Pulmonary Tests and Procedures
(Thoracotomy, Thoracoscopic Lobectomy, Removal of a Lobe of the Lungs, Lung Surgery)
What is a lobectomy?
A lobectomy is a surgical procedure performed to remove one of the lobes of the lungs. The procedure may be performed when an abnormality has been detected in a specific part of the lung. When only the affected lobe of the lung is removed, the remaining healthy tissue is spared to maintain adequate lung function.
A lobectomy is most often performed during a surgical procedure called a thoracotomy (surgical incision of the chest). Other lung surgery procedures that may be performed by thoracotomy include:
- pneumonectomy - removal of an entire lung when an abnormality or disease is detected throughout the entire lung
- wedge resection - removal of a small section of a lobe when an abnormality or disease involves only a small area of lung tissue
- segmental resection - removal of a segment, or subdivision of a lobe
- exploratory thoracotomy - opening of the chest wall for direct visualization of the lungs and other chest structures when there is evidence of an abnormality or disease that has not been verified by other diagnostic methods
There are different kinds of thoracotomies depending on the location of surgical entry and how much lung is removed. Generally, during a lobectomy the incision is made at the level of the affected lobe. The incision is made on the front of the chest under the nipple line and extends around the back under the shoulder blade. The surgeon enters the chest cavity through the exposed ribs to remove the lobe.
In certain circumstances, a minimally invasive procedure called video-assisted thoracic surgery (VATS) is used to perform a lobectomy. Specialized surgical instruments are inserted into the chest cavity through three or four small incisions. One of the instruments, a thoracoscope, has a tiny camera and transmits the image to a TV-like monitor. The surgeon is able to view the internal organs on the monitor. Through the remaining incisions, other specialized instruments are inserted and used to perform the procedure. The type of procedure performed will be determined by the surgeon, based on the patient's medical condition and other factors.
Other related procedures that may be used to diagnose problems of the lungs and respiratory tract include lung biopsy, pleural biopsy, bronchoscopy, thoracentesis, and mediastinoscopy. Please see these procedures for additional information.
Anatomy of the respiratory system:
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The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the:
The upper respiratory tract includes the:
- nasal cavity
- ethmoidal air cells
- frontal sinuses
- maxillary sinus
The lower respiratory tract includes the lungs, bronchi, and alveoli.
What are the functions of the lungs?
The lungs take in oxygen, which cells need to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body's cells.
The lungs are a pair of cone-shaped organs made up of spongy, pinkish-gray tissue. They take up most of the space in the chest, or the thorax (the part of the body between the base of the neck and diaphragm).
The lungs are enveloped in a membrane called the pleura.
The lungs are separated from each other by the mediastinum, an area that contains the following:
- the heart and its large vessels
- trachea (windpipe)
- lymph nodes
The right lung has three sections, called lobes. The left lung has two lobes. When you breathe, the air enters the body through the nose or the mouth. It then travels down the throat through the larynx (voice box) and trachea (windpipe) and goes into the lungs through tubes called main-stem bronchi.
One main-stem bronchus leads to the right lung and one to the left lung. In the lungs, the main-stem bronchi divide into smaller bronchi and then into even smaller tubes called bronchioles. Bronchioles end in tiny air sacs called alveoli.
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 non-cancerous mass
- 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 are difficult to diagnose and treat.
There may be other reasons for your physician to recommend a lobectomy.
As with any surgical procedure, complications may occur. Some possible complications include, but are not limited to, the following:
- tension pneumothorax - air becomes trapped in the pleural space (the air between the lung and the chest wall), causing the lung to collapse.
- hemorrhage (bleeding)
- bronchopleural fistula - a tube-like opening between the bronchus and pleural space causing leakage of air or fluid into the surgical area.
- empyema - an accumulation of pus in the chest cavity
There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.
- Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
- You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
- In addition to a complete medical history, your physician may perform a physical examination to ensure you are in good health before you undergo the procedure. You may also under go blood tests and other diagnostic tests.
- You will be asked to fast for eight hours before the procedure, generally after midnight.
- If you are pregnant or suspect that you are pregnant, you should notify your physician.
- Notify your physician if you are sensitive to or are allergic to any medications, latex, iodine, tape, and anesthetic agents (local or general).
- Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
- Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
- If you smoke, you should stop smoking as soon as possible prior to the procedure, in order to improve your chances for a successful recovery from surgery and to improve your overall health status.
- You may receive a sedative prior to the procedure to help you relax.
- The areas around the surgical site may be shaved.
- Based upon your medical condition, your physician may request other specific preparation.
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A lobectomy requires a hospital stay of several days. Procedures may vary depending on your condition and your physician’s practices.
Generally, a lobectomy follows this process:
- You will be asked to remove any jewelry or other objects that may interfere with the procedure.
- You will be asked to remove clothing and will be given a gown to wear.
- An intravenous (IV) line will be inserted in your arm or hand.
- A urinary catheter may be inserted into your bladder to drain urine during the procedure.
- You will be positioned on the operating table in a manner that provides the best access to the side of the chest being operated on, usually lying on the side opposite the surgical site.
- After you are sedated, the anesthesiologist will insert a tube into your lungs so that your breathing can be controlled by a ventilator. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
- The skin over the surgical site will be cleansed with an antiseptic solution.
- An incision will be made along the front aspect of the chest at the level of the lobe being removed. The incision will extend under your arm to your back.
- When the ribs are visualized, a special instrument will be used to spread the ribs apart, leaving the lung area exposed.
- The blood vessels and air tubes that supply the lobe being removed will be tied off with non-absorbable sutures.
- The lobe will be removed. In order to facilitate the removal of the lung tissue, a rib or a portion of a rib may be removed.
- One or more chest tubes may be inserted into the chest cavity to aid in the removal of air or fluid postoperatively.
- The skin incision will be closed with sutures or surgical staples.
- A sterile bandage/dressing will be applied.
- An epidural catheter to infuse pain medication into your back may be inserted before you leave the operating room or in the recovery room.
In the hospital:
After the procedure, you will be taken to the recovery room for observation. Your recovery process will vary depending upon the type of procedure performed and the type of anesthesia that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room.
You may receive pain medication as needed, either by a nurse, through an epidural catheter, or by administering it yourself through a device connected to your intravenous line.
You may have one or more chest tubes inserted near the surgical incision to drain air and/or fluid from the chest. The chest tubes may be painful when you move, cough, or breathe deeply. The chest tubes will be removed before you are discharged from the hospital.
You may need to receive oxygen for a period of time after surgery. Generally, the oxygen will be discontinued before you go home. However, some patients may need to go home with oxygen, depending on their medical condition.
You will be taught deep-breathing exercises and coughing techniques to help facilitate lung re-expansion and prevent postoperative pneumonia.
You will be encouraged to move around as tolerated while you are in bed and to get out of bed and walk around as your strength improves.
Depending on your situation, you may be given liquids to drink a few hours after surgery. Your diet may be gradually advanced to more solid foods as tolerated.
Before you are discharged from the hospital, arrangements will be made for a follow-up visit with your physician. The length of time may vary depending on the reason for your lobectomy.
Once you are home, it is important to keep the incision clean and dry. Your physician will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit.
The incision, and chest and shoulder muscles, may ache, especially with deep breathing, coughing, and exertion. Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.
You should continue the breathing exercises used in the hospital.
You will be advised to avoid exposure to upper respiratory infections (colds and flu) and irritants, such as tobacco smoke, fumes, and environmental pollution.
You should gradually increase your physical activity as tolerated. It may take several weeks to return to your previous levels of stamina.
You may be instructed to avoid lifting heavy items for several months in order to prevent strain on your chest muscles and surgical incision.
Notify your physician to report any of the following:
- fever and/or chills
- redness, swelling, or bleeding or other drainage from the incision site
- increased pain around the incision site
- difficulty breathing, chest pain, irritation cough, anxiety, or change in mental status
- green, yellow, or blood-tinged sputum (phlegm)
Following a lobectomy, your physician may give you additional or alternate instructions, depending on your particular situation.