PREOPERATIVE DIAGNOSIS: Carcinoma, left lower lobe of lung.
POSTOPERATIVE DIAGNOSIS: Carcinoma, left lower lobe of lung.
OPERATION PERFORMED: Fiberoptic bronchoscopy and left lower lobectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endobronchial.
ANESTHESIOLOGIST: Bradford Doe, MD
DESCRIPTION OF OPERATION: After percutaneous radial artery line and general endobronchial anesthesia was obtained, fiberoptic bronchoscope was passed via the endobronchial tube and all the segmental orifices visualized. In the left lower lobe particularly, there were no endobronchial lesions or central extension of the tumor. No deviation of the airways was noted to suggest adenopathy. The other segmental orifices of the upper lobe and right segmental orifices were all normal. Accurate positioning of the double endobronchial tube was also assured and then the patient was positioned in the right lateral decubitus position.
After prepping and draping, a posterolateral left thoracotomy was done sparing the serratus anterior muscle. Partially resected fifth rib posteriorly was used for mobilization, and other than a few scattered adhesions at the apex, no adhesions were present. The mediastinum was inspected for adenopathy and none found. Also, the hilar nodes were also very soft and small, not suspicious for any extension centrally. The lesion could be seen umbilicating the surface of the superior segment of the left lower lobe. The major fissure was very poorly developed. Initially, the perihilar structures were mobilized circumferentially around the left lower lobe and then posteriorly the left pulmonary artery identified and dissected.
An obvious branch immediately going to the superior segment was visualized and divided between 2-0 silk ligatures and 3-0 silk suture ligatures. One could then appreciate the normal branches extending to the upper lobe and also main trunk, extending to the lower lobe proper leading us to believe the anatomy is quite usual. The branch of the left lower lobe basal segment was divided between 2-0 silk ligature and 3-0 silk suture ligatures and then the perihilar structures dissected posteriorly and the inferior pulmonary vein circumferentially freed up.
At this point, just superior to the inferior pulmonary vein, one could appreciate another large arterial structure, surprisingly large, considering that we probably had divided the usual branches to the lower lobe already, but on tracing this back proximally, was a very large anomalous branch that passed anterior to the lower lobe bronchus or to the mediastinal aspect of the lower lobe bronchus, which was very unusual. This was traced and followed as it entered the lower lobe, and reflecting the completely freed-up hilum, one could see that no branches were passing superiorly toward the upper lobe from this large anomalous branch. The venous anatomy was normal in the anterior hilum, and after we suture ligated this large branch to the lower lobe basal segments, we then divided the inferior pulmonary vein between 2-0 silk ligatures and 3-0 silk suture ligatures.
Reflecting the lung further upwards, one could now see the previous branch that had been ligated to the basal segments. Indeed, several branches were going to the lower lobe anteriorly, but also a moderate-size branch was crossing the fissure into the lingula in addition to several other lingular branches, which were seen previously near the fissure and preserved. Since the main trunk of this vessel had already been divided, we may have devascularized the very distal most portion of the lingula, but this does not seem to be of any consequence. The bronchus to the left lower lobe was seen dividing quite early to this superior segment and to the basal segments and we carefully freed up this to make certain there was not a bronchus crossing the fissure to the upper lobe and lingula.
At this point, there was so much tissue in the area of the fissure, one could not appreciate whether there was any ventilation from this lower lobe bronchus. For this reason, we temporarily pinched the lower lobe bronchus major orifice and reventilated the left lung. It appeared the entire lingula was ventilating well without delay, and therefore, we felt safe in dividing the basal segment bronchus separately from the superior segment bronchus which was done initially before ascertaining the anatomy.
At this point, we could then carefully divide the fissure with a GIA-75 stapler. It was observed that the upper lobe bronchus was very close to the fissure and was carefully preserved as was the superior pulmonary vein, both structures of which seemed to deviate somewhat below the surface markings of the fissure. It was possible to place it so that these structures were carefully preserved. After stapling and dividing the fissure in this manner, the lower lobe was sent to pathology. The bronchial resection was nowhere near the vicinity of the tumor such that we felt a very adequate resection was obtained. A few small interlobar lymph nodes, which have been freed up during the dissection of the bronchi, were submitted separately, but they were totally innocent and tiny. The lung was then tested for air leaks. There was small air leak from the anterior portion of the lingula; it was sutured with fine 6-0 Prolene with good effect.
Hemostasis was checked and found adequate. Chest was then drained with 28 French catheters, one anteriorly and one posteriorly extending up to apex. Several side holes being added to the lower aspect of the posterior tube to provide good dependent drainage. These were brought out through separate skin sites below the incision and sutured with #1 silk suture. At this point, pericostal sutures of #1 Vicryl were placed passing subperiosteally around the inferior rib to avoid nerve impingement. Once these were tied down, the left lung was expanded again with normal ventilation. The serratus fascia was next approximated with continuous 0 Vicryl, latissimus fascia with continuous 0 Vicryl, subcutaneous with 2-0 Vicryl, and skin with 3-0 Vicryl subcuticular and Steri-Strips. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
