Lung Resection - Types, Indications and Complications

Introduction

Lung resection or pulmonary resection is a surgical procedure to remove a part or entire lungs. A lung can be resected either by minimally invasive surgery or thoracotomy. Nowadays, video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical procedure using smaller incisions to manage cardiopulmonary diseases. Adding fiber optic cameras or thoracoscopes has ultimately led to a breakthrough in minimally invasive surgery.

This allows the surgeon to visualize the entire thoracic cavity without the need to open up the chest wall. Previously thoracotomy was used as a standard approach to thoracic pathology. The various advantages of a VATS over traditional thoracotomy methods are less postoperative pain, shorter duration of hospital stay, and early restoration of pulmonary function, especially in chronic obstructive pulmonary disease patients and elderly patients. It also reduces the cost of the procedure. Lung resection is typically performed to treat infections or lung diseases such as emphysema, bronchiectasis, or lung carcinoma, either benign or malignant.

What Are the Types of Lung Resection?

A lung resection may be of different types, such as:

• Wedge resection.

• Segmentectomy.

• Lobectomy.

• Bilobectomy.

• Pneumonectomy.

Wedge Resection: It involves the removal of a wedge-shaped section of the damaged lung tissue.

Segmentectomy: It involves the removal of one to four portions of a lung lobe while still preserving the rest of the lungs.

Lobectomy: It involves the removal of an entire lobe of the lung. It is the most common type of lung resection. It is usually the most common treatment modality in patients with early stages of carcinoma, benign tumors, tuberculosis, emphysema, and bronchiectasis.

Bilobectomy: It involves the removal of two lobes of the right lung while still preserving the rest of the lung.

Pneumonectomy: It involves the removal of the entire lung because of lung carcinoma or trauma.

What Are the Indications for Lung Resection?

The indications of lung resection are as follows:

1. Pleural drainage, especially in the case of

• Hemothorax removes blood or blood clots between the pleural cavity.

• Pneumothorax to remove accumulated air in between the pleural cavity.

• Empyema is the accumulation of pus in the pericardial cavity, especially in frail patients with high surgical risk. Ultrasound confirms the entry site.

2. Pulmonary bleb or bullae resection.

3. Collapsed lung tissue or atelectasis.

4. Pulmonary emboli or blood clots in the pulmonary artery.

5. Mechanical or chemical pleurodesis prevents accumulation within the pleural cavity.

6. Excision or biopsy of mediastinal masses and nodules.

7. Excision of the esophageal diverticulum.

8. Ligation of the thoracic duct.

9. Excision of sympathetic nerves or sympathectomy.

10 Resection of chest wall tumor.

How to Prepare for Lung Resection?

The patient may be asked to stop certain drugs such as anticoagulants or blood thinners like Warfarin or Heparin. Avoid eating or drinking any liquids after midnight, just before the day of surgery. Smoking has to be stopped before surgery. The patient may be asked to do breathing exercises with a spirometer. A well-detailed clinical history with past and present medical illnesses should be assessed. The diagnostic tests that can be carried out are:

• Routine blood tests.

• Pulmonary function test or spirometry.

• Arterial blood gas analysis.

• Chest X-ray.

• High-resolution computed tomography (HRCT).

• Bronchoscopy.

• Lung tissue biopsy.

What Is the Method of Lung Resection?

The procedure involves an antibiotic prophylaxis regime with administering second-generation cephalosporins injected intravenously half an hour before the surgery to prevent infection. The duration and times depend upon the type of antibiotics used. No other antibiotics are prescribed after the surgery until and unless the patient develops an acute bacterial infection.

Typically, the procedure is carried out under general anesthesia, which induces deep sleep, and surgery may take several hours. The patient is placed in a lateral decubitus position with the arms extended and fixed on an arm-supporting frame. The surgeon may make several small incisions over the chest wall between the ribs. The fiber optic camera fitted in a narrow lumen tube is introduced through any of these incisions. In the case of lung cancer, a part of the lung and adjacent lymph nodes must be resected. Thus a radical approach has to be made. The surgeon may drain the pleural fluid from and around the lungs in case of effusion or may carry out other procedures on different thoracic organs. Once the procedure is completed, the camera is removed, and a chest tube is inserted through one of the small incisions and left there for a few days to drain fluid or air leakage into the chest cavity or may help the lungs to reinflate. The patient is usually discharged after a few days from the day of surgery. It is important to rest after the surgery, and any kind of postoperative discomfort must be reported immediately.

What Are the Complications of Lung Resection?

Early Postoperative Complications:

• Pulmonary edema.

• Pneumonia.

• Acute respiratory distress syndrome.

• Bronchial dehiscence.

• Bronchopleural fistula.

• Lobar torsion, where the lung rotates, resulting in severe airway obstruction.

• Hemothorax.

• Chylothorax, in which there is an accumulation of chyle, a digestive end product from the intestine that accumulates in the pleural cavity.

Late Postoperative Complications:

• Bronchial stenosis.

• Empyema or collection of pus in the pleural space.

• Stump thrombus or blood clot formation at the pulmonary artery stump. It is one of the most common complications after pneumonectomy or lung lobectomy.

• Esophagopleural fistula or during the early stages of fetal development, the trachea and the esophagus develop as a single passage that later divides into two separate tubes. If this division fails to occur, it can result in an esophagopleural fistula.

• Post-pneumonectomy syndrome is a unique complication of pneumonectomy, which can cause severe airway compression due to mediastinal shift and counterclockwise rotation of the heart.

Conclusion

Lung resection is the primary treatment modality in case of lung cancers such as non-small cell lung cancer or carcinoid tumors. However, chemotherapy or radiotherapy may be required to completely treat lung cancer. The main goal of lung cancer, or any cancer, is to cure the cancer patient and prolong their life. Therefore, a proper diagnosis, early intervention, and treatment is the key to cancer treatment. Further, awareness programs, educating patients, families, and communities about cancer risk, and taking precautionary steps to avoid cancer can help achieve the goal.