Lung
Surgery

Lung and Thoracic Surgery predominantly involve the removal of tumours inside the chest or lungs as well as procedures for conditions that cause fluid (pleural effusion) or air (pneumothorax) to accumulate around the lungs.

The Lungs

There are two lungs in the chest cavity and their primary function is to extract oxygen and to release carbon dioxide with each breath. The lungs are further divided into separately functioning units or lobes. There are 3 lobes on the right and 2 on the left. For patients with underlying satisfactory lung function, removing a single lobe doesn’t usually impact on the overall lung function. Additionally, patients with excellent baseline lung health can tolerate removing an entire lung if needed.

There are various approaches for lung surgery; open/ thoracotomy, minimally invasive or robotic assisted. The correct approach for surgery depends on which operation will be performed and the individual circumstances of each patient.

The lungs are contained within the pleural space on each side of the chest cavity. This is a free space which the lungs fill up entirely. However, if fluid or air leak into this space, the lung can collapse as it is compressed.

Lung Tumour
Surgery

A tumour in the lung can either be benign or malignant. This is often determined preoperatively from a needle biopsy. Lung cancer is the most common tumour that requires surgery. Unfortunately, in 80% of patients the cancer has already spread by the time of this diagnosis, which makes surgery less beneficial and these patients are generally referred for chemotherapy and radiotherapy.

Lung cancers are usually picked up incidentally when someone is undergoing imaging of their chest for other reasons. Once it has been discovered a number of tests are ordered to investigate the nature of the cancer and if there is any spread. These may include:

  • A needle biopsy to determine the nature of the cancer
  • A PET scan to see if the cancer has spread elsewhere in the body
  • A bronchoscopy where a small camera in inserted into the airways under sedation to investigate the anatomy of the patient’s airways
  • A lung function test

If the tumour is isolated to the lung, the patient may be referred to a cardiothoracic surgeon to ascertain whether it is possible to remove the tumour surgically. The aim of surgery is to remove the entire tumour and the lobe of the lung in which it is located to reduce the chance of the tumour spreading. The lymph nodes surrounding the lung are also removed and sent to the pathologist to investigate if there is any microscopic spread. This is fundamentally important as this can guide further treatment such as chemotherapy or radiotherapy by the oncology team.

Thoracotomy

An 8 – 12cm incision is made between the ribs towards the back, underneath the shoulder blade (scapula). The size and extent of the incision depends on the size and nature of the tumour.  A thoracotomy provides the best exposure of the lung and is needed in many cases. However, it is associated with a prolonged recovery and sometimes a lot of pain.

Minimally Invasive VATS

Video Assisted Thoracoscopic Surgery is a keyhole approach where a camera and specialised instruments are placed through small ports between the ribs. This approach is suitable for smaller tumours and is associated with less pain and a much quicker recovery.

Robotic Assisted

Similar to minimally invasive VATS surgery, robotic lung surgery offers patients a quicker recovery and less pain compared to a thoracotomy. The advantage of robotic surgery is that the instruments are more dexterous and the surgeon has 3D visualisation and up to 10x magnification through camera ports placed inside the chest.  This aids the surgeon in removing the tumour with precision.

What is the recovery like?

Following surgery, you will wake up in the intensive care and have a number of drains coming out of your chest to drain any blood and air that can accumulate. It is always important to let the nursing and medical staff know if you are in pain. We pay close attention to ensuring that any pain is well controlled. This is particularly important following lung surgery because if you are in significant pain you will take smaller, shallower breaths that can lead to lung collapse and pneumonia. It is also important to have good chest physiotherapy to expand the lungs appropriately.

The recovery depends on the approach to the surgery. Patients who have had a thoracotomy usually have their drains in for 3-4 days and stay in hospital for 5-7 days depending on their progress. Following minimally invasive VATS or robotic surgery the recovery is far quicker and some patients go home after 2 or 3 days. They also continue to improve more quickly in the following weeks.

What are the risks of this procedure?

The main risks following lung cancer surgery include death, heart attack, bleeding, infection and an air leak from the remaining lung. Dr Bassin will explain these risks to each patient in person and how they pertain to their specific condition.

Minimally Invasive VATS Pleurodesis

A pleurodesis is an operation to make the lung ‘stick’ to the pleural space thereby getting rid of any potential space that can be filled with air (pneumothorax) or fluid (pleural effusion). The operation is performed minimally invasively whereby any air or fluid is drained and then the pleural space is traumatised by instilling sterile talcum powder (talc pleurodesis) or by removing or scratching the inner surface of the chest wall (mechanical pleurodesis). The trauma then elicits a healing response which causes the lung to stick to the chest wall.

What is involved?

This procedure is performed under general anaesthetic. The surgeon places 2 or 3 small 1cm incisions in the chest wall and a camera is inserted. If there is any fluid it is drained and sent to a pathologist to investigate the cause under a microscope. If the operation is performed for a pneumothorax the lung will be inspected to try and find any cysts that may have ruptured – these are often found at the top of the lung where there is the most tension, the lung apex. A wedge resection is when the cysts are resected and removed to prevent a further pneumothorax. For most patients, a pleurodesis is then performed by instilling sterile talcum powder inside the chest to encourage the lung and chest wall to stick together (talc pleurodesis). For young patients who have suffered a pneumothorax, Dr Bassin would perform a mechanical pleurodesis by either scratching the inside of the chest wall or removing the lining of the chest wall (pleurectomy).

What is the recovery like?

The operation takes approximately one hour and you will wake up in the recovery room with one or two drains in your chest to remove air and blood. These drains are removed after 4-5 days once the lung has sufficiently started to stick to the chest wall. For the first 2 days the drains are kept on strict suction to ensure the lung is expanded. This means that you can’t venture out of your room- be advised to bring a good book or some movies to pass the time. Once the drains are removed patients can generally return home that day or the following day. Full recovery can take a few weeks due to varying levels of postoperative pain.

Pneumothorax

A pneumothorax occurs when air escapes from the lung into the pleural space. This can be either due to trauma such as rib fractures, or from an abnormality of the lungs where a small cyst has burst. This commonly occurs in young and thin patients, but also occurs in patients who have significant lung disease from smoking.

A patient suffering a pneumothorax will feel a sudden onset of sharp chest pain that is worse when breathing inward and may also feel short of breath.

Once in the emergency room a small tube (chest drain) is inserted into the chest cavity to re-expand the lung. If a pneumothorax recurs in the same location, the patient will generally be referred to a cardiothoracic surgeon for a pleurodesis.

Pleural Effusion

A pleural effusion occurs when fluid accumulates in the pleural space around the lung. This compresses the lung and makes it harder to breathe. A pleural effusion can be caused by many things including: heart failure, bleeding in the chest, cancer, low protein count, auto-immune disease and infection. Regardless of the cause the fluid needs to be drained for diagnostic purposes and to re-expand the lung.

If fluid continues to re-accumulate due to heart failure or cancer a patient may be referred to a cardiothoracic surgeon for a pleurodesis to stop the fluid re-accumulating and to reduce the symptoms. Most patients feel much improved following a pleurodesis for treatment of a pleural effusion.

Thymectomy

The thymus is a soft organ without distinct structure, located behind the breastbone. Its main function is to aid the immune system in maturing the specialised white cells which are termed ‘T’ cells (‘Thymic’ cells).  It is large during infancy and slowly becomes smaller with age.

A number of conditions can affect the thymus and lead to it requiring surgical removal, called thymectomy. The most common requirement for a thymectomy includes benign or malignant tumours of the thymus. Another condition that may benefit from a thymectomy is myasthenia gravis. This is a neuromuscular condition that causes weakness of skeletal muscles due to autoimmune antibodies produced by the thymus which attack muscle receptors responsible for contraction.

What is involved?

The thymus is generally removed via a sternotomy – splitting the breastbone. This is the same approach we use for open heart surgery and provides excellent exposure of the thymus and the surrounding structures. Another approach is robotic assisted thymectomy in certain patients, which can remove the thymus using a keyhole approach to avoid splitting the breastbone. This means quicker recovery and less pain, and often patients can return home from hospital 1-2 days post surgery.