Pulmonary Surgery
INDICATIONS FOR SURGERY
• Malignancy
• Inflammatory
• Lung resection is occasionally required for the
following conditions: lung abscess, tuberculosis,
bronchiectasis, aspergillosis, hydatid disease.
• Trauma: Stab wounds, gunshot wounds.
• Congenital: Arterio-venous fistula, sequestrated
lobe, lobar emphysema.
TYPES OF PULMONARY RESECTION
• Pneumonectomy: The entire lung is removed.
The resulting cavity is filled by protein rich fluid
and fibrin.
• The cavity size is reduced by lateral shift of the
trachea and heart, upward shift of the
diaphragm, and reduction of the intercostal
spaces on the operated side.
• Occasionally, and later, a scoliosis may develop.
Lobectomy
• Any of the five lobes may be removed; on the
right side the middle and lower lobes are often
removed together because of their common
lymphatic drainage.
• If a tumor in an upper lobe protrudes into the
main bronchus a cuff of main bronchus can be
removed with the lobe and the remaining lung
and bronchus is joined to the trachea.
• This is termed a sleeve lobectomy.
Segmental resection
• A bronchopulmonary segment is removed
with its segmental artery and bronchus.
• This used to be indicated for tuberculosis but
is now rarely performed.
Wedge resection
• This non-anatomical resection is used for
diagnosis in open lung biopsy and treatment
of well-localised peripheral carcinomas in
patients with reduced lung function.
INCISIONS IN THORACIC SURGERY
• Postero-lateral incision
– Most thoracic operations are performed through a postero-
lateral incision.
– This divides the lower fibers of trapezius, latissimus dorsi,
serratus anterior and the external and internal intercostal
muscles.
– A high posterior extension of the incision also divides
rhomboid major and the erector spinae group.
• Antero-lateral thoracotomy
– An antero-lateral thoracotomy is the standard approach for a
closed mitral valvotomy and is used by some surgeons for
pleurectomy.
DRAINAGE OF THE CHEST
• The purpose of drains in thoracic surgery is to
remove fluid or air which is expected to
accumulate.
• Drainage may be open or closed.
Closed drainage
• A tube with end and side holes is introduced
into the thorax via an intercostal space.
• It is connected to a closed bottle via a
transparent tube which ends under water.
• A second short tube left unconnected
maintains atmospheric pressure within the
bottle.
Open drainage
• A tube in the pleural cavity connects directly
with air.
• This arrangement is only safe when the pleural
cavity has become rigid and immovable.
COMPLICATIONS OF LUNG SURGERY
EARLY (O—2 WEEKS)
• Local
– Hemorrhage
– Atelectasis/lobar collapse
– Wound infection Surgical emphysema
– Pleural effusion Empyema
– Broncho-pleural fistula
– Nerve damage, e.g. recurrent laryngeal, phrenic
• General
– Ventilatory insufficiency
– Atrial fibrillation
– Myocardial infarction
– Pulmonary embolus/deep vein thrombosis
Late complication
• Local
– Thoracotomy wound pain
– Recurrence of carcinoma
– Chest wall deformity
– Restricted arm movements
• General
– Distant spread of carcinoma
Physiotherapy
• Each patient must be assessed individually, and at each
treatment.
• Techniques and regimes will vary with the patient’s
condition, from hospital to hospital.
• It is essential to know and abide by the surgeon’s
wishes and special routines, as well as ensuring that
the patient has adequate analgesia before treatment
starts.
Postoperative period
• Following surgery and before each treatment the physiotherapist
should check the following:
– Type of operation.
– Incision.
– Chest radiograph.
– Temperature.
– Pulse rate.
– Respiratory rate.
– Blood pressure.
– Drug chart.
– Fluid chart.
– Oxygen therapy.
– Drains - the amount of fluid drained
• whether or not there is an air leak
• whether on or off suction
• if off suction, whether or not the drain is swinging
Postoperative problem list
• Pain .
• Intercostal drains in situ.
• decreased air entry.
• Retained secretions.
• Decreased movement - especially the
shoulder on the operation side.
• Decreased mobility.
• Poor posture.
Postoperative treatment plan
• Ensure that the patient has adequate analgesia.
• Deep breathing exercises (unilateral costal on the
good side and diaphragmatic) with inspiratory
holds and sniffs in sitting or half lying.
• Unilateral shakings on the good side during
expiration.
• Huffing with good support of the incision.
• Full range active/assisted shoulder exercises.
• Active leg, foot and ankle exercises.
• Bilateral costal and diaphragmatic breathing
exercises.
• Trunk and shoulder girdle exercises and
postural correction.
• Early mobilization with controlled breathing
pattern designed to improve exercise
tolerance
