Pneumonectomy

Overview

A pneumonectomy entails the complete removal of a lung through surgery. It commonly addresses lung cancers or cancers affecting the lining of the lung (mesothelioma). Additionally, it may involve the removal of a severely damaged lung due to noncancerous conditions or injuries.

The procedure is categorized based on the side of the lung being removed, with a right-sided pneumonectomy involving the removal of the entire right lung and a left-sided pneumonectomy involving the removal of the entire left lung. Pneumonectomy represents the most extensive form of lung resection, contrasting with less comprehensive procedures like lobectomy or wedge resection, which only eliminate specific parts of the lung.

In a standard pneumonectomy, the surgeon removes the entire lung along with adjacent nerves and tissue as needed. An extrapleural pneumonectomy goes further, involving the removal of not only the lung but also the pleura (lining around the lung and chest wall), pericardium (lining around the heart), and portions of the diaphragm (the muscle beneath the lungs).

The choice between a thoracotomy and Video-Assisted Thoracic Surgery (VATS) for a pneumonectomy depends on the individual case. While VATS is a less invasive option, it may not be suitable for every situation.

Reasons for undergoing the procedure

Pneumonectomy is primarily employed by the doctor to address cancer in or around the lungs, although it is occasionally utilized for other medical conditions. Conditions for which a pneumonectomy may be considered include:

• Lung cancer
• Lung carcinoid tumors
• Pleural mesothelioma
• Specific lung injuries
• Aspergillosis
• Bronchiectasis
• Tuberculosis
• Disseminated thymoma

While a pneumonectomy is utilized for various diseases, it is most frequently employed in the treatment of lung cancer. Eligibility for a pneumonectomy depends on certain criteria:

• The cancer is confined to one lung and can be cured by removing the lung.
• The tumor is located in a part of the lung that cannot be completely excised without removing the entire lung.
• Adequate function of the heart, blood vessels, and lungs, making the individual a suitable candidate for surgery.
• A pneumonectomy should be avoided if you have:
  • Insufficient lung function.
  • Severe pulmonary hypertension.
  • Severe heart valve disease.
  • Impaired ventricular function (ability to pump blood to the body).

Risks

The doctor involved in a pneumonectomy take extensive precautions to minimize potential risks. However, it’s essential to recognize that pneumonectomy, being a major surgery, carries a heightened risk of complications compared to other lung resection procedures that only address a portion of the lung. Some potential complications include:

• Reactions to anesthesia
• Vocal cord paralysis
• Infection
• Pneumonia
• Empyema
• Air leakage in the chest cavity
• Hemothorax (bleeding in the chest cavity)
• Pulmonary embolism
• Respiratory failure
• Postpneumonectomy syndrome, where organ shifts after lung removal may stretch the remaining lung and esophagus, potentially obstructing airways. This can occur years after the surgery.
• Bronchopleural fistula (an abnormal connection between large airways and spaces between the linings of the lungs)
• Cancer recurrence despite the removal of visible tumors. Occasionally, cancer may reappear in other locations.
• Arrhythmia
• Cardiac arrest

It’s noteworthy that right-sided pneumonectomies entail a higher risk of complications than left-sided ones due to anatomical differences.

Before the procedure

In the days or weeks leading up to your surgery, your doctor will conduct various tests to assess the functionality of your heart and lungs. These tests may encompass:

• Blood tests
• Ventilation-Perfusion scan (VQ scan)
• Pulmonary function tests
• Chest X-ray
• Echocardiogram
• Positron Emission Tomography (PET) scan
• Computed Tomography (CT) scan

Your doctor will guide you on the preparations required for your pneumonectomy. Some essential steps you may need to take include:

• Arrange for someone to transport you home upon discharge.
• Organize assistance for the care of your home or pets during your hospitalization.
• Plan for potential adjustments to your home or daily routine post-hospitalization, such as enlisting help with household tasks or errands.
• Cease smoking and seek resources from your provider for quitting if applicable.
• Provide your provider with a list of medications; they may instruct you to discontinue or adjust the timing of certain medications before surgery. Continue taking your medications as scheduled unless advised otherwise.
• Inform your provider of any medication allergies.
• Refrain from eating or drinking after midnight on the day preceding your surgery.

During the procedure

The procedural steps of a pneumonectomy may vary based on whether your surgeon opts for a thoracotomy or VATS. Typically, your doctor will:

• Position you on your side.
• Administer general anesthesia to induce unconsciousness, with continuous monitoring throughout the procedure to ensure your well-being. You will not experience pain or retain any memory of the surgery.
• Prepare your skin and make an incision between two ribs on your side and back.
• Separate the ribs to access your lung, delicately manipulating or cutting tissue and structures around the lungs (including the diaphragm, pleura, and pericardium in the case of an extrapleural pneumonectomy).
• Deflate the lung and remove it through the incision, removing additional structures and tissue as necessary, depending on the surgery type.
• Reconstruct the diaphragm or pericardium if required.
• Close the ribs, muscles, and skin, covering the incision site with a surgical dressing.

Notably, surgeons often do not insert a drainage tube for fluid during a pneumonectomy.

The duration of a pneumonectomy can extend over several hours, influenced by various factors, such as whether it is a right-sided or left-sided procedure. Extrapleural pneumonectomies, being more complex, typically require a longer duration.

After the procedure

Following a pneumonectomy, your hospital stay will span several days, during which:

• Your doctor will closely monitor your vital signs, including oxygen levels, heart rate, and blood pressure, using monitoring devices.
• Oxygen may be administered through an oxygen tube under your nose if necessary.
• You will be provided with pain medication to ensure your comfort.
• Providers may conduct blood tests, imaging studies, or other assessments to track your condition, aiding in the decision of when it is safe for you to be discharged.
• Physical or occupational therapists may assist you in daily activities such as getting out of bed, walking, or engaging in breathing exercises.

Outcome

Complete recovery from a pneumonectomy may span several months, and during this period, you might:

• Experience increased fatigue.
• Require frequent breaks.
• Encounter frequent discomfort.
• Encounter limitations on certain activities, including driving or lifting.
• Find difficulty in performing daily activities as usual.

These factors may impact your capacity to resume work or school. While some changes are temporary and associated with the recovery phase, others may become a “new normal,” necessitating adjustments.