Pneumonectomy Technique

A posterolateral thoracotomy incision over the fifth or fourth intercostal space is used with possible resection of the rib for additional access. This can be done for resurgery or in the case of an extrapleural pneumonectomy.

Focus is then directed toward division of the pulmonary vessels and bronchus.

The superior and inferior pulmonary veins are isolated and stapled; occasionally, they must be clamped and oversewn.

After isolating the right main pulmonary artery, a stapler usually is used to divide the vessel, although some surgeons prefer clamping and oversewing.

The right mains stem bronchus is isolated and divided near the carina, usually with a stapler.

A standard lymph node dissection is conducted with malignant disease.

A subcostal incision or laparoscopy can be used to investigate abdominal extension when imaging suggests transdiaphragmatic involvement.

An extended posterolateral thoracotomy incision over the fifth intercostal space is then used, with adequate exposure for extrapleural dissection achieved via resection of the fifth rib. The extrapleural dissection proceeds from superiorly to inferiorly in the anterior compartment followed by the posterior compartment. Special care is taken not to avulse the internal mammary artery and vein anteriorly or the subclavian artery and vein posteriorly. Additional attention is given to the superior vena cava and azygous vein when dissecting around the apex of the lung to avoid a traction injury.

Invasion of the aorta and esophagus is assessed during the posterior dissection, as well as the pericardium via the anterior dissection.

Diaphragmatic division and dissection starts anteriorly and continues around posterolaterally, avoiding injury to the peritoneum.

The nasogastric tube can be used during posterior dissection to palpate the esophagus and to help prevent its injury. This is usually the most challenging portion of the dissection.

A rim of the crus of the diaphragm is left with the esophagus to provide a source for attachment of a patch during later stages of the surgery.

As the dissection continues and reaches the medial aspect, the pericardial incision is extended for better visualization of the inferior vena cava and hilar vessels.

Focus is then directed to division of the pulmonary vessels and bronchus. After the right main pulmonary artery is isolated, an endovascular stapler usually is used to divide the vessel from inside the pericardium adjacent to the inferior vena cava. Next, the superior and inferior pulmonary veins are isolated and stapled in the same manner.

The right mainstem bronchus is isolated and divided near the carina, usually with a stapler.

A standard lymph node dissection is conducted.

Contents of the complete dissection include the lung with parietal and visceral pleurae, ipsilateral pericardium, right hemidiaphragm, and lymph nodes.

Once the specimen is removed, the reconstruction phase of the procedure ensues.

A pericardial fat pad can be used to cover the bronchial stump.

Next, an oversized patch is sewn circumferentially to the chest wall, the rim of the crus left around the esophagus, and the edge around the pericardium.

Attempts to avoid cardiac herniation are made by placing a prosthetic patch to the pericardial defect and to the diaphragmatic patch.

The chest is then closed and a chest tube is placed to be clamped after the completion of the procedure.

The patient usually is extubated in the operating room.

This procedure is conducted in a similar manner to the right-sided technique but with the patient in the right lateral decubitus position, with a few other differences.

Additional important structures to avoid injuring include the left recurrent laryngeal nerve while dissecting the aortic arch and the intercostals vessels in posteromedial dissection.

The left main pulmonary artery may be dissected outside of the pericardium owing to its shorter length but certainly can be divided intrapericardially.

In addition, during a left-sided procedure, the aortopulmonary lymph nodes are also resected. ^{[13, 14]}