A standard anesthetic technique typical for thoracic surgical procedures is used. Single-lung ventilation is achieved with placement of a double-lumen tube. A thoracic epidural catheter is employed when an open (thoracotomy) approach is planned. In patients in whom a thoracoscopic lobectomy or segmentectomy is performed, the epidural is usually omitted. An arterial line and urinary catheter are placed. Fluid administration is limited, as with other forms of major lung resection. Extubation at the end of the operation is planned.
Preoperative bronchoscopic examination of the airway is essential. Bronchial obstruction owing to tumor or an aspirated foreign body should be ruled out. If severe inflammation of the airway mucosa is found, it may be best to defer definitive resection until better infection control is obtained. Finally, normal variations in bronchial anatomy make preoperative bronchoscopy by the surgeon advisable, particularly if a segmental resection is planned.
Our approach to surgical resection for bronchiectasis has been previously reported.6–8 Traditionally, anatomic lung resection for bronchiectasis (e.g., segmentectomy, lobectomy, pneumonectomy) has been performed via open thoracotomy. The acceptance of a video-assisted thoracoscopic (VATS) approach has been delayed by the impression that dense pleural adhesions, perihilar lymphadenopathy, and a hypertrophic bronchial circulation would make VATS resection unnecessarily challenging and potentially unsafe. However, in the last decade there have been several reports of successful resection using such an approach. We recommend a standard VATS technique utilizing two 10-mm ports and a 3- to 4-cm utility incision based over a rib space in the anterior axillary line (Fig. 94-5). No rib spreading is used. Typically, the initial two ports are placed—one in the seventh intercostal space, anterior axillary line, and the other just posterior to the scapular tip—and the safety and feasibility of a VATS approach are confirmed. The utility incision then can be made, centered over an interspace (usually fourth or fifth) to allow easy access to the area of dissection. The serratus muscle fibers are separated along the axis of the utility incision. The exact placement of the ports and the utility incision depends in part on the planned resection. Muscle transposition (latissimus dorsi, intercostal) is feasible using a thoracoscopic approach.
Target port placement for a standard VATS approach. Initially, two 10-mm ports are placed, one in the seventh intercostal space along the anterior axillary line and the second posterior to the scapular tip. A 5-cm utility incision is placed over the area of dissection, which is usually at the fourth or fifth interspace.
For patients in whom extensive extrapleural dissection is needed, an open approach is used. A lateral thoracotomy affords excellent exposure to all planned resections, with the possible exception of completion pneumonectomy, where a posterolateral incision is preferred. If possible, the latissimus dorsi muscle should be spared for possible transposition later, if needed.
After access is achieved, the anatomic resection is completed in a standard fashion, with individual ligation of the vessels and bronchus to the target lobe or segment. The resection technique is the same whether the approach is VATS or open, although stapling devices are usually mandatory when a VATS approach is used. Situations in which there is concern regarding the bronchial closure, particularly pneumonectomy, may suggest the need for an open approach to facilitate a tailored suture closure of the bronchus and tissue transposition. The diseased segment or lobe often has considerable pleural adhesions that are lysed with cautery, taking care to avoid the usually adjacent phrenic nerve (Fig. 94-6). There is usually considerable bronchial artery hypertrophy and lymphadenopathy surrounding the involved pulmonary hilum, consistent with the chronic infectious state. It is important to achieve complete resection of the diseased bronchi and associated lung tissue, if possible. We prefer in these patients to divide the lung parenchyma (e.g., along the fissures), erring on the side of the uninvolved lobe and thus ensuring complete removal of diseased tissue. In VATS cases, the soft tissues at the utility incision should be retracted and protected from contamination, and the diseased tissue removed with the use of a deployable bag or similar device. As with resections for lung cancer, this latter technique is imperative; certain NTM organisms such as Mycobacterium abscessus can cause devastating chest wall infections if a careless method is adopted for removal of the specimen.
Dense pleural adhesions are lysed to facilitate bronchial closure during an open pneumonectomy, with care to avoid the phrenic nerve.
Once the specimen is removed from the field, it is divided on the back table for appropriate cultures to guide subsequent antimicrobial therapy. We typically “double culture” specimens at two different laboratories to minimize sampling or contamination error. The intrathoracic space typically is drained with one or two 28 F thoracostomy tubes.
Tissue transposition is indicated if there is risk of potential breakdown of the bronchial stump or when a significant intrathoracic “space” is present after resection. Postoperative BPFs are more common in the setting of certain poorly controlled infections, such as multidrug-resistant M. tuberculosis, or after certain resections, such as right pneumonectomy. We favor use of either a latissimus dorsi or intercostal muscle flap for bronchial stump coverage in routine circumstances and use of omentum after pneumonectomy, particularly after a right-sided resection.9 Use of the serratus anterior muscle is often problematic because of winged scapula-related problems of wound healing and skin necrosis in these chronically malnourished patients.
Mobilization of the latissimus dorsi muscle is completed at the initiation of the procedure, and the muscle is transposed into the chest through the second or third intercostal space after resection. The omentum is mobilized before thoracotomy via laparoscopy or a limited midline abdominal incision, based on the right gastroepiploic artery and vein, and tacked to the undersurface of the appropriate hemidiaphragm for retrieval later after lung resection.
The presence of a significant intrathoracic “space” appears to be more common after major lung resection for infectious lung disease such as bronchiectasis compared with other indications for surgery. The use of transposed muscle such as latissimus dorsi minimizes the potential complications in this setting, including postresection empyema or prolonged air leak.