A pneumonectomy is a surgical procedure in which one lung is removed entirely. It is usually saved for serious lung diseases that are unresponsive to less invasive treatments. This procedure is major and carries significant risks, but it has the potential to save the lives of patients with certain conditions, particularly lung cancer.
In this article, we will explore pneumonectomy, including its history, indications, surgical procedures, postoperative care, and potential complications, providing a comprehensive understanding of this crucial surgical intervention.
What is Pneumonectomy?
Pneumonectomy is a major surgical procedure that entails the complete removal of one lung, typically performed to treat severe conditions such as lung cancer, extensive trauma, chronic infections, severe bronchiectasis, or specific congenital diseases when less invasive treatments are not viable.
Pneumonectomy has been practised since the early 1900s. Dr. Evarts Graham successfully conducted the first pneumonectomy in 1933, primarily to treat lung cancer. The patient-outcomes of pneumonectomy have greatly improved since then due to developments in surgical methods, anaesthesia, and postoperative care.
Even though this procedure can save lives, it is dangerous, and a comprehensive preoperative assessment is necessary to make sure the patient is capable of handling the loss of a lung and recovering from surgery.
Indications for Pneumonectomy
Pneumonectomy is usually indicated for:
Lung Cancer
The most common indication for pneumonectomy is lung cancer. Pneumonectomy may be required when a tumour is centrally placed in the lung or is too big to be removed by a more cautious treatment such as lobectomy (removal of a lung lobe). This approach aims to eradicate the cancerous tissue to prevent its recurrence and metastasis completely.
Trauma
A lung may need to be removed due to irreversible damage caused by severe chest trauma, which arises from an automobile accident or penetrating injury. A pneumonectomy may be necessary to stabilise the patient and stop possibly fatal outcomes in situations where the lung tissue is so severely damaged that it cannot function normally or is experiencing significant haemorrhaging.
Infections
Pneumonectomy may be necessary in cases of chronic infections like tuberculosis or serious lung abscesses that do not improve with drugs or alternative treatments. If not appropriately treated, these infections can cause significant health issues and can lead to the death of lung tissue.
Bronchiectasis
The condition causes the bronchi to expand severely and irreversibly, which can damage the lungs and cause chronic infections. Pneumonectomy may be considered in severe cases of bronchiectasis when the disease is limited to one lung and significantly decreases the quality of life and respiratory function.
Congenital Diseases
Rare congenital conditions, such as pulmonary sequestration or congenital cystic adenomatoid malformation (CCAM), can seriously compromise lung function. If these diseases result in constant infection, respiratory discomfort, or other serious health issues, a pneumonectomy is needed.
Surgical Procedure
Pneumonectomy can be performed using two primary approaches:
Open Pneumonectomy
A thoracotomy, or incision between the ribs, is a common method of reaching the chest cavity. This technique allows the surgeon to precisely dissect and remove the lung and its surrounding components. When dealing with difficult cases requiring considerable dissection or when the tumour is positioned centrally inside the lung, open pneumonectomy is frequently the recommended procedure.
Video-Assisted Thoracoscopic Surgery (VATS)
VATS pneumonectomy is a minimally invasive technique that uses small cuts and a camera to guide the surgery. It involves inserting a thoracoscope, a long, thin tube with a camera and light at the end, through small incisions in the chest.
The surgeon uses specialised instruments to remove the lung through these incisions. Although VATS is less commonly used for pneumonectomy compared to other lung surgeries, it offers the benefits of reduced postoperative pain, shorter hospital stays, and faster recovery.
Steps of the Procedure
Here are the steps of the procedure:
Anaesthesia
General anaesthesia is given to keep the patient pain-free and asleep throughout the procedure. An endotracheal tube is inserted for mechanical ventilation and airway maintenance.
Incision
To access the lung, a thoracotomy incision is made. The site and size of the incision depend on the approach (open or VATS) and the patient’s specific anatomical considerations.
Resection
The lung is carefully separated from surrounding structures and major blood vessels. This step involves meticulous dissection to avoid damaging vital structures and ensure complete removal of the diseased lung tissue.
Lung Removal
The affected lung is removed. In open pneumonectomy, the lung is removed through the thoracotomy incision, while in VATS, it is removed through small incisions using specialised instruments and techniques.
Closure
The incision is closed, and a chest tube is often placed to drain fluids and air from the chest cavity. The chest tube helps re-expand the remaining lung and prevents the accumulation of fluid and air, which can cause complications.
Postoperative Care
Postoperative care is crucial for recovery. It includes:
Pain Management
Deep breathing and coughing are necessary to prevent pneumonia and other respiratory issues, and they can only be accomplished with effective pain management. Methods of managing pain involve the use of pharmaceuticals like opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and regional anaesthesia procedures like nerve blocks or epidurals.
Respiratory Therapy
Breathing exercises, incentive spirometry, and physical therapy are used to improve lung function and avoid consequences like pneumonia and atelectasis (collapse of lung tissue). Respiratory therapists collaborate closely with their patients to create customised rehabilitation plans and guarantee that patients perform the recommended exercises.
Monitoring for Complications
Close monitoring for complications such as infection, bleeding, and respiratory distress is necessary for early detection and intervention. Patients are commonly monitored in an intensive care unit (ICU) immediately after surgery and transferred to a regular ward once their condition stabilises.
Nutrition
Adequate nutrition is essential for promoting healing and recovery. During the healing phase, patients may need to adjust their diets and take nutritional supplements to fulfil their increased needs for protein and calories. Dietitians provide nutritional support to patients, ensuring they obtain the proper nutrients to support overall health and wound healing.
Complications and Risks
Pneumonectomy is associated with significant risks, including:
Respiratory Complications
Possible respiratory problems include bronchopleural fistula, pneumonia, and acute respiratory distress syndrome (ARDS). Impaired lung function and inadequate secretion clearance can result in pneumonia. ARDS, a severe type of respiratory failure, may occur after surgery. A bronchopleural fistula is a tube between the pleural space and the bronchial tree. It can cause continuous air leaks and require additional surgical intervention.
Cardiovascular Complications
Increased cardiovascular system stress can result in arrhythmias, heart failure, and pulmonary hypertension. Following a pneumonectomy, arrhythmias like atrial fibrillation are prevalent and may need to be managed medically. Intensified stress on the heart can lead to heart failure, especially in people with previous cardiac conditions. Reduced lung capacity and higher resistance in the pulmonary circulation can lead to the development of pulmonary hypertension, which is indicated by elevated blood pressure in the pulmonary arteries.
Infection
Potential side effects from wound contamination or systemic infections include sepsis and surgical site infections. Strict hygienic practices and postoperative antibiotic, prophylaxis, lower the risk of infections. Early spotting and treatment of infections are critical to prevent the development of sepsis, a life-threatening condition characterised by widespread inflammation and organ dysfunction.
Blood Clots
Significant concerns after major surgery, such as a pneumonectomy, include deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots that crop up in the deep veins, commonly seen in the legs, can cause DVT and can give rise to pulmonary embolism (PE). Anticoagulant drugs, compression stockings, and early mobilisation are examples of preventive treatments that lower the chance of clot formation.
Residual Lung Function
Pneumonectomy is expected to result in reduced lung capacity and long-term breathing issues. Due to the loss of lung tissue, patients may experience weariness, shortness of breath, and fatigue more quickly. Training for pulmonary rehabilitation and lifestyle changes like quitting smoking and adopting a regular exercising schedule can help better lung function and quality of life.
Conclusion
In conclusion, pneumonectomy is a major surgical procedure with significant risks, but it can be life-saving for patients with severe lung conditions. Due to improvements in surgical procedures, anaesthesia, and postoperative care, the treatment is now more feasible for individuals who need it the most. Postoperative care is essential to maximising healing and quality of life. Pneumonectomy can provide patients with potentially incurable lung disorders with a considerable possibility of improved health and increased survival.
