Continuing Education Activity

The anatomic resection of an entire lobe of a lung is called a lobectomy. It is usually done with the help of the video scope and with less than an 8 cm incision. Although done for several benign and malignant pulmonary conditions, lung cancer remains the most common indication. This activity reviews indications, surgical anatomy, surgical technique, and perioperative management of patients undergoing lobectomy by the healthcare team.

Objectives:

• Describe the thoracic surgical anatomy.
• Review the equipment, personnel, preparation, and techniques of lobectomy.
• Summarize the complications of the lobectomy procedure.
• Explain the importance of interprofessional management when performing a lobectomy.

Introduction

Lobectomy is the surgical removal of the entire lobe of the lung. Dr. Davies performed the first reported lobectomy in 1913, but the patient died one week later due to a postoperative infection. With time, the surgical skills got refined, and with improvement in anesthesia technique and infection control, lobectomy became more prevalent with better outcomes. Traditionally, lobectomy has used a thoracotomy approach, but with the advent of video thoracoscope (video-assisted thoracoscopic surgery, VATS) has become the procedure of choice. Lobectomy is useful for varied benign and malignant lung diseases. The candidate for lobectomy should have an adequate pulmonary reserve to tolerate resection.[1][2] The preoperative assessment focuses on cardiopulmonary function, functional patient's status, and postoperative mortality stratification.[3] Growing evidence has shown that VATS lobectomy is efficient and lowers mortality and morbidity rates for what has become recommended as the first option in early-stage lung cancer and selected cases of benign lung diseases.[4] Adequate postoperative management of the patient undergoing lobectomy, in conjunction with the VATS approach, promotes fast-tracking in thoracic surgery.[5][6]

Anatomy and Physiology

Pulmonary Surgical Anatomy

Pulmonary surgical anatomy spans a complex subdivision of anatomical structures involved in a lobectomy. It could sort out as lung parenchyma, vascular system, and bronchial division. Classic pulmonary anatomy nomenclature has become simplified with the advent of 3D-CT anatomy for VATS segmentectomy.[7]

Lung Parenchymal Division The lung parenchyma is the functional tissue of the lung, and its segmentary division uses the S prefix.[7]

1.  Right Lung Parenchymal Division Right upper lobe: Posterior segment (S2), apical segment (S1), and anterior segment S3. Right middle lobe: lateral segment (S4) and the medial segment (S5). Right lower lobe: superior segment (S6), medial basal segment (S7), anterior basal segment (S8), lateral basal segment (S9), and posterior basal segment (S10).[7][8]

2. Left Lung Parenchymal Division Left upper lobe: apico-posterior segment (S1+2) and anterior segment (S3). Left upper lobe lingular division: superior segment (S4) and inferior segment (S5). Left lower lobe: superior segment (S6), anteromedial basal segment (S7+8), lateral basal segment (S9), and posterior basal segment (S10).[7][8]

Bronchial Topographic Anatomy And Segmentary Division

1. Right Main Bronchus The right main bronchus anatomy divides into three segments; the right upper bronchus, the bronchus intermedius, and the lower lobe bronchus. The right main bronchus highlights are; 1.2 to 1.5 cm in length for the right upper lobe bronchus. The bronchus intermedius highlights are; approximately 2 cm in length and form the middle lobe bronchus (anterior) and superior segmental bronchus (posterior). The lower lobe bronchus forms the lower basal bronchi.[9][10]

• Right bronchus segmentary division. The segmental bronchial division uses the B prefix with B1-B10 terminology with the same previous lung segmentary (S) names[7][8]. Right upper lobe bronchus: Right upper lobe bronchus is segmented when entering into the lung parenchyma. The most common presentation is a common trunk for B1+2 and a single B3. Another segmentary presentation is an independent branch for each B1, B2, and B3, respectively.[7][8]
• Right bronchus intermedius: The right bronchus intermedius feeds to the middle lobe bronchus, which becomes segmented when entering the parenchyma. 90 % presentation has a common trunk for B4+5. In some cases, B4 and B5 are separated branches. The right superior segmental bronchus raises from the intermedius bronchus as a single  B6 branch. Another presentation is a double B6 branch.[7][8]
• Right lower lobe bronchus:  The lower lobe bronchus is a common basal trunk forming three bronchial branches (when entering into the parenchyma); B7+8, B9, and B10. Other anatomic bronchial variants are; 8% is B7, B8+9, and B10 presentation, and 6% have B7, B8, B9, and B10 separated branches presentation.[7][8]

2. Left Main Bronchus It is more simple than the main right bronchus; it consists of a main left bronchus that length 4 to 6 cm and forms the upper lobe and lower lobe bronchi. The bronchial segmentary division consists of the upper lobe and lower lobe bronchi. The bronchial division uses the B prefix with B1-B10 nomenclature with the same previous segmentary names; B7 in some literature does not exist or has the name B7+8.[9][10][7]

• Upper lobe bronchus: bifurcates and forms a common trunk for B1+2, B3, and a lingular bronchus for B4+5.[7][8] 
• Lower lobe bronchus: bifurcates giving B6 and common basal trunk giving B8 and B9+10 (80%); in other cases, B8+7, B9, and B10 are isolated branches (16%).[7][8]

Vascular Topographic Anatomy And Segmentary Division

The lung's vascular supply consists of two systems; the bronchial and pulmonary vascular (arterial and venous) systems.[9][10]

Arterial Bronchial Supply Arterial bronchial supply is a high-pressure system with low capacitance for bronchi irrigation. It runs posteriorly to the airways and progressively is segmented to irrigate lobar and segmental bronchi. Characteristics of the topographic anatomy of the bronchial vascular system depend on each main bronchus irrigation. The most common configuration is one right and two left bronchial arteries. This one to two arterial arrangement in surgical terms makes the right main bronchus more susceptible to ischemia.[8][9][10] The right bronchus artery emerges from the intercostal arteries (2 to 3 cm distal to the left subclavian artery). The two left bronchial arteries emerge from the descending aorta (anterolateral).[7][8] Anatomical variants are; One right bronchial artery (from intercostal) and one left bronchial artery (from the aorta). Two right bronchial arteries (one from the intercostal and one from the aorta) and two left bronchial arteries (from the aorta). Two right bronchial arteries (one from the intercostal and one from the aorta) and one left bronchial artery (from the aorta).[9][10]

Venous Bronchial System Proximal right and lefts bronchial veins drain into the pulmonary veins. Segmental and subsegmental right bronchial veins drain into the azygos vein. Segmental and subsegmental left bronchial veins drain into the hemiazygos vein.[8][9][10]

Pulmonary Vascular System The pulmonary vascular system consists of a main pulmonary artery and one superior and one inferior pulmonary vein (left and right), which are progressively segmented to give vascular supply for lobar, segmental, and subsegmental lung.[8][9][10]

Pulmonary Artery System The pulmonary arterial circulation is a low-pressure system with high capacitance for gas exchange, which is the main airways irrigation supply (75% to 90%) at the level of lobar and segmental bronchi. Before this level exists, a rich anastomosis interconnection network with bronchial arterial circulation. The pulmonary arterial system's topographic-anatomical configuration is the main pulmonary artery (pulmonary trunk) that emerges from the right ventricle, the pulmonary trunk (below the aortic arch) forming the right and left pulmonary arteries.[8][9][10]

Right Pulmonary Artery Topographic Anatomy The right pulmonary artery highlights are; intra-pericardial portion (over 3/4 length is into the pericardium, runs below the carina behind the ascending aorta and superior vena cava), and an extra-pericardial portion (run anterior and inferior to the right main bronchus). For topographic surgical anatomy comprehension, the central running of the extra-pericardial right pulmonary artery gets divided. Each division subsequently forms important branches for lobar and segmental irrigation. Extrapericardial right pulmonary artery division is a right pulmonary artery and the right interlobar artery (between the fissure). The right pulmonary artery (first extra-pericardial portion) irrigates the right upper lobe. The right interlobar artery (inferior to bronchus intermedius and anterior to superior pulmonary vein) gives irrigation for S2 (some cases), middle lobe, and inferior lobe.[8][9][10]

Right Pulmonary Artery Segmentary Division The right pulmonary artery segmental anatomy uses "A" prefix nomenclature with the same previous bronchi segmentary names.[7][8] Right upper lobe arterial irrigation: the extra-pericardial right artery forms two segmental branches; the anterior truncus for A1+3 and A2 separated branch (In literature, A2 is commonly named ascending posterior artery "Asc.A2"). From a right upper lobectomy standpoint, S2 arterial supply is the highlighting point. In 10% of cases, the main A2 irrigation could emerge from the interlobar artery (posterior surface and opposite to middle lobe artery) or inferior lobe artery (common trunk with A6 or arterial basal trunk). S2 could have double irrigation with a recurrent A2 (Rec.A2, 72% of cases) from anterior truncus or only have irrigation from anterior truncus trifurcation (A1+2+3).[7][8] Right middle lobe arterial irrigation: irrigation of the middle lobe is by the middle lobe artery that emerges from the interlobar pulmonary artery. The middle lobe artery leads to a common trunk A4+5. Anatomical variation can present as an A4 and A5 isolated branches from the interlobar pulmonary artery.[7][8] Right lower lobe arterial irrigation: The right lower lobe is irrigated by the superior segmental artery (A6), which emerges from the interlobar artery (opposite to middle lobe artery), and the arterial basal trunk artery that forks in A7+8 and A8+9. From a right lower lobectomy standpoint. S6 has a single A6 branch (sometimes can be double or triple) that arises from the interlobar pulmonary artery. Common anatomic variations are; A6 could share a common trunk with A2 or rise from the arterial basal trunk. The arterial basal trunk divides into two terminal trunks, A7+8 and A9+10. From a segmentectomy standpoint, it highlights anatomic variations are; A9+10 and A8 separately trunks from the common basal trunk (90%) and A7 lacking (16%).[7][8]

Left Pulmonary Artery Topographic Anatomy The left pulmonary artery highlights are; Intra-pericardial portion run below the aortic arch (aortopulmonary window). Long length extra-pericardial-portion that exits pericardium at ligamentum arteriosum level runs above and behind left main bronchus (arc 3/4 left main bronchus circumference). The extra-pericardial left pulmonary artery divides, forming the branches for the left superior lobe, lingular lobe, and left lower lobe.[8][9][10] 

Left Pulmonary Artery Segmentary Division The left arterial segmental anatomy uses "A" prefix nomenclature with the same previous bronchi segmentary names.[7][8] Left upper lobe arterial irrigation: The left pulmonary artery forms diverse configurations of arterial branches for each upper lobe segment. The most common anatomic pattern is; A truncus anterior artery, the posterior arteries, and the lingular artery. The truncus anterior artery becomes two branches, one common branch A1+2 and an isolated A3 branch. The posterior arteries give irrigation to the apical-posterior lung segment; the number of posterior arteries can be from 1-5. Still, the most common pattern is 2 to 3. These posterior arteries emerge of the left pulmonary artery interlobar segment at the posterior surface and are opposite to the lingular artery.[7][8] The lingular artery arises from the anterior aspect of the left pulmonary artery within the fissure, is considered in diverse literature the last branch of the posterior arteries; however, this artery rises in an anterior aspect. It also has been considered an individual branch with distinct anatomic variants for lobectomy porpoise. In 80% of cases, the lingular artery is a common trunk A4+5. In 26% of cases, A4 and A5 raise as separated branches. The truncus anterior artery branches off an occult artery named the mediastinal lingular artery for the lingula (suspect when lingular artery is tiny or absent), A4 could send arteries to the basilar trunk (inferior lung irrigation) or for S8, and A4 artery could share a common trunk with A3.[7][8] Left lower lobe arterial anatomy: The interlobar segment of the left pulmonary artery gives the superior segmental artery (A6) and the basal trunk artery. The A6 superior segment artery is a single branch (diverges in two or three branches for S6, rise in the posterior aspect of the left interlobar pulmonary artery). In 80% of cases, it is double in 18% and is triple in 2% of cases. Highlight anatomic variants are;  Posterior branch (A2) can raise close to A6 or have a common trunk with A6. The basal trunk diverges in two main arterial trunks, A8 and A9+10. Anatomic variants highlights of the basal irrigation are; The basal segments can be irrigated by A8, A9, and A10 isolated branches, and a lingular artery can arise from the basal trunk.[7][8]

Pulmonary Venous System The pulmonary venous system flows through four pulmonary veins that drain into the left atrium. Pulmonary veins enter the mediastinum anterior and below the pulmonary artery. The pulmonary veins' topographic arrangement is; one superior and one inferior pulmonary vein for each lung (4 pulmonary veins).[8][9][10]

Right Pulmonary Veins Topographic Anatomy The superior pulmonary vein drains the right upper and middle lobes, the lower lobe is drained by the inferior pulmonary vein. At the hilum, the superior pulmonary vein is the most anterior structure, and the inferior vein is the most inferior structure.[8][9][10] 

Right Superior Pulmonary Vein Segmentary Division The right superior pulmonary vein has three branches; The upper root that gives V1, the central vein that gives V2+3, and the middle lobe vein V4+5.[7][8] These branches have specific anatomic configurations for surgery purposes. V1 is the uppermost branch, is the most anterior and superior vessel, and it is in the upper lobe anterior hilum. The central vein is within the fissure and forms a long V2 branch and short V3 tributaries. In some cases, the central vein also forms a V2t that runs posterior to Asc.A2. The middle lobe vein is the most inferior branch of the superior pulmonary vein; it can present as a common trunk for V4+5 or as V4 and V5 isolated branches. The middle lobe vein can arise from the right inferior pulmonary vein.[7][8]

Right Inferior Pulmonary Vein Segmentary Division The right inferior pulmonary vein has three principal branches; Superior segment vein V6, the inferior basilar vein V9+10, and the superior basilar vein V7+8. Anatomic variants highlights are; the two basilar veins could have a common trunk, the basilar veins can present as isolated intercommunicating branches.[7][8]

Left Pulmonary Veins Topographic Anatomy The superior pulmonary vein drains the left upper lobe, and the inferior pulmonary vein drains the lower lobe. At the hilum, the superior pulmonary vein is the most anterior structure, and the inferior vein is the most inferior structure. The superior and inferior pulmonary veins could share a large or short common trunk that drains into the left atrium in 25% of cases.[9]

Left Superior Pulmonary Vein Segmentary Division The left superior pulmonary vein has three principal branches;  The superior vein, the middle vein, and the inferior (lingular) vein.[7][8] The superior vein forms V1+2. The middle vein forms V3; in some cases, the superior and the middle vein could share a common trunk. The lingular vein is the lowermost branch of the left superior pulmonary vein that forms V4+V5. The anatomic variant highlights are; the left superior pulmonary vein can present as multiple radiating branches; in this case, the lingular vein is considered the most lower branch. The lingular vein can arise from the left inferior pulmonary vein.[7][8]

Left Inferior Pulmonary Vein Segmentary Division The left inferior pulmonary vein has three principal branches; The superior segment vein V6, the inferior basal vein, and the superior basal vein.[7][8] The superior segment vein gives the V6 branch. The inferior basilar vein form a common trunk V9+10. The superior basilar vein forms V8. Anatomic variants highlights are; The superior basal vein can have a V8 (anterior branch) and V9 isolated branches. The inferior basal vein can drain S8, and the left lower lobe can drain by a V6 and a common basal vein.[7][8]

Indications

Benign Conditions 

Infectious

Any chronic infectious process not controlled with antibiotic therapy can benefit from surgical resection. Tuberculosis is the most common reason for lobectomy worldwide. 

Tuberculosis and its sequelae.[11] Although antitubercular antibiotics remain the standard treatment for the patient with tuberculosis, selected patients with localized disease or its complications like a large cavity, localized bronchiectasis can undergo lobectomy after optimal medical therapy. They have high postoperative mortality and morbidity and require close follow-up. 

Non-infectious 

Developmental anomaly Congenital bronchial atresia, pulmonary sequestration, bronchogenic cyst, congenital cystic adenomatous malformation.[12][13]

Bleeding. Massive hemoptysis due to aspergilloma, cavity, AV malformation, and bronchiectasis are controllable with lobectomy. Lobectomy in trauma is indicated in hilar vessels or bronchi hilar injuries; the associated mortality is up to 40%.[14]

Malignant Conditions

Lobectomy is the standard surgical approach for stage I-II non–small cell lung cancer.[15] As lung cancer is most common in the right upper lobe, the right upper lobectomy is the most common procedure for lung cancer. Other less common neoplastic indications include mucoepidermoid tumors, adenoid cystic tumors, and sarcomas. Lobectomy may also be an option in a patient with localized pulmonary metastasis.

Contraindications

The outcome of the procedure is largely dependent on patient selection. Information about the patient's physiological ability to tolerate lobectomy will help to risk-stratify the potential operative candidacy. Patients with forced expiratory volume in 1 second (FEV1) less than 800 cc or diffusion capacity of carbon monoxide (DLCO) less than 40% are considered high-risk patients. These patients are better served with sub-lobar resection or nonoperative therapy.

If possible, lobectomy should also be avoided in patients with recent myocardial infarction and severe cardiovascular disease. VATS lobectomy should also be avoided in patients with tumors larger than 6 cm due to technical challenges.

Equipment

For conventional lobectomy procedures, a rib retractor is the mainstay surgical tool. Long instrumental is essential to reach the hilar structures, and vascular instrumental must be at hand due to the risk of major vessel injuries. Lung parenchyma and hilar structures transection could be done by stapler or cut incision with hand-sewn techniques repair. For VATS lobectomy, some endoscopic instrumental is different than conventional endoscopic surgery.[5][16]

Open Lobectomy

The essential equipment for open lobectomy is; rib spreader, scapula retractor, periosteal elevator.[5] 

VATS Lobectomy

The basic equipment for VATS lobectomy is; video system, 10 mm 30-degree video-thoracoscope, light source power, energy dissection devices (ultrasonic dissector-coagulator or bipolar electrocautery devices), Long curved VATS instruments with double articulation, vascular clips, curved-tipped endoscopic staplers, plastic endobag, wound protectors for the utility port and 10 mm trocars.[5]

Personnel

Personnel needs depend on the etiology and previous medical management. Lung disease care commonly involves pulmonology, infectious disease, internal medicine, oncology, and thoracic surgery departments.

Lobectomy surgery staff: An anesthesiologist, thoracic surgeon, assisting surgeon, and scrub nurse competent in thoracic surgical procedures.[16][17]

Postoperative management in thoracic surgery uses an intensive care unit (ICU) because cardiopulmonary complications require active, life-supporting treatments. When the patient remains stable for a few hours, it must be transferred to the general thoracic ward.[18]

Preparation

The preoperative evaluation focuses on the suspected diagnosis. Personal factors (smoking, pre-existing comorbidities), performance status evaluation, clinical examination, blood test, imaging, bronchoscopy, and cardiac risk evaluation are the cornerstone of the initial assessment. In lung cancer, preoperative staging protocol must take place. Highlights are positron emission tomography-computed tomography (PET/CT) and invasive mediastinal staging (IMS).[3]

With a defined diagnosis with an established need for lobectomy, a preoperative assessment for a thoracic surgery patient is necessary. The ACCP, BTS (British Thoracic Society), and ERS/ESTS (European Respiratory Society/European Society of Thoracic Surgery) have proposed different preoperative assessment criteria. Highlights are mortality risk and respiratory function.[3]

Mortality Risk

Thoracoscope, ESTS model, VA (veterans affair) model, ACS-NSQIP (The ACS National Surgical Quality Improvement Program) scales have been recommended to stratify the risk of mortality and morbidity in thoracic surgery patients.[19][20][21]

Respiratory Function

Essential tools for respiratory function evaluation are spirometry, DLCO (diffusing capacity of the lung for carbon monoxide), V/Q (ventilation/perfusion), scintigraphy scan, cardiopulmonary exercise test, low technology exercise tests, and arterial blood gas. Respiratory function assessment is crucial in determining whether the patient will tolerate lung resection. ERS/ESTS and ACCP guidelines have been performed algorithms for this purpose. BTS (British Thoracic Society) guidelines recommend absolute preoperative FEV1 of 1.5 L, and ACCP suggests greater than 60% (DLCO or FEV1) of the percentage of predicted postoperative values without high cardiac risk to perform lobectomy.[3] 

Anesthesia Lung Isolation 

Double-lumen endotracheal tubes and bronchial blockers are the standards of care in anatomical lung resections because these devices facilitate hilar dissection.[22] Lately, awake video-assisted surgery has been the procedure for major pulmonary resection in carefully selected patients.[23]

Technique or Treatment

Over time the technical aspects of lobectomy have changed. The surgeon can perform the surgical approach by conventional open surgery, VATS, or robotics. Different methodologies for dissecting hilar structures exist. The most important aspects are focused on the hilum approach (anterior or posterior mediastinum) and the hilum dissection sequence (anterior or posterior), emphasizing in perform an isolated dissection and division of the hilar structures (vein, artery, and bronchus). The patient should be in lateral decubitus for open and VATS lobectomy.[4][5][16]

Conventional Open Lobectomy

Posterolateral thoracotomy is the conventional open approach. Its uses have been decreasing over time; however, it is preferred under complex conditions (both in lung cancer and benign disease). Highlight complex conditions are; Centrally located tumors, tumors >6 cm, endobronchial tumors, thick adhesions due to inflammatory processes, complex congenital lung malformations. The hilum approach and hilum dissection sequence depend on the surgeon's preference (posterior to anterior, anterior to posterior). For hilar division and repair, staplers or hand-sewn techniques are the choices.[4][16]

VATS Lobectomy

The Cancer and Leukemia Group B (CALGB) has settled down the most accepted definition for VATS lobectomy; the essential point is to perform an anterior utility port incision with 8 cm maximum length without rib spreading.[16][24]

Proposals exist for different minimally invasive approaches. Currently, the most common minimally invasive techniques are Duke, Copenhagen, and uniportal VATS. The common denominators between these techniques are; Anterior utility port incision, anterior surgeon's position (patient abdomen), anterior hilum approach (anterior mediastinum), and anterior to posterior hilum dissection sequence. The anterior utility port is a 5 cm length incision performed in the fourth or fifth intercostal space between the anterior and middle axillary lines. It is constant in the five types of lobectomy (right superior, right middle, right lower, left superior, left lower lobectomies).[4][16][25]

Differences between Duke's, Copenhagen's, and uniportal VATS  techniques are: the Duke approach has two incisions, the utility port and the camera port; the last is a 5 to 10 mm counter-incision adjacent to the posterior vertex of the utility port incision in the same intercostal space.[25] The Copenhagen technique is a three portal approach, the anterior utility port incision, the camera port incision 1 cm located at the top of the diaphragm in the axillary anterior line, and a 1.5 cm working port incision located at the same level of the camera port straight down the line from the scapula.[16] Uniportal VATS has only the anterior utility port incision.[26]

Hilum Approach, Hilum Dissection Sequence, and Fissure Technique

The cornerstone of lobectomy is the individual dissection of the vein, arteries, and airway for the lobe. Currently, the most popular is the anterior approach (anterior mediastinum). the dissection sequence is anterior to posterior in a single direction.[16][27] The fissure-less technique is when the division of the pulmonary fissures with direct stapling over the visceral pleura is performed lately in the surgery.[28] The fissure-last technique is when the fissure is open late in surgery to expose arterial structures.[29] If the fissure is open first in surgery, it is called the fissure-first technique (tunnel technique). The Fissure-first technique merits consideration when the hilum dissection is complicated, and the vascular and bronchial structures plane dissections are challenging to identify[30]; however, the fissure-less technique has been the recommended approach due to the minor risk of postoperative air leak.[28][31] 

Lobectomy Technical Aspects

In this paper, the Copenhagen anterior approach designed for VATS will be described due to the various proposed surgical technics. It is essential to highlight that in the uniportal VATS technique, the order sequence of vascular dissection is different in some steps. The division of hilar structures uses staplers and vascular clips.[16][32]

Right Upper Lobectomy

Hilum approach; Open the mediastinal pleura over the anterior hilum; the reference landmark is the azygos vein. The sequence dissection and division of hilar structures (anterior to posterior in a single direction) is; Superior portion of the pulmonary vein (superior and central vein), the anterior truncus of the pulmonary artery, anterior part of the minor fissure, ascending posterior artery and remaining arterial branches for the upper lobe, upper bronchus, and posterior part of the fissure. Pitfalls are: identify the lower portion of the upper pulmonary vein, identify the ascending posterior artery, differentiate it from the middle lobe artery (interlobar artery exposed after the division of the anterior part of the fissure), and identify anatomical variants (especially in the ascending posterior artery).[16][33] In the uniportal VATS technique, the anterior truncus of the pulmonary artery is the first hilum structure transected.[34]

Right Middle Lobectomy

Hilum approach: Open the mediastinal pleura over the anterior hilum over the pulmonary veins. The sequence and division of hilar structures (anterior to posterior in a single direction) are as follows: middle lobe vein, anterior part of the mayor fissure, middle lobe bronchus, middle lobe artery, and the remaining fissures. Pitfalls are: identify vein and arterial anatomical variants.[16][33] In the uniportal VATS technique, the middle lobe artery is transected before the middle lobe bronchus (beneath the middle lobe artery).[35][36]

Right Lower Lobectomy

First, transect the inferior ligament to expose and open the mediastinal pleura over the inferior pulmonary vein (superior traction of the lower lobe). The hilum approach: Open the mediastinal pleura over the inferior pulmonary vein. The sequence and division of hilar structures (anterior to posterior in a single direction) are the following: the inferior pulmonary vein, anterior part of the mayor fissure, inferior pulmonary artery, inferior lobe bronchus, and the remaining fissure. Pitfalls include the anatomical variations of the lower lobe arterial supply irrigation supply (superior segmentary artery); the inferior vein dissection takes place in the posterior hilum, which becomes exposed with the upper traction of the lower lobe, the rest hilum dissection uses the anterior approach.[16][33] Uniportal VATS technique hilum sequence is similar to the conventional VATS technique.[36]

Left Upper Lobectomy

Hilum approach: Open the mediastinal pleura over the anterior hilum over both artery (superior) and pulmonary vein (inferior). The sequence and division of hilar structures (anterior to posterior in a single direction) are: upper lobe vein, anterior truncus of the pulmonary artery, left upper bronchus, posterior arteries for the upper lobe, lingular artery, and fissure. Pitfalls include the left upper lobectomy being the most challenging lobe resection. The tunnel technique (fissure-first) is a good option. The superior and inferior pulmonary veins could share a common trunk; arterial anatomical variants for the upper lobe are common. The sequence of hilum dissection in the uniportal VATS  should be from anterior to the superior hilum and posterior to the inferior hilum; this is called the tangential sequence technique. Also, in uniportal VATS, the fissure-first technique permits an adequate exposure of arterial branches when these are short and are challenging to individualize.

Left Inferior Lobectomy

Hilum approach and hilum structures division sequence is the same for the right lower lobectomy; the highlighted difference is that the incision of the utility port is in the middle axillary line due to the hearth position.[16][33] Uniportal VATS technique is similar to the right lower lobectomy. Pitfalls are; the inferior pulmonary vein could share a common trunk with the superior pulmonary vein, the arterial anatomic variants, especially the mediastinal lingular artery (common trunk with inferior basal artery), and the superior segmental artery could send branches to the upper lobe.[7][36]

Lymph Node Management

In lung cancer, lymph node management uses the IASLC (International Association of the Study of Lung Cancer) or NCCN recommendations.[37][16]

Postoperative Management

The most important features following lobectomy are pain control, pulmonary physiotherapy, and chest tube management.[18][38]

Complications

Lobectomy complications incidence depends on etiology, patient diagnosis, and resected lobe.[39] Complications after lobectomy usually occur in the early postoperative period (within 48 hours), unlike pneumonectomy, which presents late complications due to the risk of pleural fluid infection.[40] A National Cancer Database review found that lobectomy mortality is  2.6%, and morbidity is 10% to 50%, mortality and comorbidity risks increases in patients over 75 years old.[41][42]

The main postoperative lobectomy complications are prolonged air leak (15% to 18%), subcutaneous emphysema, pneumonia/mucus plugging/atelectasis (6%), pleural empyema (1% to 3%), persistent space (9.5%) atrial fibrillation (33%), right middle lobe torsion (0.09 to 0.4%), hemorrhage (2.9%), chylothorax (0.7% to 2%), phrenic nerve injury and recurrent laryngeal nerve injury, wound infection, tumor embolization (less than 1%) and very rarely bronchopleural fistula.[40][43]

Clinical Significance

Lobectomy surgery effectiveness depends on etiology and the surgical approach (open lobectomy and VATS lobectomy). VATS has been the preferred approach due mainly to the results in postoperative recovery. However, when VATS is not indicated, open lobectomy is performed to improve patient transoperative safety.[4][44]

VATS lobectomy for infectious focal bronchiectasis or cavities can be performed safely with low rates of mortality (0% to 1%) and morbidity (9% to 23%), the mean length of hospital stay is four days, also VATS lobectomy for congenital lung diseases is feasible and effective in selected patients, with a conversion rate is 4%. NCCN recommends VATS lobectomy for lung cancer resection; research has shown VATS lobectomy to have minor complications rates and better long-term survival compared to open thoracotomy lobectomy for NSCLC.[11][45][46]

Enhancing Healthcare Team Outcomes

Lobectomy patient interprofessional care focuses on postoperative care. The interprofessional team includes the thoracic surgeon, anesthesia team, nurse staff (operation room, postoperative care unit, thoracic surgery unit), chest physical therapy, and social services. The surgical team directs decisions. Postoperative management will be by nursing staff (pain medication, thoracic drainage, monitorization vigilance, and chest physical therapy instructions), pharmacy (pain control), and adequate pulmonary hygiene are essential for fast-tracking results. Patient education consists of teaching respiratory therapy exercises and early mobilization to enhance pulmonary recovery. This patient health care pathway has demonstrated a reduction in the length of hospital stay and costs.[6] Lately, consistent data from meta-analyses have shown that  VATS lobectomy with lower complication rates and improved quality of life. Survival advantages in lung cancer resection compared with open lobectomy is moderate.[47] [Level 2]

Nursing staff, including operating room specialty nursing, can prepare the patient for the procedure, assist and monitor during the surgery, and provide post-operative care (including antimicrobial measures as needed) and monitoring, alerting the surgeon of any concerns they encounter. With appropriate interprofessional measures as outlined above, patient outcomes can reach their optimal potential. [Level 5]