Pneumonectomia

General principles and initial stages

Surgical removal of the lung can be performed via several standard approaches: lateral (along the fifth intercostal space), posterior (along the sixth intercostal space), or anterior (along the fourth or fifth intercostal space). The choice depends on the localization of the pathological process and the surgeon's preference.

Regardless of the side of intervention, the operation 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 incising the mediastinal pleura directly above 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. Once 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 dissected in the surrounding mediastinal fatty tissue. A dissector is passed beneath the vessel. Then, the artery is ligated and hand-sewn or stapled using a mechanical suture (e.g., US stapler), after which it is divided.
• Pulmonary veins (superior and inferior) are dissected, managed, and divided in the same sequence and using a similar technique.

Bronchial management: The right main bronchus is carefully dissected all the way to the trachea. A US stapler 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 air tightness. The stump is submerged under a layer of fluid to ensure no air bubbles appear. After confirming tightness, pleuralization is performed: the stump is carefully covered with a flap formed 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 operation also begins with the incision of the mediastinal pleura. However, vascular preparation on this side is technically more difficult 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 dissected first. After 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) suturing is used for the vessels.
2. Bronchial stage: Large bronchial arteries are often located on the wall of the left main bronchus and must be ligated and divided. The bronchus itself is pulled out and dissected deeply — down to the tracheobronchial angle. Stapling with a US stapler (or manually) is performed as high as possible. The main feature of the left-sided operation is that it is not necessary to pleuralize the left bronchus stump. After transection, it spontaneously retracts and hides deep within the mediastinal adipose tissue beneath the cover of the aortic arch.

Intrapericardial ligation

This technique is resorted to if standard mobilization of the 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 dorsally and parallel to the n. phrenicus). Then, the posterior layer of the pericardium covering the vessels is incised. Inside the pericardial cavity, the sequence of ligation changes:

1. Inferior pulmonary vein.
2. Superior pulmonary vein.
3. Artéria pulmonar.

The vessels are sutured 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 part of the pericardium. At the end of the operation, the defect in the pericardium is closed with interrupted sutures. This is critically important to prevent cardiac luxation (displacement) into the empty right pleural cavity.

Anesthetic management and risks

When managing the bronchus manually, there is a high risk of severe gas exchange disorders. When the bronchial lumen is opened, the gas-narcotic mixture under pressure begins to discharge from the trachea directly into the pleural cavity.

To prevent this complication, anesthesiologists use specialized intubation: either a double-lumen tube with an extended tip inserted into the left bronchus, or a long single-lumen tube also placed into 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 intensely ventilates the remaining lung.

Resumo: perguntas e respostas sobre o tema

Questões de aulas e exames

O que mais estudar sobre o tema

• Topographic anatomy of the elements of the right and left lung root (syntopy of vessels and bronchi).
• Design and operating principle of US and UC staplers.
• Options for plasty (pleuralization) of the right main bronchus stump, including the use of the azygos vein.
• Complicações da pneumonectomia: fístulas broncopleurais e empiema pleural.

Outros tópicos da seção «Operações na parede torácica e órgãos da cavidade torácica»

Material preparado por professores da WhiteCoat Pro de acordo com o currículo de medicina. Possui caráter educacional.