Lung Cancer Surgery

Lung cancer is the unchecked growth of abnormal cells in the lung tissue known as a tumour of the lung. Therefore, surgery is done to remove the tumour part along with some of the surrounding part of the lung or the entire lung to cure lung cancer. It is very unfortunate that lung cancer is difficult to diagnose in its early stages, so many people remain undiagnosed. The first step considered in the treatment of lung cancer is surgery. However, this is a treatment option in some individuals only, which depends on various factors, such as the type, location and stage of lung cancer and other existing medical conditions, if any. Otherwise, depending on the individual case, the right blend of surgery and several other therapies, such as chemotherapy and radiotherapy are given.

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Early stage cancer, such as stage I in which tumour size is less than 7 cm and doesn’t involve lymph nodes (small structures that act as a filter for harmful substances); stage II in which tumour size is more than 7 cm and lymph nodes are not involved, is usually treated with surgery.

Small cell lung cancer (SCLC), the fastest growing lung cancer, which spreads more rapidly than the non-small cell lung cancer, is rarely treated with surgery. On the other hand, non-small cell lung cancer (NSCLC), the most common type of lung cancer, which grows and spreads more slowly than small cell lung cancer is usually treated with surgery only.

There are two main aspects of lung cancer surgery:

• To remove the primary lung tumour.
• To assess the draining lymph node, which provides useful information for the staging of lung cancer.

The type of surgery you need depends upon the size, position, type and the extent of spread of the tumour.

• If your surgeon/doctor thinks that surgery is needed in your case, he/she will advise you some tests before the lung cancer surgery, such as lung function tests. These tests will be done to assess the remaining healthy lung tissue. To check whether you are healthy enough for surgery, various other tests are also done, such as:
  • Complete blood count test,
  • Heart activity test (ECG)
  • Kidney function test
  • Liver function test
  • Mediastinoscopy (to assess the spread of cancer to adjacent lymph nodes)
• Your doctor will advise you to stop smoking before lung cancer surgery and even after the surgery to reduce the chances of any serious complications.
• Your surgeon will advise you to stop taking some medications, such as blood-thinning medicines (Aspirin), to prevent excessive bleeding during or after surgery.
• It is also advised to exercise every day to improve your health and quality of life before undergoing surgery. A few exercises and relaxation techniques that you may practice are discussed below:
  • Relaxation breathing exercise can reduce stress and anxiety before the surgery and it can also be useful after surgery, which helps in fast healing. 
  • Stretching increases the lung capacity (to increase the volume of air going in and out of the lungs), increase the range of bodily movements, decrease body stiffness, increase oxygen supply to the muscles, and help the body to repair.
  • Aerobic exercises, such as walking and dancing reduce body fitness and improve the oxygen-carrying capacity of the blood.
  • Strength training exercises improve the strength of the muscles and help in combating fatigue, which is the most common problem faced in lung cancer.

Thoracotomy

Your surgeon will use general anaesthesia, which puts you in a sleep-like state before the surgery is started. Once you are under the effect of anaesthesia, open surgery is performed wherein a 5-8 cm cut or incision is made between the ribs on the side of the chest. 

Minimally invasive surgery

This is the less invasive type of surgery. It is also known as keyhole surgery or VATS (Video-Assisted Thoracic Surgery). In this technique, a small cut is made as compared to thoracotomy and a thin, rigid tube, which is attached to a video camera on the end of the tube is inserted. It will help the surgeon to see the inside of your chest on the screen. This will facilitate the surgeon to perform the operation successfully. In VATS lobectomy, the lobe of the lung with the tumour is removed with high-resolution video imaging. It is an alternative to open thoracotomy and the advantages include fewer complications, less blood loss and short duration of hospitalisation.

Robotic surgery

With recent advances in technology, these lung surgeries are performed by robots. This is known as Robotic surgery. This surgery is safer, more precise and comfortable in terms of instrument use. There are 3-4 access parts of the robot and one assessment part for stapling (to stitch) and retracting (to hold and pull back the skin) during surgery. The camera has a dual lens system, which provides a three dimensional and enlarged view with a full range of movements during lung cancer surgery. Your surgeon will be seated in a comfortable position and will operate the robot. The only disadvantage of robotic surgery is its high cost.

Types of procedures

Lungs are divided into sections which are known as lobes. There are two lobes in the left lung and three lobes in the right one So, in total, there are five lobes of lungs. The operation of lung cancer is a major surgery, which is performed in various ways such as:

Removing the lobes of the affected lung

• Lobectomy
  It is the gold standard for lung cancer surgery, which means to remove one lobe of the lung with the tumour. It is usually done when the tumour size is less than 2 cm. It is the ideal operation performed on a single lobe of the lung as it leaves sufficient lung volume to fill the pleural space (the space between the two protective coverings of the lungs). It is the most common type of procedure done in the early stages of lung cancer.
• Bilobectomy
  In this procedure, two lobes of the affected lung are removed.
• Pneumonectomy
  Pneumonectomy involves the removal of the whole lung This surgery might be needed in case tumour is close to the centre of the chest and it may be the most appropriate treatment in some cases. Before pneumonectomy, a complete evaluation of the body is done to avoid further complications after complete removal of the lung.

Removing sections of the lungs

• Segmentectomy/Wedge resection
  It is the removal of a part/segment/section of the lung. This procedure begins with the formal lobectomy. It is also known as atypical resection.
• Sleeve resection or segmentectomies
  It is the removal of a part of the lobar bronchus (the airway passage that conducts air into your lungs) and then the airway is reconstructed. It is done only when the tumour is very close to the origin of the segmented bronchus. Your surgeon may perform this operation to preserve more of your lung function.

After your lung cancer surgery was done, you may stay for 2-3 days in the ICU (Intensive Care Unit) of the hospital. A few tubes may be connected to your chest to drain out excess fluid and air. You need to take care of the following things,

• Wear special stockings to prevent the blood clot in the legs.
• Take medicines as and when prescribed by your surgeon. These are given to relieve pain, prevent blood clot formation and reduce the swelling. 
• While coughing, make use of a pillow and place it against the dressing to prevent any pressure on the wound.
• Maintain hygiene as much as possible to avoid any infection.
• Take care of the wound. It should be dry and clean.
• Visit your surgeon whenever required, at least once after your surgery as scheduled by your surgeon.
• Physiotherapy may help you in your fast recovery.

After your surgery, the recovery time depends upon how well you take care of yourself. Strictly follow the instructions given by your surgeon after the surgery, such as:

• Avoid lifting heavy weights and vigorous exercise.
• Do not touch the wound area with dirty hands.
• Remove slippery rugs or mats in your house and if needed, install grab bars in the bathroom or toilet. This will prevent any accidents or falls.
• Avoid playing games that cause exertion or have chances of getting hit.
• Do not go to crowded places until you recover.
• Do not drink alcohol or smoke. Also, make sure no one else smokes in or near your house. 
• If your medicines make you drowsy, you should avoid driving until your doctor asks to stop them.
• Do not scrub the wound to remove glue or tapes as it may stretch stitches and cause pain or bleeding.
• Avoid soaking in a bathtub. Use a shower or bucket while bathing.

During surgery

After your surgery is done, you might find a few tubes connected to your chest as you wake up from the effect of anaesthesia. These tubes allow the drainage of excess air and fluid. When the air and fluid leak subsides, the tubes will be removed. You will need to spend 1 day in the hospital after your surgery. During recovery, you may experience a few conditions, such as:

• Pain in the chest area where surgery was done.
• Difficulty in breathing or dyspnea after surgery.
• Fatigue or feeling tired with very low energy. This may interfere with your daily activities for some time.
• Constipation, which develops due to certain drugs that are used to treat cancer.
• Coughing, which may last for a long time because of the removal of lymph nodes.

After surgery

• Arrhythmia
  Arrhythmia, also known as an irregular heartbeat, means an abnormal speed and pattern of the beating of the heart. The heart might beat too fast or too slow with an irregular pattern. It is the most common complication after lung cancer surgery and may require a prolonged hospital stay. 
• Postoperative haemorrhage
  It is also known as postoperative bleeding. It happens after the surgery, which can be within 24 hours of the operation (known as reactive bleeding in which the damaged blood vessels start to bleed more when the blood pressure rises) or within 7-10 days after the operation (known as secondary bleeding, which is mostly associated with spreading infection in the wound). On examination, your surgeon will look for any signs of external bleeding, swelling, discolouration and tenderness around the surgical site.
• Prolonged air leak
  It means leakage of air in the chest cavity for more than 5 days after lung surgery. It is also one of the most common complications after lung cancer surgery.
• Wound infection
  When germs or bacteria grow on the damaged skin of the wound, it causes pain, swelling and redness.
• Postoperative pneumonia
  Pneumonia (infection of the lung tissue) is a serious and life-threatening complication. It is caused due to various risk factors, such as history of heavy smoking, more anaesthesia time (when your surgeon will put you into a deep sleep), transfusion of red blood cells during the operation), long-term lung diseases like COPD or chronic obstructive pulmonary disease wherein the airflow gets blocked and makes it difficult to breathe, and other medical conditions existing along with it.
• Hypoxia
  It is the absence of enough oxygen to maintain body functions.
• Haemoptysis
  Coughing up blood. 
• Delirium
  Delirium is when a person has confused thinking and decreased awareness of one’s surroundings. 
• Cerebrovascular diseases
  Damage to the brain when the blood supply is interrupted. 
• Respiratory failure
  Also known as respiratory insufficiency in which respiratory system fails to maintain the proper lung function, which leads to a decrease in oxygen uptake and inadequate delivery of oxygen to the body’s tissues. 
• Blood clots
  Usually, the blood clots form in the legs, which can possibly lead to pain in the affected area.

Once your lung cancer surgery is done, you need not visit the hospital again and again to ease the discomfort you used to have because of cancer. After surgery, painkillers are not required very often and the functions of the lungs are improved. Surgical treatment helps to achieve the best result in terms of long healthy living. You need to take care of a few things during your recovery period such as:

• Get adequate amount of sleep.
• Have a diet that is nutritious with lots of fibre for faster recovery.
• Exercise may help you to feel better physically and mentally.
• After surgery, there are high chances of developing poor posture. So, it's important to stand and sit straight to maintain the right posture while also taking care of your comfort.
• Make sure you wear clean and comfortable clothes.

The outcome of lung cancer surgery depends upon the type of surgery performed according to the involvement of the tissue or lobe or segment of the lung. It also depends upon the extent of lung cancer. Certain types of lung cancer have high chances of spreading to the rest of the body. In such cases, more prompt treatment is required and you may have to undergo another surgery with/without chemotherapy. The success of the surgery is also decided by the kind of care that is given in the hospital and at home after surgery. Also, if your overall health before and after surgery is good, then the outcome of the surgery will also be good.

You may visit your doctor for follow up after your lung surgery was done. It may be scheduled after 6 months for 2 years, then annually. During your follow up visit, your doctor may ask you about:

• Medical history.
• Examination of your full body.
• Chest CT scan.

But, in case, if you find any symptoms, such as shortness of breath, a cough that is getting worse with time, coughing up blood, any pain in the chest or backside or any other unusual finding which you notice, don’t delay and visit your doctor immediately.

Getting a surgery done is a tough decision to make and so is the journey from getting all the tests done, entering the operation theatre and then recovering from it. All this can drain you emotionally, physically and financially. You may seek support from family members, relatives, friends, social groups, online sites and volunteer groups for emotional, mental, physical and financial support.

• Before the day of surgery, they may encourage and help you in taking the decision.
• On the day of surgery, they may provide the transport to and from the hospital.
• During surgery, your surgeon and nursing staff will be there to support you and they will prepare you mentally.
• After surgery, you may take help from the physiotherapist for faster recovery. The family members or friends may support you to attend the follow-up appointments.

By all means, seeking support helps you to manage your expectations during your rough time.