Pneumonectomy
Pneumonectomy is a surgical procedure involving the complete removal of one lung, utilized primarily to treat lung cancer or, less frequently, conditions like severe chest trauma or extensive unilateral tuberculosis. A specific variant known as extrapleural pneumonectomy involves the removal of the lung along with surrounding structures, such as part of the diaphragm and membranes covering the heart. Prior to surgery, detailed imaging and tests are conducted to ensure the cancer has not metastasized and to assess the patient's overall health and lung function.
The procedure requires general anesthesia and involves careful surgical steps to safely remove the lung, after which the patient is monitored in a surgical intensive care unit (SICU) for recovery. Postoperative care focuses on preventing complications such as pneumonia and ensuring the remaining lung compensates for the loss. Recovery can be lengthy, often requiring months, and some patients may need lifelong supplemental oxygen. While pneumonectomy was historically a key treatment for lung cancer, advances in thoracic surgery techniques are increasingly providing less invasive options, leading to a decline in the necessity of this procedure. Risks associated with pneumonectomy include infection, bleeding, and respiratory complications, making careful management crucial for patient outcomes.
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Subject Terms
Pneumonectomy
ALSO KNOWN AS: Lung removal, extrapleural pneumonectomy
DEFINITION: Pneumonectomy is the surgical removal of the entire lung. Extrapleural pneumonectomy is the surgical removal of the lung, a portion of the membrane covering the heart, the membrane lining the affected side of the chest cavity, and a portion of the diaphragm.
Cancers treated:Lung cancer, mesothelioma
Why performed: Pneumonectomy is a surgical procedure used to treat lung cancer when the tumor cannot be removed by a less extensive procedure. It may also be performed in the presence of severe chest trauma. Rarely, pneumonectomy is used for the treatment of bronchiectasis, lung abscesses, or extensive unilateral tuberculosis. Extrapleural pneumonectomy is sometimes a treatment option for those patients with mesothelioma.
Patient preparation: Before planning surgery, a computed tomography (CT) scan of the head and abdomen and a bone scan are typically performed to confirm that the cancer has not spread to other areas of the body. If the cancer has spread, then pneumonectomy may not be a treatment option.
Before surgery, studies are performed to check for abnormalities and establish a baseline for postoperative comparison. These studies include a chest X-ray, electrocardiogram (EKG), bleeding time, and blood tests to check kidney function; electrolyte, hemoglobin, and oxygen levels; and white blood cell count. Pulmonary function tests are performed to evaluate lung function and to determine whether the remaining lung is healthy enough to handle the increased workload. A blood sample is also drawn to check the patient’s blood type if a transfusion is needed during surgery.
A week before surgery, aspirin and anti-inflammatory drugs are stopped. The patient is given special instructions about when to stop taking anticoagulants, if prescribed. The patient must not eat or drink for at least eight hours before surgery, and an intravenous (IV) is inserted to deliver fluids and medications. An indwelling urinary catheter is also inserted so that urine output can be monitored closely during and after the procedure.
Steps of the procedure: When the patient arrives in the operating suite, an arterial catheter may be inserted to monitor the patient’s blood pressure and oxygenation. An epidural catheter may also be inserted for postoperative pain control. An endotracheal tube is inserted through the nose or mouth to maintain the patient’s airway and provide oxygenation during surgery.
After the patient is anesthetized, the surgeon makes an into the chest cavity. When the chest cavity is entered, the lung collapses. The surgeon locates and ties off the pulmonary artery supplying the lung and the pulmonary veins. The ribs are spread, and the lung is exposed for removal. In some cases, it is necessary to remove a rib. The mainstem bronchus is divided, and the affected lung is removed. The surgeon staples or sutures the bronchial stump. Chest tubes typically are not inserted into the chest; instead, fluid is permitted to accumulate inside the empty chest cavity, preventing mediastinal shift. Finally, after ensuring the bronchial stump is not leaking air, the surgeon closes the chest cavity and applies a sterile dressing.
When an extrapleural pneumonectomy is necessary, the surgeon removes the lung, a portion of the membrane covering the heart, the membrane lining the affected side of the chest cavity, and a portion of the diaphragm and replaces them with synthetic patches.
After the procedure: The patient is transferred to the surgical intensive care unit (SICU) and attached to a monitor that displays the patient’s heart rhythm, blood pressure, and oxygen saturation. These devices help the SICU nurses monitor the patient’s condition closely. The patient may have an endotracheal tube in place and require mechanical ventilation to assist breathing. If mechanical ventilation is unnecessary, the patient will receive supplemental oxygen through a nasal cannula or facemask. The patient is encouraged to cough, breathe deeply, and use an incentive spirometer to prevent pneumonia. If the patient requires mechanical ventilation immediately after surgery, early extubation is the goal to prevent ventilator-associated pneumonia. The head of the patient’s bed is elevated at least 30 degrees to help prevent pneumonia. The patient is turned every two hours from the back to the nonoperative side to prevent the heart and remaining lung from shifting toward the operative side. Fluids are administered conservatively through an IV infusion pump to prevent fluid overload. Sequential compression devices are attached to the patient’s legs to help prevent blood clot formation. Pain medications are administered continuously, either through an epidural catheter or through an IV catheter, as needed.
When considered stable, typically a few days after surgery, the patient is transferred to a medical-surgical floor and then discharged home. The patient is instructed to resume activities of daily living slowly to allow the remaining lung to compensate for its increased workload. Recovery commonly takes several months because shortness of breath significantly limits the patient’s ability to exercise. Some patients require lifelong supplemental oxygen therapy.
As the twenty-first century progressed, advances in thoracic surgery reduced the need for pneumonectomy. Sleeve lobectomy and bronchoplastic resections are surgical techniques that have proven more effective in treating non-small cell lung cancer than traditional pneumonectomy. Further, increased attention was given to the perioperative management of patients undergoing pneumonectomy in hopes of reducing mortality rates.
Risks: The risks of pneumonectomy include surgical site infection, pneumonia, empyema (pus in the pleural space), hemorrhage, pulmonary edema, myocardial infarction, cardiac arrhythmia, pulmonary embolism, and ventilator-dependent respiratory failure. Rarely, stump failure results in cardiopulmonary arrest.
Results: Pathologic examination of the lung specimen reveals the type of cancer.
Bibliography
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