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.
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.
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; lung function testing, a needle biopsy to determine the nature of the cancer and a PET scan to see if the cancer has spread elsewhere in the body. Sometimes a bronchoscopy is performed where a small camera in inserted into the airways under sedation to investigate the anatomy of the patient’s airways.
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.
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.
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.
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.
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).