Equipment

Thoracotomy instruments are used for pneumonectomy and extrapleural pneumonectomy.

Patient Preparation

Prior to the start of surgery, a thoracic epidural catheter, arterial line, central venous catheter, and oximeter are placed for monitoring during the procedure.

The patient is intubated with a double-lumen tube or endobronchial blocker and placed in the lateral decubitus position. A nasogastric tube can then be placed and used intraoperatively for palpation of the esophageal position and postoperatively for stomach decompression.

Anesthesia

General anesthesia with an epidural or alternative is used.

Positioning

The patient should be positioned in the lateral decubitus position to allow proper surgical access and secured to the operating table with a safety belt across the upper thighs or tape across the hip.

Monitoring & Follow-up

A chest tube is unnecessary but often is used.^[6]

The postpneumonectomy space is expected to slowly fill with fluid and air.^[12]

Pain relief should be established via epidural blocks, along with patient-controlled analgesia and/or pain pumps.^[4]

Thrombolytic prophylaxis is necessary in all thoracotomy patients and can include sequential compression devices only.

Several anatomic changes are expected: mediastinal shift, spleen, and liver position changes.^[6]

Technique

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A Randomised Comparison of Intravenous vs. Lumbar and Thoracic Epidural Fentanyl for Analgesia after Thoracotomy. Guinard J et al. Anesthesiology, 77:1108-1115, 1992.
Harpole, DH, Liptay, MJ, DeCamp, MM, et al. Prospective analysis of pneumonectomy: Risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996; 61:977.
Romano, PS, Mark, DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992; 101:1332.
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Paajanen J, Laaksonen S, Ilonen I, Wolff H, Husgafvel-Pursiainen K, Kuosma E, et al. Computed tomography in the evaluation of malignant pleural mesothelioma-Association of tumor size to a sarcomatoid histology, a more advanced TNM stage and poor survival. Lung Cancer. 2018 Feb. 116:73-79. [QxMD MEDLINE Link].
Kopec, SE, Irwin, RS, Umali-Torres, CB, et al. The postpneumonectomy state. Chest 1998; 114:1158.
Argote-Greene LM, Chang MY, Sugarbaker DJ. Extrapleural pneumonectomy for malignant pleural mesothelioma. Available at http://ctsnetjournals.org.
Shields TW, Locicero J, Ponn RB, Rusch VW, Ed. Chang MY, Sugarbaker, DJ. "Technique of Extrapleural Pneumonectomy for Diffuse Malignant Pleural Mesothelioma." General Thoracic Surgery. PA: Lippincott Williams & Wilkins; 2005. 1(6): 922-929.
Foroulis, CN, Kotoulas, C, Lachanas, H, et al. Factors associated with cardiac rhythm disturbances in the early post-pneumonectomy period: a study on 259 pneumonectomies. Eur J Cardiothorac Surg 2003; 23:384.
Hollaus, PH, Setinek, U, Lax, F, Pridun, NS. Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter. Thorac Cardiovasc Surg 2003; 51:162.
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