Pulmonary lobectomy

Pulmonary lobectomy is a surgery that is performed to remove one of the (affected) lobes of the lung, for the treatment of diseases, tumours or infections.

The air inhaled through the nose or mouth flows into the windpipe, from which it goes into two separate pipes and then in each lung. The lungs are divided into small sections called lobes; the left and right lungs have two and three lobes respectively. When a disease affects one of the lobes of the lungs, a lobectomy is recommended. The surgery involves the removal of the diseased/affected lobe to allow healthy functioning of other lobes of the lungs.

This surgery can be performed by two methods: thoracotomy or video-assisted thoracoscopic surgery (VATS). The former requires a single large cut, whereas the latter requires three to four smaller cuts.

A surgeon may recommend this surgery if you have any of the following lung or health conditions:

• Emphysema: This disease affects the motion of the lungs (while breathing) due to damage to the elastic fibres of the lungs. Some symptoms of emphysema are:

  • Wheezing or whistling sound from nose or mouth
  • Shortness of breath
  • Continuous production of mucous 
  • Chronic fatigue
• Lung abscess: It is the accumulation of the small or large amount of pus in the lungs. If the pus cannot be treated with antibiotics, then lobectomy is recommended. Symptoms of lung abscess include:
  • Fever accompanied by shivering
  • Loss of weight
  • Sweating during night-time
• Tuberculosis: It is a chronic bacterial infection that affects the lungs. Symptoms of tuberculosis include:
  • Sweating during night-time
  • Fever
  • Unexpected loss of weight 
  • Cough lasting for more than three weeks
• Fungal infection: Fungal growth in the lungs can cause an infection. Symptoms of fungal infection in the lungs are:
  • Pain in the chest
  • Wheezing or whistling sound from the nose or mouth
  • Difficulty in breathing
  • Fever
• Benign tumour: This is a non-cancerous growth of cells that can put pressure on nearby blood vessels and affect lung function. Benign lung tumours do not present any symptoms. They are often discovered accidentally during imaging studies like x-rays. Sometimes, the following symptoms may be observed:
  • Bringing up blood while coughing
  • Continuous wheezing or coughing
  • Rattling sound in the lungs 
• Lung cancer: This is a cancerous growth of cells that affects the airways and other tissues of lungs. It can also affect or spread to other nearby organs of the body. Symptoms of lung cancer include:
  • Breathlessness that persists
  • Bringing up blood while coughing 
  • Pain while breathing or coughing
  • Loss of appetite

You may be advised to avoid this surgery if the results of your lung function tests are poor or if you have heart-related ailments. The VATS surgery is not recommended for a lung tumour that is more than 6 cm.

As part of the preoperative assessment, the surgeon will assess your medical history and conduct a physical examination. The following medical tests will also be conducted before surgery:

• Electrocardiogram (to check the electrical activity of the heart)
• Chest x-rays (to assess the condition of your lungs, along with the shape and size of your heart)
• Pulmonary function tests (to check the working of your lungs)
• Blood tests (to determine your blood group and look for other diseases or infections)
• Bronchoscopy (a procedure to look inside your windpipe and lungs to assess their condition)
• Positron emission tomography (to analyse the stage of lung cancer)
• Computed tomography scan (a type of x-ray to create a detailed image of your internal organs)
• Computed tomography biopsy (a procedure wherein a sample of lung tissue is taken for analysis)

The surgeon will discuss the details of the procedure beforehand. You will be asked to sign a consent form, which will grant permission to perform the surgery. In addition, you will be asked if you are pregnant or have any bleeding disorders or allergy to contrast dye, latex, medicines, tape or anaesthesia.

You will be asked to share the list of all medicines (prescription and over-the-counter), herbs, vitamins and supplements that you are currently taking. Also, you may have to temporarily discontinue medicines that affect blood clotting such as aspirin or blood-thinning medicines.

Stop smoking as it can increase the risk of complications that could occur during and after surgery.

The following preparation may be needed before visiting the hospital for surgery:

• Follow the instructions for fasting provided by your surgeon.
• Arrange for someone to drive you home after the surgery.
• You need to have a shower or bath before the surgery, especially with an antiseptic skin wash, to reduce the risk of infections.

On the day of surgery, you can expect the following at the hospital before the surgery:

• The hospital staff will ask you to wear a hospital or theatre gown.
• You will be provided with stockings that prevent the formation of blood clots in the blood vessels of your leg during surgery.
• You will be asked to take off your jewellery and accessories.
• You will be given medicines to relieve anxiety and make you feel sleepy.
• After this, you will be shifted to the operation theatre.

The surgery conducted via thoracotomy usually involves the following steps:

• The surgeon will insert an intravenous line into your arm and you will be given antibiotics during and after the procedure.
• An anesthesiologist will administer you with general anaesthesia to put you under sleep.
• To help maintain your body functions during the procedure:
  • The surgeon will then place a breathing tube (attached to a breathing machine) down your throat to ensure proper breathing. Your vitals will be monitored throughout the surgery.
  • Another surgeon will insert a soft and flexible tube in your bladder (a catheter) to drain out urine.
• A healthcare practitioner will remove your hair at the site of surgery clean the area with an antiseptic solution.
• Once that is done, the surgeon will place an incision over the lobe that needs to be removed. The cut usually begins under the nipple and travels under your arm to under the shoulder blade on the back.
• The surgeon will use a special tool to move your ribs aside and reach your lung. He/she will drain the blood from the blood vessels that supply to and from the lobe. 
• Once that is done, the surgeon will tie and move aside the blood vessels.
• After this, the surgeon will separate the part of your windpipe that supplies air to the lobe and then remove the affected lobe along with the surrounding lymph nodes.
• He/she will place one to two tubes (drains) inside your chest to drain out any residual air and fluid post-surgery.
• Finally, the surgeon will close the cut/incision via staples or sutures, and cover the area with a bandage or dressing.
• After the procedure, you will be shifted to the recovery ward.

In VATS, the surgeon makes three to four tiny cuts (called ports) instead of one large cut over the affected area. Small tools, including a thoracoscope, are inserted through these ports. A thoracoscope has a tube attached to a light source and camera. It takes images of your internal organs and displays them on a computer screen during surgery. The other devices are used to cut and remove the affected lobe.

You may need to spend two to four days in the hospital after surgery, during which you can expect the following:

• You may have a feeling of confusion and sleepiness after waking up from surgery. This is due to anaesthesia and will wear off soon. 
• Your vital signs will be continually observed in the recovery room. 
• You will be given fluids to drink a few hours after the surgery.
• You will be given pain-relieving medicines.
• After the surgery, a chest x-ray will be taken to ensure smooth functioning of your lungs.
• The tubes inserted in your chest may cause pain while moving, deep breathing and coughing. These tubes will be removed before you are discharged from the hospital.
• You will be asked to move as much as possible while in the hospital to speed up your healing.
• You may need oxygen during your stay at the hospital. The hospital staff will also teach you proper coughing methods and deep breathing exercises to help you in breathing and expanding your lungs. These exercises also help in preventing pneumonia after surgery.
• If your condition is stable, you will be discharged from the hospital. It is essential that you properly plan your follow-up visits.

You can expect the following while taking care of yourself at home after surgery:

• Pain medicines: You will be prescribed medicines for pain for about a week. You may also be prescribed laxatives as some pain medicines cause constipation.
• Exercises: The coughing technique and deep breathing exercises taught at the hospital should be done at home too. You should also move and walk as much as possible but do not exhaust yourself in the process.
• Showering: Daily shower/bath is essential to ensure cleanliness of the surgical site. You must avoid the use of powder or deodorant on the wound or around it.
• Smoking: You should avoid smoking as it harms the lungs and causes discomfort.
• Diet: You can have a normal diet at home. However, it is recommended that you consume high-protein foods to assist in healing.
• Alcohol: Avoid drinking alcohol as it can react with your medications.
• Strength: You will slowly regain your strength after surgery. Whenever you feel tired or breathless, it is advisable that you take short naps instead of going to bed.
• Driving and travelling: You should resume driving or flying only after discussing with your doctor.
• Resuming work: Whether you can resume work is based on the nature of your work, your condition and as decided by the doctor.

When to see the doctor?

You should call the surgeon if you experience any of the following symptoms after surgery:

• Cough
• Blood in sputum
• Pain in chest
• Difficulty breathing or breathlessness
• Nausea or vomiting
• Drainage from the site of surgery
• High fever with temperature over 38^ºC 
• Signs of infection
• Arrhythmia
• Confusion
• Sputum of yellow or green colour

The surgery is associated with following risks/complications:

• Infection
• Bleeding
• Prolonged need for a drainage tube to drain out fluids from lungs
• Risks from general anaesthesia such as stroke, heart attack, blood clots or pneumonia
• Damage to other organs around the surgery site
• Lung collapse
• Pus collection in the area

A follow-up visit will be planned before you are discharged from the hospital, at which time, your sutures will be removed.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.