Lung Segmentectomy and Limited Pulmonary Resection Technique

Updated: Feb 06, 2014
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Dale K Mueller, MD  more...
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Technique

Approach Considerations

Segmentectomy

Several small studies indicate that thoracoscopic segmentectomy for lung cancer or for congenital and acquired lung disease leads to greater preservation of lung function and exercise capacity compared with a formal lobectomy. However, there is a need for continued follow up to ensure that there is no disease recurrence. [17, 18, 19, 20, 21, 22]

Segmentectomy is performed in the standard lateral decubitus position. The patient is positioned with proper padding of the knees, elbows, and dependent axilla. [4]

Various instruments should be used to hold the patient stable in this position, including placement of sandbags under the operating table mattress, rolled sheets in the front and back, and a beanbag.

The dependent arm is flexed at the elbow. If shaving is necessary, only the hair in the incision line should be removed. It is often helpful to outline the proposed incision with a marking pen. Most segmental resections are ideally performed via a fifth interspace incision.

The incision usually starts in front of the anterior axillary line and curves about 4 cm under the tip of the scapula. The incision then proceeds vertically between the posterior midline over the vertebral column and the medial edge of the scapula.

It is usually unnecessary to go farther than the level of the spine of the scapula. A double-lumen endotracheal tube is preferred.

Once the chest cavity is entered, the lung is collapsed and the entire pleural cavity is examined.

Prior to starting the segmentectomy, the hilum is identified. All surgeons who perform segmentectomy via VATS or an open procedure must be familiar with the anatomy of the bronchus, pulmonary artery, and veins. [23, 24]

With a double-lumen endotracheal tube, it is easy to inflate the entire lung and clamp on the bronchus concerned. Once the segment is identified, the rest of the lung can be deflated. The inflated segment will remain filled with air for some time, allowing for easier dissection. Once the bronchus has been identified, it can be divided manually or with the use of a mechanical stapler. Unlike with a lobectomy, additional coverage of bronchial closure is usually unnecessary. [4]

Once the artery and bronchus are ligated, traction is applied on the bronchus and the segment is removed in a retrograde fashion. This plane is developed with gentle blunt dissection, but the pleura is usually divided with scissors. The pulmonary veins come into view as they cross in the intersegmental planes. The segmental veins provide the best view of segmental anatomy. All the individual vein branches are isolated and divided sequentially. This can also be done with a stapler to avoid possible air leak.

Once the lung specimen is removed, the raw surfaces of the lung parenchyma are examined for bleeding. The lung needs to be expanded gently and assessed for any bleeding or air leak. If the dissection was done in a segmental fashion, there should be no or minimal air leak. The minor air leaks often seal within a few minutes after lung expansion. However, if an air leak is present, it should be addressed. Moderately sized leaks caused by segmentectomy can persist and lead to infections and residual airspace. If the moderate leak persists, the area may need to be reinforced with a pleural flap or a pulmonary sealant. Suturing the two adjacent lung segments is not recommended, as it may lead to tearing of the lung parenchyma. [25]

Once the lung is expanded, one or two chest tubes should be placed—one in the apex and one in the base. A size 20 tube can be placed in the apex, and a size 28 tube should be placed at the base of the lung. The tubes should be connected to an underwater drainage system, but suction should be avoided until after extubation. Suction with positive-pressure ventilation often leads to an increase in air leaks. Once the patient is breathing spontaneously, the tubes can be connected to suction. At no time should these chest tubes be clamped during transfer of the patient from the operating room to the recovery room or the ICU.

The subsequent management of the chest tubes is that for any other lung surgery.

Lesser Lung Resection (Wedge Resection)

Because of the complexity of performing segmental resection, most surgeons today simply perform a nonanatomic lung resection, better known as wedge resection. This technique is widely used to resect lung masses, metastatic lesions, and even localized suppurative infections. Almost any metastatic lesion can be resected using a wedge resection technique. The technique can also be used to resect multiple lesions from the same lobe or excise segment(s) from multiple lobes.

The one negative aspect of performing an anatomic lung resection is that it removes a significant amount of normal lung; while this may be of no significance in healthy people, it may compromise breathing in patients with limited lung reserve. [4]

Limited lung resection may be approached via a standard thoracotomy; sternotomy may be an option in patients with bilateral lung disease. The procedure can also be performed using video-assisted thoracostomy. [26, 12]

Most patients who undergo the procedure via lateral thoracotomy undergo general anesthesia. A double-lumen endotracheal tube is preferred. Once the chest cavity is entered, the entire pleural cavity is examined for disease. The lung should be thoroughly palpated to identity any metastatic lesions. Today, the use of staples has made nonanatomic resection very easy.

The lung is grasped along the edges and a stapler is fired. These staplers fire a row of staples while simultaneously transecting the lung tissue. The lesion may be wedged out in a V- or U-shaped incision.

If electrocautery is used, a superficial linear incision is first made over the lung with a staple or a clamp. Electrocautery is then used to cut out the lung tissue. However, the edges of the lung must be reinforced with a running suture to ensure hemostasis and to avoid air leaks. At higher power, the electrocautery coagulates most blood small vessels. The biggest disadvantage of electrocautery is that the cautery tip persistently sticks to lung tissues and needs to be scraped constantly.

The postoperative care is the same as that for lobectomy.