Lung resection

Indications and classification of interventions

Surgical interventions on the respiratory system are diverse, but they can be divided into several basic categories. Lung resection involves the partial removal of the organ. If a single lobe is removed, it is a lobectomy; two lobes — a bilobectomy; and the excision of a bronchopulmonary segment is called a segmentectomy. The complete removal of the entire organ is a pneumonectomy. In addition, thoracic surgery distinguishes pneumotomy (open incision of abscesses or tuberculous cavities) and pleurectomy with decortication (removal of a dense purulent shell preventing the organ from expanding in chronic empyema).

The main reasons for performing a resection include:

• Malignant and benign neoplasms.
• Chronic suppurative destructive processes (abscesses, pleural empyema).
• Bronchiectasis.
• Severe forms of tuberculosis (particularly the fibrocavernous variant).

Lung mobilization

Any resection begins with lung mobilization — its release from surrounding adhesions. The extent of dissection must be complete so that the surgeon can fully palpate the tissues, assess the scale of the pathology, and provide conditions for the subsequent expansion of the remaining healthy part of the organ.

If the adhesions are loose, they are separated bluntly using a gauze sponge or a hand. Dense and highly vascularized adhesions require long curved scissors, an electrocautery, or preliminary suture ligation to avoid massive hemorrhage.

A special approach is required when the organ is densely adhered to the chest wall across its entire surface. In such cases, extrapleural dissection is performed: the lung is peeled off along with the thickened parietal fascia, endothoracic fascia, and sometimes the rib periosteum, without separating the pleural leaves. This minimizes blood loss and prevents accidental opening of superficial cavities or abscesses. To stop bleeding during such dissection, tight packing with hot isotonic solution-soaked sponges and electrocoagulation are used. Surgeons often alternate intrapleural and extrapleural approaches to facilitate access to the root.

Management of root elements

The key stage of the operation is the separate management of the root elements (arteries, veins, and bronchi). Mass ligation (tying all structures together as a single block) is permissible only in emergency and exceptional situations.

Vessel transection: Usually, arteries are ligated first, followed by veins. This prevents the resected area from becoming engorged with venous blood. However, in oncological diseases, the tactic is strictly reversed: veins are ligated first to prevent cancer cells from entering the systemic circulation during manipulations. The vessel is carefully isolated with a dissector and cleared of adventitia. Two ligatures are applied to the central and peripheral ends, transfixion sutures are added between them, and only then is the vessel transected.

Bronchial closure: The bronchus is isolated, secured with a traction suture, and transected so that the residual stump is no more than 5–7 mm. A longer remnant can cause secretion accumulation and purulent inflammation. Closure is performed either manually with non-absorbable sutures (the central suture is placed first, then the membranous part is pulled toward the cartilage) or mechanically using a stapler (UO apparatus).

A mandatory final step of this stage is the leak test. The stump is immersed in a warm sodium chloride solution, and the anesthesiologist increases the airway pressure to 20–25 cm H2O. The absence of gas bubbles indicates a secure suture. Afterward, the stump is pleurized — covered with the adjacent pleural fold.

Segmentectomy and atypical resections

Segmentectomy This is a standard anatomical resection. The area is removed strictly within anatomical boundaries after vessel ligation, pulling from the root toward the periphery. It is important to properly manage the intersegmental veins, which are strongly stretched during fragment isolation. The question of whether the resulting lung parenchyma wound surface needs to be sutured is decided on an individual basis. Approximating the edges impairs ventilation and reduces the functional volume of the organ, but omitting it risks prolonged air leaks and bronchial fistulas.

Atypical resections These include marginal, planar, or wedge excisions. They are performed without regard to anatomical segment boundaries, usually to remove small peripheral lesions. Stapling devices are used for this: the jaws are applied to the tissue, secured with tantalum staples, and the section is excised with a scalpel. At the slightest sign of air leakage (aerostasis failure), the mechanical suture line is additionally reinforced with interrupted or U-shaped manual sutures.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographical anatomy of the root elements of the right and left lungs
• Operating principles of US and UO staplers in thoracic surgery
• Pneumonectomy surgical technique
• Pleural cavity drainage following lung surgeries
• Complications after resection: bronchial fistulas and atelectasis

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

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