What is Lobectomy?
Lobectomy is a surgical procedure where a portion of the lung called a lobe that is affected by the disease is surgically removed.
The lungs are our organs of respiration, where exchange of oxygen and carbon dioxide take place. They are placed on either side of the chest surrounded by a double-layered membrane called the pleural membrane. Each lung is naturally subdivided into smaller divisions called lobes. The right lung has three lobes, the left lung has two. Each lobe is connected to the windpipe through a separate bronchus.
Lobectomy is a more restricted surgery compared to pneumonectomy, in which the whole lung is removed.
Which Patients require Lobectomy?
Lobectomy is used for conditions that affect a large part of a lung lobe and remain limited to the lobe. Lobectomy prevents the spread of the cancer to other parts of the lung, or beyond the lung.
Lobectomy can also be done for benign or non-cancerous lung diseases limited to a lung lobe which may include lung abscess, tuberculosis, fungal infections like aspergillosis, or severe tears of a lung lobe due to trauma.
What are the Types of Lobectomy?
Depending on the procedure adopted, lobectomy is of several types. These include:
Traditional thoracotomy: The traditional form of thoracotomy is an open surgical procedure in which a large incision is made on the side of the chest through which the affected lung lobe is removed
Video-assisted thoracoscopic surgery (VATS) / VATS lobectomy: VATS is a minimally-invasive procedure used to perform lobectomy with the help of an endoscopic instrument called a thoracoscope and instruments, which are introduced through entry points called ports. The VATS procedure is often used for early stage lung cancer, with no lymph node involvement, though more advanced stages are also being considered for the procedure.
The VATS procedure has the following advantages over traditional thoracotomy:
- The incisions are smaller
- Recovery is quicker with lesser pain and shorter duration of hospital stay
- Complications are less
- Chest drainage following the procedure is less
Depending on the number of ports used for the procedure, VATS can be classified as:
- Classical VATS, which is performed through 3 to 4 ports
- Biportal VATS, which is performed through 2 ports
- Uniport VATS, which is performed through 1 port
Robot-assisted thoracoscopic surgery (RATS): RATS is a surgical technique that uses a machine called the da Vinci surgical system. The surgeon sits at a console and controls the robotic arms attached to miniature instruments to carry out the surgery with precision. The procedure is usually more expensive than a lobectomy or a VATS.
What are the Tests and Preparations done before Lobectomy?
Tests done before lobectomy include:
Tests that are required to confirm the presence and extent of the lung disease:
Imaging tests: Imaging tests like chest CT scan can help the doctor to determine the presence of the cancer. An x-ray can be used if CT scan is not available
For a CT scan, you will be asked to lie down still on a special table for a few minutes. A doughnut-shaped instrument will pass over your chest, and images will be taken. A contrast may be injected into your vein; therefore you should inform the radiologist if you suffer from any allergies.
Other imaging test like PET-CT can help to detect the spread of the cancer to other sites, which helps to stage the cancer and decide the course of treatment.
The ventilation / perfusion scan is an imaging test to test how much lung can be safely removed. You will be asked to lie on a special table that passes into a scanner and asked to hold your breath while the image is taken. For the ventilation scan, you will have to breathe in some radioactive gas along with some air. Before the perfusion scan, a radioactive substance is injected into your vein.
Bronchoscopy: Bronchoscopy is a procedure where a tube with a camera at its lower end is inserted through the mouth and throat into the bronchi and lungs to look out for any pathology. The procedure is done in the doctor’s office following spraying of a local anesthetic on the throat. If a suspicious growth is noted, a biopsy is obtained and is sent for pathological examination. Another endoscopic method called mediastinoscopy, where the endoscope is introduced into the chest cavity and outside the lung, may be used in some cases.
Pulmonary function tests: Lung function tests are carried out to check the functional capacity of the lungs. The patient is asked to breath into a small instrument while various measurements are obtained.
Once it is confirmed that the patient needs the surgery, routine tests are required and include the following:
- Blood tests like hemoglobin levels, blood group, liver and kidney function tests
- Urine tests
- ECG to study the electrical activity of the heart
- Chest x-ray
Pre-operative Check-up: Routine tests as indicated above are ordered a few days before the surgery. Admission is required a day or two before the surgery. Drugs like aspirin and blood thinners will have to be discontinued a few days before the procedure.
Fasting before surgery: Overnight fasting is required and occasionally intravenous fluid maybe required to keep you well hydrated. You should avoid smoking at least a few weeks before and after surgery, if you are a smoker. Sedation is sometimes required for good overnight sleep before the surgery.
What is the Procedure for Lobectomy?
Type of Anesthesia: The lobectomy procedure is usually under general anesthesia. You will be asleep during the procedure and will not be aware of what is going on.
Shift from the ward or room to the waiting area in the operating room - An hour or two before the surgery, you will be shifted to the operating room waiting area on a trolley.
Once the surgical room is ready, you will be shifted to the operating room.
Shift to the Operating room: The ambience in the operating room can sometimes be very daunting and a small amount of sedation can help overcome your anxiety. From the trolley, you will be shifted on to the operating table. As you look up, you will see the operating light console and at the head end will be the anesthesia machine. There may also be monitors to check oxygen levels, ECG and other vital parameters. A constant beeping sound may be present from the monitors, which may sometimes be irritating.
Anesthesia before surgery: The anesthetist will inject drugs through an intravenous line and make you inhale some gases through a mask that will put you in deep sleep for anesthesia. Once you are in deep sleep, a tube will be inserted into your mouth and windpipe to administer the anesthesia gases to overcome pain and keep you comfortable.
Before the surgery, the lung to be operated upon will be deflated and collapsed.
You will be placed on your side during the procedure and paddings are put at pressure points. Antibiotics may be administered to prevent infection.
If you undergo thoracotomy, the surgeon will make an incision on the side of the chest between the ribs. The VATS procedure is usually done through three or four small chest incisions. The incisions are even smaller for a robotic surgery.
During thoracotomy, following the skin incision, the underlying muscle is separated and the pleural cavity is entered. The surgeon examines the lungs and identifies the affected lobe. The artery, vein and bronchus connected to the lobe are identified, tied or stapled, and separated along with the tissue between the lobes, and the lobe is removed. Surrounding lymph nodes are also dissected out.
Once it is confirmed that there is no bleeding, the remaining lung is expanded and checked for air leaks. If everything appears fine, the incisions are closed with sutures. A chest tube connected to an underwater drainage system is put into the chest to facilitate drainage of fluid, air and blood.
Waking up from Anesthesia: Once the surgery is over, you will wake up and the tube down the wind pipe will be removed. You will be asked to open your eyes before the tube is removed. You will be sedated and the voice of the anesthetist may be faint. Once the tube is out, you may have cough and sometimes nausea.
There may be a tube going into the stomach called a nasogastric or Ryle’s tube to keep it empty. There will also be an intravenous line. You will remain on oxygen. You will also have a drainage tube coming out from the side of the chest that has been operated on. Once fully awake, you will be shifted on the trolley and taken to the recovery room.
Recovery room: In the recovery room, a nurse will monitor your vitals and observe you for an hour or two before shifting you to the room or a ward.
Post-operative recovery: You will remain in the hospital for a few days following the procedure. Normally, on the first day, you will not be allowed much to drink or eat. You will be given fluids and a light diet in around one to three days. Chest physiotherapy will be started to prevent chest infection and to expand your lungs. Your chest tube will be removed after 2 to 3 days once the air leak is sealed and lung expansion can be demonstrated on chest film. Painkillers are used to control your pain. Severe pain may require injections.
DVT Prevention: Early movement of your legs and some mobilization prevents DVT or deep vein thrombosis; DVT is a condition where a clot is formed in the deep veins of the legs. The clot can travel up to the lungs and even be fatal. Other measures like small dose of heparin (a blood thinner) and special stockings may also be used to prevent DVT.
Instructions following discharge:
Following discharge, you will be asked to avoid smoking, and exposure to environmental pollutants and people with respiratory tract infections
You will be asked to come for regular check-ups. You should visit your doctor on an urgent basis if you suffer from symptoms of fever, breathlessness or excess pain or any other unusual symptom.
What are the Complications of Lobectomy?
Complications of lobectomy may include the following:
- Prolonged air leak, that is, air leak for more than 5 days. It is treated by continuous negative pressure suction with a water-sealed bottle
- Heart problems like atrial fibrillation (abnormal heart rhythm), or a bleed around the heart. The accumulated blood can exert pressure on the heart resulting in a condition called cardiac tamponade
- Lung problems like injury to the bronchi, bronchopleural fistula (abnormal communication between a bronchus and the pleural cavity) and collapse to the lung. Lung infection (pneumonia) may occur following the surgery
- Recurrence of the cancer, which will require additional treatment