RIGHT UPPER LOBECTOMY This is performed through either 4th or 5th intercostal space.

Most surgeons prefer entering the 5th intercostal space through a posterolateral thoracotomy.

The anterior surface of the hilum is dissected by incising the mediastinal pleura to expose the pulmonary veins.

Again the most anterior structure is taken first, i.e. the right superior pulmonary vein is identified.

The right upper lobe pulmonary vein is ligated.

Care is taken to preserve the right middle lobe vein since injury to this may cause venous stasis and infarction of the right middle lobe.

The right upper lobe pulmonary vein is then divided exposing the large anterior branch of the right pulmonary artery.

The fissure is developed and the large truncus anterior branch of the right pulmonary artery is taken anterosuperiorly near the hilum.

It should be noted that this is taken outside the fissure. The only branch to the right upper lobe which is taken in the fissure is the recurrent ascending posterior artery.

This is a very important point since taking only the truncus anterior without entering the fissure will miss the recurrent ascending posterior branch and could be torn when removing the right upper lobe.

The right upper lobe bronchus is the final structure and is taken with a TA-30 4.8mm staple gun.

Next the right middle lobe may be plicated to the right lower lobe with 2-0 chromic stitches to prevent torsion.

It should be noted that mobilization of the inferior pulmonary ligament is critical since it permits the remaining lung to be better able to occupy the remaining pleural space.

RIGHT MIDDLE LOBECTOMY This is approached again via standard lateral decubitus position.

A posterolateral thoracotomy is employed, again entering the 5th interspace using a serratus sparing incision if possible.

The inferior pulmonary ligament is mobilized.

The mediastinal pleura is incised to identify and ligate the right middle lobe vein.

This is a branch of the right superior pulmonary vein.

Next the right middle lobe pulmonary artery is identified and taken.

One must be careful to avoid the posterior recurrent ascending branch to the upper lobe as well as the superior segmental branch to the lower lobe.

All these vessels come off very close to one another.

Finally the right middle lobe bronchus is taken.

This is found beneath the right pulmonary artery.

Again care must be taken to avoid injury to the superior segmental bronchus which comes out very close to the right middle lobe orifice.

RIGHT LOWER LOBECTOMY The right lower lobectomy is performed through the 6th intercostal space.

The inferior pulmonary ligament is divided up to the level of the inferior pulmonary vein; this is then taken, either with ligatures or preferably now with a TA vascular stapling instrument.

The right lower lobe pulmonary artery is then exposed to the fissure.

This superior segmental artery is taken.

This is at the level of the right middle lobe pulmonary artery and care must be taken not to injure this artery.

Then the basal portion of the right lower lobe pulmonary artery is identified and taken.

The right lower lobe bronchus is exposed and the superior segmental bronchus is carefully identified to avoid narrowing of the right middle lobe bronchus when taking the right lower lobe bronchus with a stapler.

As one can see from the above discussion, the general plan of the procedure is generally the same for all lobes.

Sequentially, the vein, then artery, then bronchus are divided in that order.

Alternatively, one may take the artery first to allow for pulmonary devascularization prior to removal.

LEFT UPPER LOBECTOMY This is done via a posterolateral thoracotomy through the 4th or 5th intercos- tal space.

The left upper lobe is swept down from the apex of the left pleural space.

The left upper lobe pulmonary artery is taken as it curves over the left upper lobe bronchus.

Notice that on the left side the bronchus is hyparterial, i.e. it is inferior and anterior to the left pulmonary artery.

It is easiest to identify the anterior and apical-posterior segmental arteries of the left upper lobe pulmonary artery in the base of the fissure.

The lingula branch is then identified.

All these branches are then ligated, and the left upper lobe pulmonary artery is ligated proximally.

As mentioned before, it may be possible on the left side to simply ligate the left upper lobe pulmonary artery proximally and distally, since this artery is longer than on the right side.

The left superior pulmonary vein is then taken, preferably with a TA vascular stapling device.

The left Going back to the separation of the arteries, one needs to separately take the anterior, apical-posterior and lingular arteries.

The posterior and apical arteries are taken anterosuperiorly outside the fissure; the lingula artery and anterior arteries are taken from the fissure aspect.

LEFT LOWER LOBECTOMY

This is similar in nearly all respects to right lower lobectomy. It is done through a 6th intercostal space via a posterolateral thoracotomy.

The inferior pulmonary vein is taken at the superiormost aspect of the inferior pulmonary ligament.

The left lower lobe pulmonary artery is then taken in the fissure near the takeoff of the lingular artery.

The left lower lobe bronchus is then taken by a stapling device being sure to avoid the left upper lobe bronchus which is close to the take-off of the superior segmental bronchus of the lower lobe.

Clear definition is important to avoid injury of the left upper lobe bronchus.

Postoperative Care General criteria for tube removal: No air leak Output < 200 cc /24 hrs Ancef for all tubes for 24 hours Typical Postoperative Course

DOS: Epidural for pain control, minimize sedation Lopressor (Hold if HR<55, SBP<100 mm Hg) Chest tubes to -20 suction, Nebulizers NPO, Pepcid Heplock SQ Heparin TID or Lovenox daily ( HOLD 24 hrs prior to epidural removal ) I Ancef x 24 hours stop Lines Peripheral Lines Insulin Protocol

Post- Operative Day 1: Sips of clears and advance diet as tolerated (1500cc fluid restriction) Chest tubes to water seal Diuresis later in day Ambulate with assistance

Post- Operative Day 2: Oral Medication Chest tubes can start to be removed Diuresis if indicated Ambulate with assistance

Post- Operative Day 3: Remaining chest tubes are removed Epidural stopped removed after chest tubes removed D/C Foley 4 hours after epidural removed Ambulate with assistance Diuresis if indicated Reconcile medications with preoperative medications

Post- Operative Day 4- Post- Operative Day 5: Discharge