Overview of Lobectomy
A lobectomy is a type of surgery where a lobe (section) of the lung is removed. This operation first took place in 1913 by Dr. Davies, although the patient unfortunately did not survive due to a post-surgery infection. However, as surgeons’ skills, anesthesia techniques, and infection control methods improved over time, lobectomy became a safer and more common surgery with better results.
Originally, this surgery was done through a process called a thoracotomy, which involves making a large cut into the chest. Recently though, a technique called video-assisted thoracoscopic surgery (VATS) has become the preferred method. VATS is a type of keyhole surgery where small cuts are made in the chest and a special camera (a thoracoscope) is used to guide the operation.
Lobectomy can be useful for a variety of benign (non-cancerous) and malignant (cancerous) lung diseases. An important factor to consider before surgery is that the patient should have enough lung capacity to manage after part of their lung is removed. This, along with the person’s overall health status and risk of post-surgery complications, is part of the pre-surgery assessment.
There is growing evidence showing that VATS lobectomy is effective and reduces death and complications rates. As such, it’s now recommended as the first choice for early-stage lung cancer and certain cases of non-cancerous lung diseases. Managing the patient’s care after the surgery with this VATS approach can also help speed up recovery in chest surgeries.
Anatomy and Physiology of Lobectomy
The surgical anatomy of the lungs is complex and covers areas like the functional tissue of the lung, blood system, and bronchial division. The naming of these lung areas has been made easier with the development of 3D-CT scans, especially for surgeries like VATS segmentectomy, which is a less invasive way of removing a part of your lung.
The functional part of the lung, called lung parenchyma, is broken down into segments. In the right lung, each lobe – upper, middle, and lower – has different segments. Meanwhile, in the left lung, the upper lobe, lingular division of the upper lobe, and the lower lobe also have their segments.
The bronchial anatomy, focusing on the air passages of your lungs, is also divided into segments. Each bronchus, which is a passage that allows air to move into and out of your lungs, highlights different segments in both right and left lungs. For instance, the right main bronchus splits into three different bronchi: the right upper bronchus, the bronchus intermedius, and the lower lobe bronchus.
Each one of these bronchial branches has different variants and can vary in their length and structural forms. Similarly, the left main bronchus splits into the upper lobe and lower lobe bronchi, which have their own segmentary divisions.
The nutritional needs of the lungs are covered by two blood systems: the bronchial and pulmonary vascular systems. The bronchial blood supply provides nutrition to the bronchi or air passages, and its characteristics depend on their origin. They usually come from certain arteries near your heart. The bronchial drains, parts that carry used blood back to the heart, go into the pulmonary veins or drain into the azygos vein and hemiazygos vein, which are large veins near your heart.
The pulmonary vascular system includes a pulmonary artery and superior and inferior veins in both right and left lungs. They provide blood supply for different lung segments. The pulmonary arterial circulation gives the major blood supply to the airways and is primarily used for exchanging gases like oxygen and carbon dioxide.
Why do People Need Lobectomy
Doctors recommend surgery known as lobectomy to treat certain lung conditions. It’s called “benign” when the conditions are not cancerous and “malignant” when they are. These conditions can be both related or not related to infections.
From the infectious viewpoint, certain chronic infections that don’t respond to antibiotic treatment might require a lobectomy. The most common instance is in the treatment of Tuberculosis. While antibiotics generally help control tuberculosis, surgery becomes necessary for those who have localized disease or issues such as a large cavity or bronchiectasis – a condition where certain areas of the lung are permanently enlarged and damaged. But it is important to know that individuals undergoing such operation require careful post-surgery monitoring, as the risk of complications is high.
Non-infectious diseases requiring a lobectomy are often due to abnormal development of lung structures. Specifically, conditions such as congenital bronchial atresia (a birth defect of the lungs), pulmonary sequestration (abnormal tissue or cysts in the lungs), bronchogenic cyst, and congenital cystic adenomatous malformation often warrant a lobectomy.
Frequent, severe bleeding or excessive coughing up of blood, known as massive hemoptysis, could be another reason to have a lobectomy. This can be a result of conditions like aspergilloma (a type of fungal growth in the lungs), cavities in the lungs, abnormal blood vessel formation (AV malformation), or bronchiectasis. Injuries that involve the main blood vessels or air passages in the lungs (hilar injuries) can also be addressed by a lobectomy. However, this situation is quite high risk, with a mortality rate of up to 40%.
As for malignant or cancerous conditions, a lobectomy is commonly used when treating stage I-II non-small cell lung cancer, the most common type of lung cancer. Other types of rarer lung tumors, like mucoepidermoid tumors, adenoid cystic tumors, or sarcomas, may also require a lobectomy. Additionally, if cancer from another part of the body has spread to a specific area of the lungs, a lobectomy might be part of the treatment plan.
When a Person Should Avoid Lobectomy
The success of a surgical procedure often depends on choosing the right patients. For instance, understanding a person’s ability to endure a lobectomy – that’s a surgery where a part of your lung is removed – can guide doctors on who’s more likely to do well after the operation.
Patients with an ‘forced expiratory volume in 1 second’ (FEV1) of less than 800 cc or ‘diffusion capacity of carbon monoxide’ (DLCO) less than 40% are seen as high-risk. In simple terms, folks with these conditions have difficulties in breathing out and how well their lungs can transfer gases, making the surgery riskier. For these patients, it might be safer to have a smaller operation that removes less of the lung, or even no operation at all.
The lobectomy operation should also ideally not be performed on patients who recently had a heart attack, or those with severe heart disease. Additionally, the procedure might not be suitable for patients with pretty large tumors (more than 6 centimeters), due to the technicalities involved in the operation.
Equipment used for Lobectomy
For regular lung removal surgeries, a device designed to move ribs apart is the primary tool used. Longer surgical tools are necessary to reach the lung structures, and instruments specifically designed for blood vessels should be readily available due to the risk of significant blood vessel damage. The lung tissue and structures can be separated by using a stapler or by making a cut and then repairing it by hand. For a minimally invasive type of lung-removal surgery (known as VATS), some of the tools used are different than those in conventional endoscopic surgery.[5][16]
For Open Lung Removal Surgery
The key equipment for this type of surgery is a rib spreader (to separate the ribs), a shoulder blade retractor (to hold the shoulder blade in place), and a tool known as a periosteal elevator (used to separate tissues from bone).[5]
For Minimally Invasive Lung Removal Surgery (VATS)
The basic equipment for VATS includes: video system to visualize the surgical area, a special kind of medical telescope with a 30-degree view, a light source to illuminate the surgical site, energy dissection devices (tools that use sound waves or electricity to cut tissue), long curved tools with double articulation specifically designed for VATS, clips to control bleeding, curved staplers designed for endoscopic surgery, and a plastic endobag for collecting tissue, along with protectors for the surgical opening and special ports (hole created in the body to allow the insertion of surgical tools).[5]
Who is needed to perform Lobectomy?
The team taking care of your lung condition depends on what caused the disease and the treatments you’ve had before. This usually includes lung doctors, infectious disease specialists, general physicians, cancer doctors, and chest surgeons.
If you need to have lung surgery, called a lobectomy, you will have a team helping you. This includes an anesthesiologist who manages your pain and puts you to sleep during surgery, a specialized chest surgeon who performs the operation, an assisting surgeon, and a nurse trained in these types of surgeries.
After the surgery, you will be taken to an Intensive Care Unit (ICU) where the nurses and doctors are experts in caring for people who have just had surgery and who might have heart and lung complications. ICU offers close monitoring and life support treatments if needed. Once you have been stable for a few hours, you will be moved to the regular hospital floor where the hospital staff will ensure your recovery continues smoothly.
Preparing for Lobectomy
Before a patient goes into surgery for lung cancer, the healthcare team conducts several tests to understand the patient’s health condition. They consider things like whether the patient smokes, the presence of other health issues, physical examination results, blood tests, and heart health. Also, they also use advanced scanning methods like the PET/CT scan to get a more precise understanding of the cancer’s spread.
Once the diagnosis is established and it’s decided that the patient needs a surgery called lobectomy, the healthcare team then conducts a special health check-up just for patients getting chest surgeries. Three well-known societies in the medical field have suggested different methods for this check-up, focusing mainly on identifying the risks for the patient and checking the lungs’ health condition.
Different scales or models, such as the Thoracoscope, ESTS model, VA model, and ACS-NSQIP, have been recommended to evaluate the potential risks for the patient during and after chest surgery.
In terms of the lungs’ health condition, the healthcare team uses tools and tests like spirometry, DLCO, V/Q, scintigraphy scan, and a few others to understand the lungs’ capacity and efficiency. This is critical to knowing if the patient can undergo a lung surgery. Specific guidelines recommend different levels of lung health for a patient to be considered for surgery. For instance, one society suggests a specific measure of lung volume, while another suggests certain percentages of lung health.
During surgery, a tube will be put into the patient’s throat to help them breathe. This is considered the standard of care for lung surgery because it makes the process easier. Additionally, in certain careful situations, an awake surgery with video assistance has increasingly been used for major lung surgeries.
How is Lobectomy performed
A lobectomy is a surgical operation where a lobe from one of your lungs is removed. This procedure has continuously advanced over time, and there are several ways that the doctors can carry it out. Some of these methods include conventional open surgery, Video-Assisted Thoracoscopic Surgery (VATS), or using robotic assistance. The choice of method depends on the nature of your condition and what the surgeon considers best.
Conventional open surgery is the traditional method, and while it’s less commonly used these days, it’s sometimes preferred in complex conditions, such as large tumors or severe lung diseases. Your doctor will make a significant incision and directly operate on your lungs. The sequence in which parts of the lungs (vein, artery, and bronchus) are dissected and removed can vary, depending on what the surgeon deems most suitable.
VATS, on the other hand, is a type of minimally invasive surgery. It requires smaller incisions and inserts a camera to assist the surgeon in visualizing the operation. Some popular VATS techniques include the Duke, Copenhagen, and uniportal. These techniques use minimal incisions, primarily focused on the anterior or front of the body. They may vary depending on the number and location of incision points used, but their primary focus is to minimize the invasiveness of the surgery.
The difference between these techniques lies in the number and positioning of the incisions. The Duke approach uses two incisions. The Copenhagen technique uses three incisions. In contrast, the Uniportal involves only a single incision. The sequence of removing vein, arteries, and airway for the respective lobe during the operation can vary, but it usually proceeds from front to back. The procedure can also involve late division of the lung’s fissures (separation between lobes) to prevent complications like postoperative air leaks.
Whether the operation uses the conventional open method or VATS, the surgeon will open up the lung area and carefully identify and dissect the areas needing surgery. They’ll then resect, or cut away, the necessary parts. The sequence of these steps depends on the specific operation, like a right upper lobectomy, right middle lobectomy, or right lower lobectomy.
The goal of all these techniques ensures the safe and effective removal of the affected lung lobe while minimizing complications.
Possible Complications of Lobectomy
After a surgery called a lobectomy, which removes a part of the lung, some people might experience complications. These complications mostly occur in the first 48 hours after the operation. A review from a large cancer database showed that about 2.6% of people die after this surgery, while between 10% to 50% face some difficulties, especially older patients above 75.
One common issue after a lobectomy is a prolonged air leak, which happens in about 15% to 18% of people. This means air might leave the lungs and get trapped in places it doesn’t belong. Other possible complications include subcutaneous emphysema, which is when air gets trapped under the skin, and pneumonia or a blockage caused by mucus buildup (in about 6% of people), which can make it harder to breathe.
Sometimes, an infection can develop in the space between the lungs, known as pleural empyema, and this occurs in about 1% to 3% of patients. An irregular heartbeat, or atrial fibrillation, can happen in 33% of people after a lobectomy. Other, rarer complications involve issues with the middle part of the right lung, bleeding issues (2.9% of cases), a condition called chylothorax where a certain type of body fluid accumulates in the chest (found in 0.7% – 2% of people), and injuries to two nerves that run near the lungs.
In some cases, an infection at the wound site, or the place where the surgeon made the incision, might develop. Very rare complications include tumor embolization, a serious complication where tumor cells spread to other parts of the body, and bronchopleural fistula, an abnormal connection between the airways in your lungs and the space around your lungs, both of which occurs in less than 1% of patients.
What Else Should I Know About Lobectomy?
There are two main methods used in a procedure called lobectomy, where a section of the lung is removed. These approaches are open lobectomy and VATS (video-assisted thoracoscopic surgery) lobectomy. Most of the time, doctors prefer using VATS because patients tend to recover more quickly after the operation.
However, if it’s not possible or safe to use VATS, then doctors do an open lobectomy instead. This will increase the safety of the patient during the operation.
The VATS method is quite safe and effective when dealing with lung issues like bronchiectasis (damaged and widened air passages) or lung cavities caused by an infection. The chances of complications or death are quite low, and patients usually spend about four days in the hospital afterward. VATS is also used safely for congenital lung diseases, those that are present at birth.
In the case of lung cancer, medical guidelines recommend VATS for the removal of the tumor, as research has shown that VATS leads to fewer complications and improves long-term survival chances compared to open surgery (also known as thoracotomy lobectomy) for a condition called non-small cell lung cancer.
