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Thoracic Surgery

Thoracic Surgery

Thoracic surgery is the repair of organs located in the thorax, or chest. The thoracic cavity lies between the neck and thediaphragm, and contains the heart and lungs (cardiopulmonary system), the esophagus, trachea, pleura, mediastinum,chest wall, and diaphragm.

Lobectomy and Pneumonectomy

Pneumonectomy

A surgical procedure in which an entire lung is removed. A pneumonectomy is most often done for cancer of the lung that cannot be treated by removal of a smaller portion of the lung or in old tuberculosis, bronchiectasis when disease has destroyed major portion of lung. A pneumonectomy is an open chest technique (thoracotomy).

Lobectomy

Also called a pulmonary lobectomy, it is a common surgical procedure that removes one lobe of the lung that contains tuberculosis associated bleeding cavity, aspergilloma , bronchiectasis or cancer which is localized. Removal of two lobes is called lobectomy.

Sleeve Lobectomy

A surgical procedure that removes a cancerous lobe of the lung along with part of the bronchus (air passage) that attaches to it. The remaining lobe(s) is then reconnected to the remaining segment of the bronchus. This procedure preserves part of a lung,

Wedge Resection

A wedge resection is a surgical procedure during which the surgeon removes a small, wedge-shaped portion of the lung containing the cancerous cells along with healthy tissue that surrounds the area. The surgery is performed to remove a small tumor or to diagnose lung cancer. Also when interstitial lung disease or Connective tissue disorder requires lung biopsy. A wedge resection can be performed by minimally-invasive video-assisted thoracoscopic surgery (VATS) or a thoracotomy (open chest surgery).

Segment Reaction (Segmentectomy)

A segment resection removes a larger portion of the lung lobe than a wedge resection, but does not remove the whole lobe.

Reasons for the procedure

A lobectomy may be performed when a lung abnormality or condition has been identified that requires surgical removal. A lobe may be removed to avoid spread of the disease-causing pathogen to the other lobes, as with tuberculosis or certain cancerous lung tumors.

Conditions of the chest and lungs for which a lobectomy may be performed include, but are not limited to, the following:-

  • Tuberculosis (TB). A chronic bacterial infection that usually infects the lungs, although other organs may be involved. TB is primarily an airborne disease (spread by air droplets from infected people when they cough or sneeze).
  • Lung abscess. A localized collection of pus that may form in the lung. If the abscess does not resolve with antibiotic therapy, it may “wall off” so that it does not infect the rest of the body.
  • Emphysema. A chronic illness that results from the chemical breakdown of the elastic fibers in the lungs, interfering with expansion and contraction of the lungs.
  • Benign tumor. A noncancerous mass that can press on major blood vessels and affect the function of other organs.
    Lung cancer. A group of cancers that may affect the bronchi, one or more lobes of the lungs, the pleural lining, and/or other lung tissue.
  • Fungal infections. Fungi are a group of organisms that, although rare, may cause infections in various parts of the body. Fungal infections can be difficult to diagnose and treat.

There may be other reasons for your doctor to recommend a lobectomy.

Risks of the procedure

As with any surgical procedure, complications may occur. Some possible complications include, but are not limited to, the following:

Infection Tension pneumothorax occurs when air becomes trapped in the pleural space (the air between the lung and the chest wall), causing the lung to collapse.
Bronchopleural fistula is a tube-like opening between the bronchus and pleural space causing leakage of air or fluid into the surgical area.
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedureSurgery: The operation is done under a general anaesthetic and takes between one and three hours. It is routine practice to check the airway for any abnormality. This is done by putting a bronchoscope (surgical telescope) into your windpipe via your mouth. You will then be positioned on your side with your arm above your head. The surgeon will make a cut starting under your shoulder blade, along the line of the rib. The ribs are separated from each other to gain access to the organs within. Occasionally ribs may be broken during this procedure.
Post operative period: The surgeon will leave a chest tube in the space where the lung was. This will be clamped and the clamps will be removed every few hours for a few minutes at a time. The drain will be secured with a stitch and an additional one to close the skin when the drain is removed. The drain normally stays in for 24 hours. Pain killers: mostly after surgery a small needle based catheter is placed in the vertebral column near to spinal cord. This keeps the upper chest numb and thus the pain perception is very less and patient does not feel much pain.
Physiotherapists will show you how to do breathing exercise and how to cough to help prevent a chest infection. You will be shown how to exercise your shoulder to prevent getting a frozen shoulder. It is very important to do these exercises as they will help with your recovery
Eventually you should be able to return to your normal activities; however you will probably have to take more time to do things and not rush.
Coughing up blood It is normal to cough up a little blood for the first few days after lung surgery. The nurses and physiotherapists will help you with breathing exercises post surgery to clear this. It will gradually get less over time. Chest infection Breathing exercises, early mobilisation and adequate pain relief can help reduce this risk. If you do develop a chest infection you may need physiotherapy and sometimes treatment with antibiotics.
Broncho-pleural fistula: Very occasionally the stitch line on the bronchus from where the lung has been removed develops a small hole. This means that a drain has to be put into the space where the fluid builds up to drain out all the fluid. The drain will need to stay in for a while, and it may be necessary to have antibiotics

Lung Decortication

Chronic pleural empyaema is the last phase of the inflammatory process occurring in parapneumonic effusion (fluid collection in the pleural space due to infection in lung). Purulent fluid accumulates in the pleural space, and fibrin is deposited on both pleural surfaces, forming a thick peel that restricts the underlying lung ( this can be understood as , when a mixture of water and dust is kept for some time the mud settles down and the water remain on the top). so even when the water (or pus) is drained out by needle aspiration or Intercostal drainage with tube, the fibrin and purulent slough along with the protenecious deposits settle on the collapsed lung and does not allow the lung to expand (Restriction). The restriction of the lung and the impairment of chest wall elasticity due to the thickened pleural layer cause thoracic asymmetry in the late phase of empyaema. the collapsed lung as does not expand thus.

Decortication is a medical procedure involving the surgical removal of the surface layer which is called “PEEL” a membrane, or fibrous cover of an organ. The procedure is usually performed when the lung is covered by a thick, inelastic pleural peel restricting lung expansion. In a non-medical aspect, decortication is the removal of the bark, husk, or outer layer, or peel of an object. It is the primary treatment for fibrothorax.

Decortication is performed under general anaesthesia. It is a major thoracic operation that has traditionally required a full thoracotomy. the pleural peel removal is important for setting the lung free from entrapment and lung expansion , where as the perietal peel removal is required for relieving the intercostal muscles free which eventually allows the chest wall to regain normalcy (else the intercostal muscles shrink and the ribs get crowded, which leads to deformity of chest wall ).

Since the early ’90s this procedure has increasingly been performed using more minimally invasive thoracoscopy. All fibrous tissue is removed from the visceral pleural peel and pus is subsequently drained from the pleural space.

Eloessures Window

This surgery is a salvage procedure , when the decortication is not fully successful and te lung has not expanded fully expanded, during decortication the lung is badly injured or the reason of collapsed lung is old ruptured lung abscess or parenchymal necrosis, or non repairable bronchopleural fistula. in this after decortication a small piece of rib is excised and the skin is sutured rolled back into the perietal pleura. this makes a small window in the chest wall which can be utilised for lavage of cavity . as grasdually the cavity becomes sterile and gets epithelised and healthy granulation is formed the window is closed using a vascularised pedicle of muscle or directly.

Contraindications

Other than the overall health of the patients, there are no absolute contraindications. In some lung-disease patients, the lung will not expand after removal of the pleural peel, rendering the surgery futile. Other diseases that render decortication futile are narrowing of the large airway stenosis and uncontrolled pleural infection. With these conditions, the lung will not expand to fill the thorax space.

Bronchopleural fistula repair (Coming Soon...)

Lung Cancer surgery/ Mediastinal (chest) tumors (Coming Soon...)

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