Chapter 69: The Five Lobectomies: Preoperative Evaluation, Operative Technique, and Postoperative Management

INTRODUCTION

The ability to select appropriate patients, perform a competent pulmonary lobectomy, and manage these patients safely in the postoperative interval defines a good general thoracic surgeon, more than any other part of the job. Lung cancer patients make up the majority of general thoracic surgical patients. Lobectomies, including the extended versions (i.e., sleeve lobectomy and lung and chest wall resection), constitute the majority of a general thoracic surgeon’s work. In no other endeavor does a thoracic surgeon have more impact on his or her patients.

However, an operation frequently performed is not necessarily an operation done well. 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 is likely because general thoracic surgery is a secondary occupation for many general and cardiac surgeons.² Whatever the reasons, appropriate performance of this common, but potentially dangerous, operation is important for our patients.

While lobectomy is the standard of care for even stage I cancer, an increasing literature demonstrates that lesser resections (wedges or segmentectomies) are appropriate for small cancers 1 cm in size or less.^3,4 Recent series have worked to hone down on which patients could safely undergo lesser resections and have generally found that patients with lesions smaller than 1 cm have the same survival no matter their approach.⁵ Lesions between 1 and 2 cm may be safely resected with segmentectomies, while anything larger requires lobectomy. These data are consistent with older large series—most patients with lung cancer should undergo lobectomy unless compelling reasons demand otherwise.^6,7

Lobectomies can be done in different ways, but the sites of potential inadvertent injury and thus danger usually remain the same. (These danger points are summarized in Tables 69-1 through 69-10.) In fact, a surgeon may choose an unusual approach if it lessens the chance of problems for a particular patient compared to the standard approach.