Pneumonectomy

General principles and initial steps

Surgical removal of a lung can be performed via several standard approaches: lateral (through the 5th intercostal space), posterior (through the 6th intercostal space), or anterior (through the 4th or 5th intercostal space). The choice depends on the localization of the pathological process and the surgeon's preference.

Regardless of the side of intervention, the surgery begins with the mobilization of the organ. The lung is completely freed from any adhesions to the chest wall. Then the surgeon ligates and divides the pulmonary ligament (lig. pulmonale). The next crucial step is the incision of the mediastinal pleura directly over the lung root. This incision is always made dorsal to the phrenic nerve (n. phrenicus) and runs parallel to its course to avoid accidental injury.

Technique of right-sided pneumonectomy

The anatomical structure of the right root dictates its own rules for management. After the mediastinal pleura is opened, the anterior trunk of the right pulmonary artery is visualized first in the upper part of the root.

Vascular management:

• The right pulmonary artery (usually quite short and wide) is carefully isolated in the surrounding mediastinal adipose tissue. A dissector is passed beneath the vessel. Then the artery is ligated and suture-ligated manually or using a mechanical stapler (e.g., the US stapler), after which it is divided.
• Pulmonary veins (superior and inferior) are isolated, managed, and divided in the same sequence and using a similar technique.

Bronchial management: The right main bronchus is meticulously isolated all the way to the trachea. A mechanical stapler (UO) is used to staple it. After applying a special clamp to the peripheral part, the bronchus is divided and the lung is completely removed.

The final step in managing the bronchus is checking for airtightness. The stump is submerged under a layer of fluid to ensure no air bubbles are present. Once airtightness is confirmed, pleuroplasty is performed: the stump is carefully covered with a flap created from the mediastinal pleura. In some cases, tissues around the arch of the azygos vein (v. azygos) are additionally used for this purpose.

Features of left-sided pneumonectomy

On the left side, the surgery also begins with the incision of the mediastinal pleura. However, vascular dissection on this side is technically more challenging due to the pronounced pulsation of the left ventricle of the heart, which is transmitted to the surrounding tissues.

1. Vascular stage: In the upper zone of the root, the left pulmonary artery is isolated first. Following it, the superior pulmonary vein is managed. To gain access to the inferior pulmonary vein, the surgeon must strongly retract the lower lobe of the lung laterally. Manual or mechanical (US stapler) sutures are used for the vessels.
2. Bronchial stage: Large bronchial arteries are frequently located on the wall of the left main bronchus and must be ligated and divided. The bronchus itself is pulled out and isolated deeply—all the way to the tracheobronchial angle. Stapling with a UO stapler (or manually) is performed as high as possible. The main feature of the left-sided surgery is that pleuroplasty of the left bronchial stump is not required. After division, it retracts spontaneously and hides deep within the mediastinal adipose tissue beneath the cover of the aortic arch.

Intrapericardial ligation

This technique is resorted to if standard isolation of root elements is impossible due to a dense inflammatory infiltrate or tumor invasion.

The surgeon makes a 6–8 cm incision in the pericardium (also dorsal and parallel to the n. phrenicus). Then the posterior layer of the pericardium covering the vessels is incised. Inside the pericardial cavity, the ligation sequence changes:

1. Inferior pulmonary vein.
2. Superior pulmonary vein.
3. Pulmonary artery.

The vessels are suture-ligated manually or with a US stapler through the pericardial cavity and divided. The peripheral ends of the vessels must be clamped to prevent massive backbleeding from the removed lung. The organ is removed along with the resected portion of the pericardium. At the end of the surgery, the pericardial defect is closed with interrupted sutures. This is critically important to prevent cardiac luxation (prolapse) into the empty right pleural cavity.

Anesthetic management and risks

When managing the bronchus manually, there is a high risk of developing severe gas exchange disorders. When the bronchial lumen is opened, the anesthetic gas mixture under pressure starts discharging from the trachea directly into the pleural cavity.

To prevent this complication, anesthesiologists use specialized intubation: either a double-lumen tube with an extended end advanced into the left bronchus, or a long single-lumen tube also placed in the left main bronchus. If separate intubation is unavailable for any reason, surgeons use an alternative method: the open bronchial stump is periodically packed tightly with a moist gauze sponge, while the anesthesiologist performs high-frequency ventilation of the remaining lung.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the elements of the right and left lung root (syntopy of vessels and bronchi).
• Design and operating principle of UO and US staplers.
• Options for plasty (pleurization) of the right main bronchus stump, including the use of the azygos vein.
• Complications of pneumonectomy: bronchopleural fistulas and pleural empyema.

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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