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Thoracoscopic Lobectomy


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Thoracoscopy was first described in the early 1900s, and by the mid-1990s, thoracoscopic lung biopsy had become accepted as a superior technique for obtaining tissue in cases of interstitial lung disease or malignancy. Thoracoscopy has also become the preferred approach in the treatment of most mediastinal masses in children. However, the thoracoscopic approach for lobectomy, because of the complex nature of the disease process and the anatomic dissection, has not been as readily accepted. Improvements in instrumentation and operative technique over the past two decades have made thoracoscopic lobectomy for congenital and acquired lung disease in children a safe and viable option. In most cases, it is the preferred approach to avoid the morbidity of a thoracotomy incision.

Indications for Workup and Operation

Indications for lobectomy include both congenital and acquired disease. Congenital lesions include congenital pulmonary adenomatoid malformation (CPAM), intralobar and extralobar bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE), and more rare causes of congenital airway obstruction that result in lung parenchymal injury. Acquired etiologies include severe bronchiectasis, right middle lobe syndrome, necrotizing pneumonia, and malignancy. In most cases, the preoperative evaluation consists of a chest radiograph and computed tomography scan. Occasionally, other studies such as a ventilation-perfusion scan may be needed to determine the degree of lung injury and whether a lobectomy is possible. Rarely, an aortogram or a magnetic resonance angiogram helps identify a systemic vessel or aberrant vascular supply, as in the case of a sequestration. Bronchoscopy should be performed in cases where abnormal bronchial anatomy or obstruction is suspected.

Operative Technique

The procedure varies slightly depending on the lobe being resected, but all procedures are performed with the patient in a lateral decubitus position. The room and personnel setup for a left lower lobectomy are shown in Figure 32-1 . The surgeon and assistant stand at the patient’s front with the monitor over the patient’s back. In all cases, single-lung ventilation is desirable if at all possible, but a successful lobectomy can be performed just using CO 2 insufflation to collapse the lung. In larger patients, a double-lumen endotracheal tube is beneficial. In infants and smaller children, single-lung ventilation is obtained by mainstem intubation of the contralateral side or by use of a bronchial blocker. A first- or second-generation cephalosporin is administered for prophylaxis in patients not already on antibiotics.

Fig. 32-1, The room and personnel setup for a left lower lobectomy. The surgeon ( S ) and surgical assistant/camera holder ( SA/C ) stand at the patient’s front, with the monitor ( M ) over the patient’s back. The scrub nurse ( SN ) can be positioned at the discretion of the surgeon. If the scrub nurse is positioned opposite the surgeon, as shown here, a second monitor may be helpful for viewing by the scrub nurse. A, anesthesiologist.

Lobar Anatomy

It is important to understand the anatomy of the structures in the various fissures. The anatomy of the fissure between the upper and lower lobes of the left lung is depicted in Figure 32-2 . The anatomy of the structures in the major and minor fissures between the three lobes of the right lung is seen in Figure 32-3 . When working anteriorly to posteriorly in the fissures, the surgeon encounters the arteries to the lobes first, followed by the bronchial structures. The lobar veins are not adjacent to the arteries and bronchi in the fissures but are seen more inferiorly in the mediastinum.

Fig. 32-2, The anatomy seen by the surgeon when the contents of the fissure between the left upper and lower lobes are exposed. The arteries are visualized first within the fissure, and the bronchial structures are behind the arteries. The pulmonary veins exit from the inferior portion of these lobes and drain into the heart.

Fig. 32-3, The anatomy as seen by the surgeon when dissecting in the major and minor fissures of the right lung. The arteries are the first structures seen in the fissure, and the bronchial structures are behind the arteries. The pulmonary veins are inferior to the arteries and bronchial structures and drain into the heart.

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