Main»Pulmonary Resection

Pulmonary Resection

Pulmonary Resection

1. Resections

A. Right upper lobectomy
1) incise hilar pleura
2) visualize pulmonary vein
3) pulmonary artery lies superior and posterior to the vein
4) dissection is carried out to the anterior-apical artery
5) artery and vein are dissected circumferentially being careful of the takeoff of the middle lobe artery
6) upper lobe bronchus is identified just inferior to the azygos
B. Right middle lobectomy
1) track the anterior basal segmental artery (visible subpleurally) back to its origin from the PA deep in the fissure; then identify the posterior branch to the RUL & superior segment branch to the RLL
2) identify two arterial branches to the middle lobe
3) middle lobe vein most commonly drains to the superior vein
4) key is to divide the vein first, followed by the bronchus, and finally the artery
C. Right lower lobectomy
1) dissection begun in the major fissure
2) artery seen and dissected distally
3) bronchus is visualized after division of the artery and then divided after identifying the middle lobe bronchus
4) finally the vein is divided
D. Right pneumonectomy
1) incise the hilar pleura
2) dissect the pulmonary veins
3) dissect the pulmonary artery (may need to open the pericardium)
4) isolate mainstem bronchus
5) cover the bronchial stump
E. Right sided lymph node dissection
1) dissect the area bordered by:
a) inferiorly - azygos vein
b) superiorly - subclavian vein
c) posteriorly - trachea
d) anteriorly - superior vena cava
F. Left upper lobectomy
1) incise the hilar pleura
2) pulmonary artery is the most superior structure in the hilum
3) ligamentum arteriosum can be divided to obtain length
4) dissect the artery to the superior segment of the LLL
5) divide the fissure to expose the lingular arteries
6) divide the artery, then the vein , and finally the bronchus
G. Left lower lobectomy
1) begin in the fissure if complete, otherwise begin at the hilum
2) visualize the superior segment artery
3) divide the posterior aspect of the fissure
4) dissect the artery onto the basilar trunk
5) expose the inferior vein in the inferior pulmonary ligament
6) divide the artery, vein , and bronchus
H. Left pneumonectomy
1) identify the pulmonary artery, and vein
2) traction is needed to expose the proximal mainstem bronchus
3) Divide the artery, vein, and bronchus
I. Left lymph node dissection
1) dissect lateral to the ligamentum, between the aortic arch and the pulmonary artery
2) dissect superior to the arch
3) dissect the inferior pulmonary ligament
J. Pointers for the left side
1) aortopulmonary window may be difficult to dissect secondary to infiltration of disease, and a very friable, tethered artery
2) apical- anterior artery is tenuous
3) left mainstem is difficult to dissect