Thoracotomy

The most common use of a thoracotomy with a lobectomy (removal of a lung lobe) is to remove a cancer. Thoracotomy with lobectomy may also be used to remove fungal, bacterial, or tuberculosis infections; as well as to treat congenital malformations or chronic obstructive pulmonary disease (COPD).

It is a standard recommendation that patients with stage I and II of non-small cell lung cancer have surgery if their lungs can tolerate it. Certain stage III lung cancers may also benefit from surgery.

The patient and their oncology team discuss treatment option and determine a treatment plan that may include chemotherapy and radiation before and/or after surgery.

The lung has three lobes on the right and two lobes on the left. A person with adequate lung function may have a lobe resected and still be able to breathe comfortably. Some individuals have enough reserve lung function to have two lobes taken from the right lung (bi-lobectomy) or even one side of a lung completely removed (pneumonectomy).

What type of resection a patient has depends on where the cancer is located and the state of the patient's lungs. This should be discussed with your thoracic surgeon.

A variety of scans and labs may be done prior to discussion of surgery with your thoracic surgery and oncology team. These may include:

• A computed tomography (CT) scan - done before surgery to assess the size and structure of the lesion, especially in relation to other body structures
• A positron emission tomography (PET) scan - done to assess the potential of the lesion being cancerous and whether the cancer has moved to the lymph nodes or to other parts of the body (metastasized)
• An electrocardiogram (EKG) - performed for individuals with a history of high blood pressure, any heart condition or who are around the age of 45 or older
• Pulmonary function tests are done to determine if a patient is a candidate for lung surgery with resection
• Cardiac stress testing and echocardiograms may also be performed prior to surgery

Before a lobectomy, a patient will need either a mediastinoscopy, endobronchial ultrasound (EBUS) with biopsy, superDimensional bronchoscopy, and/or a video assisted thoracic surgery with wedge resection to get an accurate diagnosis of the cancer and whether it has metastasized.

Stage IV and certain stage III non small cell lung cancer patients show no benefit with surgery so it is important to make sure that the patient has lymph nodes checked for metastasis (spread) of the tumor.

After a patient is asleep with general anesthesia, they are placed in a position on their side that prevents pressure or stretching of any of the limbs or body. The lung is deflated on the side of surgery providing the surgeon with plenty of room to safely work in the chest cavity without injuring the lung or vessels. The other lung continues to ventilate and bring oxygen to the heart and body.

Approximately an 8-10 centimeter incision is made between the ribs, below the axilla (armpit). Depending on exposure, part of a rib may have to be removed so that the thoracic surgeon can optimally visualize inside the lung cavity.

The vessels and airway going to the lobe are carefully stapled and cut. Lymph nodes around the lung and mediastinum (the space in between the lungs that contains the heart, esophagus and airway) are taken out to assess for metastatic cancer (cancer that has spread to body parts other than the original site).

At the end of surgery, the lung area is carefully checked to make sure there are no blood or air leaks. The lung is watched as it is inflated. Two chest tubes are placed to drain fluid and assess for lung air leaks. Generally, the chest tubes are removed 2-3 days after surgery.

A patient's expected hospital stay is generally 3-5 days. Floor nurses, physical therapists and a pain team work daily with the patient to ensure they are on a good road to recovery after surgery; our physicians and thoracic team often stop in several times a day to visit the patient.