Perioperative management - Uniportal VATS pneumonectomy right

In general, the indications for a pneumonectomy have become significantly rarer with the improvement of surgical techniques and good results of bronchial anastomosis in sleeve resection.

Oncological

• For centrally located bronchial carcinomas in an operable stage
• In very rare exceptional cases for pleural mesothelioma or bronchial carcinoma with unilateral lung metastasis
• Palliative resection, for example, in obstruction of the main bronchus with recurrent pneumonias and lung abscesses or recurrent bleeding.

Non-Oncological

• Destroyed lung lobe after infectious disease (e.g., tuberculosis)
• Severe bronchiectasis
• Stenosis of the main bronchus
• Iatrogenic injury to the pulmonary artery, for example, during a lobectomy

Pneumonectomy carries a variety of postoperative consequences with particularly significant cardiopulmonary risks and usually a lifelong reduction in quality of life. The 30-day mortality rate remains high at 5% to 12%, making thorough patient selection and strict indication setting important.

• Lack of cardiopulmonary reserve for a lung resection procedure
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapy concept regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

• Oncological Diagnostics

In case of suspected bronchial carcinoma, the staging examinations outlined in the guidelines should be conducted before any surgery.

• Computed tomography of the thorax with upper abdomen, contrast-enhanced
• PET-CT
• MR of the skull
• Bronchoscopy
  • Note: Preoperative bronchoscopy by the surgeon is recommended, especially to recognize anatomical norm variants of the bronchial system.
• Cardiopulmonary endurance

The assessment of cardiopulmonary endurance and estimation of postoperative outcomes is a very important and sometimes challenging aspect of thoracic surgery. Based on the algorithms of the ERS (= European Respiratory Society) and ESTS (= European Society of Thoracic Surgeons), the following procedure has proven effective:

• Basic diagnostics: Medical history, ECG
  • If there is an indication of increased perioperative cardiac risk ('Revised-Cardiac-Risk-Index"), further cardiological evaluation is necessary.
  • If there is a discrepancy between the anamnesis-based resilience (climbing stairs, gardening, walking) and the parameters of lung function tests, the results should be critically questioned and the examinations repeated if necessary.
• Lung function: Diffusion capacity (DLCO), Body plethysmography (FEV1)
  • FEV1 and DLCO >80% of the predicted value allow for surgery up to pneumonectomy from a lung function perspective.
  • FEV1 and DLCO <80% require further diagnostics using spiroergometry and determination of maximum oxygen uptake (VO2max)
    • With VO2max > 20ml/kg/BW (>75%), surgery up to pneumonectomy is possible from a lung function perspective.
    • With VO2max < 10ml/kg/BW (< 35%), surgery is contraindicated.

Especially in cases of VO2max 10-20ml/kg/BW or restrictive cardiac preconditions, in addition to further diagnostics (e.g., perfusion scintigraphy, "lung segment counting"), an interdisciplinary individual case decision with experienced colleagues is essential.

• Shaving of the right thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Bronchial stump insufficiency, bronchial fistula requiring intervention, possibly also re-operation
• Postoperative lymph fistula with chylothorax
• Postoperative hemorrhage with possibly necessary re-operation
• Conversion to thoracotomy and possibly extension of the resection, approach depending on intraoperative findings
• Injury to adjacent structures, especially the trachea and main bronchi, large vessels, and the esophagus, requiring corresponding extension of the procedure
• Damage to the phrenic nerve with elevation of the diaphragm on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paresis on the affected side
• Positioning injuries
• Cardiac arrhythmias

Alternative treatment: Depending on the disease, in the case of an oncological diagnosis, definitive radiochemotherapy.

Intubation anesthesia with one-lung ventilation of the opposite side.

The standard positioning for minimally invasive thoracic surgical procedures is the hyperextended lateral position.

• Bending of the operating table at the level of the scapula tip
• Horizontal alignment of the thoracic wall using a slight anti-Trendelenburg position
• Stabilization of the position using padded lateral supports in the area of the abdomen and lumbar spine, as well as a U-shaped pillow between the legs. It may occasionally be helpful to use an additional shoulder support.

Finally, it is important to pad pressure-sensitive areas and position the head on a gel ring to avoid excessive bending of the cervical spine. The arm on the operating side is positioned laterally using an arm holder and should be placed below shoulder level to avoid potential obstruction during the subsequent operation.

The arrangement as shown in the picture of the surgeon and assistant ventrally and opposite the surgical nurse was described by the Copenhagen working group led by Hendrik Hansen. Especially in uniportal VATS but also in 3-port VATS, optimal work can be done here through the anterolateral minithoracotomy.

• Wound protection ring foil (wound retractor)
• Standard VATS instrumentation with curved instruments
  • An ultrasonic scalpel can be helpful for bloodless and thus clear dissection.
• Endoscopic stapling device
  • Staple magazines with a curved tip assist in the gentle bypassing of smaller vessels.
  • In emphysematous lung tissue, staple line reinforcement before parenchyma transection is advisable.
• Titanium clip applicator

• Postoperative Analgesia

Due to the pain caused by the thoracic drainage, a combination analgesia of a non-opioid analgesic (e.g., metamizole) in combination with a low-dose opioid (e.g., tilidine) is advisable. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Management of Acute Perioperative and Post-Traumatic Pain.

• Medical Follow-up Treatment
  • After pneumonectomy, postoperative monitoring should be ensured through interdisciplinary intensive medical care.
  • X-ray control on the operating table
  • 1 to 2 thoracic drains for approximately 2-4 days postoperatively, removal after X-ray control
  • Bronchoscopic bronchial stump control on the 1st and 6th postoperative day.
• Thrombosis Prophylaxis

Standard thrombosis prophylaxis for 14 days with low molecular weight heparin subcutaneously, considering comorbidities, renal function, and laboratory control to exclude HIT. Link to the current guideline: Prophylaxis of Venous Thromboembolism (VTE)

• Mobilization

Full mobilization possible from the 1st postoperative day

• Physical Therapy

Mobilization, deep breathing exercises, and secretion mobilization

• Dietary Progression

Regular diet

• Bowel Regulation

Accompanying opioid analgesia

• Incapacity for Work

Generally, patients after pneumonectomy are not able to work postoperatively in most professions either due to further tumor treatment or due to reduced physical capacity.