prior irradiation
 EMPYEMA
 Atelectasis & Pneumonia
 Wound Infection
 P O Bleeding
 Post Pneumonectomy Pulm. Oeema

18. DECORTICATION
Pre operative Post operative

19. DECORTICTION
Before operation After operation

20. PHYSIOLOGICAL LUNG
EXCLUSION
 MAJOR CAUSES OF MASSIVE
HEMOTYSIS ARE . TUBERCULOSIS
. BRONCHIECTASIS
 LUNG RESECTION IS TREATMENT OF
CHOICE
RESECTION MAY BE HAZARDOUS OR
NOT POSSIBLE DUE TO
DENSE FIBROSIS, VASCULAR
ADHESIONS & CALCFICATION
* ALTERNATIVE LIFE SAVING PPRROOCCEEDDUURREE
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21. PHYSIOLOGICAL LUNG
EXCLUSION
 PHYSIOLOGICAL BASIS
 INVOLVED PART OF LUNG ISOLATED BY
DIVISION OF
* PULMONARY ARTERY
* BRONCHUS & BRONCHIAL ARTERIES
* VIABILITY OF ISOLATED LUNG MAINTAINED
BY
* VASCULAR ADHESIONS WITH CHEST WALL
* INTACT PULMONARY VEINS FOR DRAINAGE

22. PHYSIOLOGICAL LUNG EXCLUSION-SURGICAL
TECHNIQUE
 ANTERO LATERAL THORACOTOMY /
PARTIAL STERNOTOMY / P L T
 MINIMUM LUNG MOBILISATION NEAR
HILUM
 PULMONARY ARTERY LIGATION
EXTRA OR INTRAPERICARDIALLY
• INVOLVED BRONCHUS DIVIDED AND
CLOSED
* PULMONARY VEINS PRESERVED

25. CONCLUSIONS
PHYSIOLOGICAL LUNG EXCLUSION
IS
AN EFFECTIVE ALTERNATIVE OPERATION
FOR
CONTROL OF MASSIVE OR RECURRENT
HEMOPTYSIS
WHERE
LUNG RESECTION IS DIFFICULT/HAZARDOUS
DUE TO
DENSE FIBROSIS, VASCULAR ADHESIONS &
CALCIFICATION

26. Post operative x ray Rt upper lobe
after Phys.Lung Exclusion