Lung Segmentectomy and Limited Pulmonary Resection Periprocedural Care

Preoperative education of the patient should include techniques of maintaining good bronchial hygiene. The patient must be taught how to generate an effective cough and use the incentive spirometer. Pillows should also be provided to help patients exhale forcefully.

All thoracic surgery procedures carry risks. Preoperative risk identification and amelioration enhance postoperative outcomes. Factors that increase postoperative risk include the following:

• American Society of Anesthesiologists (ASA) class greater than 2
• Advanced age
• Coronary artery disease (CAD)
• Chronic obstructive pulmonary disease (COPD), asthma
• Emergency procedure
• Extensive lung resection
• Immunocompromised individual
• Morbid obesity
• Prolonged surgery
• Extensive bleeding during surgery
• Smoking

If any of the above factors are present, it is important to work up the patient so as to avoid unnecessary complications. Important components of the preoperative workup include the following:

• Thorough history and physical examination
• Pulmonary function test
• Spirometry, blood gas
• Split lung function tests (selectively)
• Cardiopulmonary stress test

Routine pulmonary function tests that must be performed in all thoracic surgery patients include lung volume, lung mechanism, airflow, and gas exchange. Pulmonary function criteria for lung resection include a forced expiratory volume in 1 second (FEV₁) of greater than 60%.

Cardiac workup

It is also important to assess the cardiac risk factors in patients undergoing segmentectomy. Thoracic procedures have the highest incidence of associated postoperative congestive heart failure, arrhythmias, and myocardial reinfarction. A thorough cardiac history is vital in the preoperative evaluation of thoracic surgery patients, and the findings should be correlated with appropriate physical finding and results of laboratory testing.

Patients who are completely asymptomatic and have no cardiac risk factors for CAD, regardless of age, usually do not need cardiac testing. Patients with symptomatic heart disease or electrocardiographic (ECG) or laboratory evidence of a cardiac dysfunction suggestive of cardiac disease need further assessment. If symptoms of cardiac disease are present, stress testing should be considered.

Management after segmentectomy or wedge resection is no different from that after lobectomy. Unlike lobectomy, however, segmental and lesser lung resections do not significantly affect lung function.

The decision to initiate or continue mechanical ventilation is usually based on assessment of gas exchange, impending respiratory failure, and the ability to protect the airway. Patients undergoing thoracic surgery usually have an arterial line inserted in the operating room (OR). This allows dynamic blood pressure monitoring and facilitates single-lung ventilation. Arterial blood gas should be frequently sampled to assess both arterial oxygen tension (PaO₂) and arterial carbon dioxide tension (PaCO₂). Most patients do well with oxygen delivered via facemask or nasal cannula. The thoracic incision does make it painful to take deep breaths; consequently, adequate analgesia is recommended.

Most patients who undergo these procedures can be extubated in the OR. Most patients are transferred to the surgical floor postoperatively, but an overnight stay in the intensive care unit (ICU) is occasionally recommended. To reduce fluid overload, thoracic patients are kept on the dry side. Unless the patient is not eating at all, intravenous (IV) fluids are maintained at a minimum.

Chest tubes are monitored for both air leakage and fluid drainage every 8 hours. Blood work is usually performed once on the following day to assess hemoglobin and renal function. Postoperative chest radiography is routine. Unless the patient has a problem, some surgeons obtain radiographs only before and after removal of a chest tube. ^[18]

Most patients need good pain control. Today, patient-controlled analgesia (PCA) and epidural catheterization are routinely available in most hospitals and help ease the pain for several days following the procedure. Once the chest tubes are removed, the patient can receive oral narcotics augmented with nonsteroid anti-inflammatory drugs (NSAIDs). If epidural catheters cannot be placed or are contraindicated, pain pumps can be placed in the OR just prior to closure.

Other factors in postoperative care include chest physiotherapy, tracheal suctioning, and ambulation. To prevent atelectasis, incentive spirometry is vital and should be a part of preoperative teaching. The cardiovascular system also has to be closely monitored after surgery. Arrhythmias and myocardial infarction can occur; thus, cardiac monitoring for the first 48 hours is required. The incidence of cardiac complications is higher in elderly patients and in those with preexisting cardiac risk factors.

Most patients remain in the hospital until the chest tubes have been removed and they are able to ambulate and at least tolerate a semisolid diet. Occasionally, in the context of a prolonged air leak, patients are discharged with chest tubes remaining.

Physical therapy is a vital component of postoperative care and should be encouraged.

Prophylaxis of deep vein thrombosis (DVT) is highly encouraged even if patients are ambulatory.

Because most thoracic surgery patients are present or past smokers, oxygen and nebulizer therapy are common.

The average stay after a thoracotomy ranges from 3 to 5 days, but patients who undergo segmentectomy via VATS may be able to go home sooner pending resolution of their air leak. Several series show that VATS allows rapid recovery, is associated with significantly less pain, and reduces postoperative complications.

Irrespective of the type of surgery, most patients need a prescription-strength pain medication for a few weeks at home. Others may benefit from a fentanyl patch.

All patients are seen within 1-2 weeks after discharge. At the first postoperative visit, staples (if placed) may be removed, and a wound check is performed. Chest radiography is performed to assess for full lung expansion, pneumothorax, or pleural effusion. If the procedure was performed for a benign tumor or bronchiectasis, subsequent follow-up is with a pulmonologist. If the mass removed was malignant, continued follow-up with both the surgeon and an oncologist is common.

All patients are encouraged to continue with physical therapy.