71: The Five Lobectomies

Introduction

The ability to select patients appropriately, perform a competent pulmonary lobectomy, and manage patients safely in the postoperative interval epitomizes the skills of a good general thoracic surgeon, more than any other aspect of the job. Lung cancer patients comprise a majority of general thoracic surgical patients, and lobectomy, particularly the extended versions (i.e., sleeve lobectomy and lung and chest wall resection), constitutes most of a general thoracic surgeon's work. In no other endeavor does a thoracic surgeon have more impact on his or her patients.

However, the frequency with which an operation is performed often does not mean that it is well performed. A recent evaluation of the National Cancer Database revealed that many or most lobectomies in the United States were done without checking surgical margins or performing mediastinal lymph node dissections despite extensive evidence that these actions are important for long-term survival after cancer resections.¹

The reason for this lack of uniformity is not entirely clear but it is probably that many surgeons, both general and cardiac, regard general thoracic surgery as a secondary rather than primary occupation.² Whatever the reasons, appropriate performance of this common but potentially dangerous operation is important for our patients.

Lobectomies can be done in many different ways, but the sites of danger usually remain the same. In fact, a surgeon may choose an unusual approach because it lessens the chance of problems for a particular patient compared with the standard approach.

Preoperative Evaluation

Staging

Preresection staging should be done for all patients undergoing lung resection. At this time, a complete history and physical examination focusing on involvement of lymph nodes and liver masses, followed by chest CT scan and PET scan, are appropriate. The latter evaluation will rule out distant metastases other than brain metastases. Patients without symptoms of headache are unlikely to have brain metastases, and therefore, head CT scan or MRI is not obligatory.

All patients with lung cancer may have mediastinal metastases. Although PET scans are quite sensitive for identifying mediastinal metastases, they remain less accurate than mediastinoscopy (see Chapter 70). Preoperative mediastinoscopy is indicated for all patients with a PET scan-positive mediastinum and should be considered for certain patients with a PET scan-negative mediastinum (i.e., those with enlarged nodes on CT scan or with hilar lesions). Although the PET scan remains useful for ruling out distant metastases, it should not be the only study performed to evaluate the mediastinum. Many patients have been denied resection because their PET scan was positive in the mediastinum, only to find a more knowledgeable physician who, on mediastinoscopy, diagnosed mediastinal granulomatous disease instead and then successfully resected the patient's stage I cancer (Table 71-1).