What is pneumonectomy?

Cancers treated:
Lung cancer, mesothelioma

Why performed: Pneumonectomy is a surgical procedure used to treat lung cancer when the tumor cannot be removed by a less extensive procedure. It may also be performed in the presence of severe chest trauma. Rarely, pneumonectomy is used for treatment of bronchiectasis, lung abscesses, or extensive unilateral tuberculosis. Extrapleural pneumonectomy is sometimes a treatment option for those patients with malignant
mesothelioma.

Patient preparation: Before planning surgery, a computed tomography> (CT) scan of the head and abdomen and a bone scan are typically performed to confirm that the cancer has not spread to other areas of the body. If the cancer has spread, then pneumonectomy may not be a treatment option.

Before surgery, studies are performed to check for abnormalities and establish a baseline for postoperative comparison. These studies include a chest X ray, electrocardiogram (EKG), bleeding time, and blood tests to check kidney function; electrolyte, hemoglobin, and oxygen levels; and white blood cell count. Pulmonary function tests are performed to evaluate lung function and to determine whether the remaining lung is healthy enough to handle the increased workload. A blood sample is also drawn to check the patient’s blood type in case a transfusion is needed during surgery.

A week before surgery, aspirin and anti-inflammatory drugs are stopped. The patient is given special instructions about when to stop taking anticoagulants, if prescribed. The patient must not eat or drink for at least eight hours before surgery, and an intravenous (IV) catheter is inserted for the delivery of fluids and medications. An indwelling urinary catheter is also inserted so that urine output can be monitored closely during and after the procedure.

Steps of the procedure: When the patient arrives in the operating suite, an arterial catheter may be inserted to monitor the patient’s blood pressure and oxygenation. An epidural catheter may also be inserted for postoperative pain control. An endotracheal tube is inserted through the nose or mouth to maintain the patient’s airway and provide oxygenation during surgery.

After the patient is anesthetized, the surgeon makes an incision into the chest cavity. When the chest cavity is entered, the lung collapses. The surgeon locates and ties off the pulmonary artery supplying the lung and the pulmonary veins. The ribs are spread, and the lung is exposed for removal. In some cases, it is necessary to remove a rib. The mainstem bronchus is divided, and the affected lung is removed. The surgeon staples or sutures the bronchial stump. Chest tubes typically are not inserted into the chest; instead fluid is permitted to accumulate inside the empty chest cavity, preventing mediastinal shift. Finally, after making sure that the bronchial stump is not leaking air, the surgeon closes the chest cavity and applies a sterile dressing.

When an extrapleural pneumonectomy is necessary, the surgeon removes the lung, a portion of the membrane covering the heart, the membrane lining the affected side of the chest cavity, and a portion of the diaphragm and replaces them with synthetic patches.

After the procedure: The patient is transferred to the surgical intensive care unit (SICU) and attached to a monitor that displays the patient’s heart rhythm, blood pressure, and oxygen saturation. These devices help the SICU nurses monitor the patient’s condition closely. The patient may have an endotracheal tube in place and require mechanical ventilation to assist breathing. If mechanical ventilation is not necessary, then the patient will receive supplemental oxygen through a nasal cannula or facemask. The patient is encouraged to cough, deep-breathe, and use an incentive spirometer to prevent pneumonia. If the patient requires mechanical ventilation immediately after surgery, then early extubation is the goal to prevent ventilator-associated pneumonia. The head of the patient’s bed is elevated at least 30 degrees to help prevent pneumonia. The patient is turned every two hours from the back to the nonoperative side to prevent the heart and remaining lung from shifting toward the operative side. Fluids are administered conservatively through an IV infusion pump to prevent fluid overload. Sequential compression devices are attached to the patient’s legs to help prevent blood clot formation. Pain medications are administered continuously either through an epidural catheter or through an IV catheter, as needed.

The patient is transferred to a medical surgical floor when considered stable, typically a few days after surgery, and then discharged to home. The patient is instructed to resume activities of daily living slowly in order to allow the remaining lung to compensate for its increased workload. Recovery commonly takes several months because shortness of breath significantly limits the patient’s ability to exercise. Some patients require lifelong supplemental oxygen therapy.

Risks: The risks of pneumonectomy include surgical site infection, pneumonia, empyema (pus in the pleural space), hemorrhage, pulmonary edema, myocardial infarction, cardiac arrhythmia, pulmonary embolism, and ventilator-dependent respiratory failure. Rarely, stump failure results in cardiopulmonary arrest.

Results: Pathologic examination of the lung specimen reveals the type of cancer.

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