Perioperative management - Uniportal trisegmentectomy S1-3 left with ICG

Oncological

• Parenchyma-sparing resection of bronchial carcinomas
  • For tumors < 2cm in tumor stages I and II
  • If a lobectomy cannot be performed due to limited lung function or comorbidities, anatomical segment resection is recommended.
• Removal of metastases and unconfirmed central nodules
   

Non-Oncological

Restricted to the corresponding segment:

• Infectious changes such as abscesses, mycetomas, aspergilloma, or cavities
• Post-inflammatory residues (e.g., after tuberculosis)
• Bronchiectasis

• 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 therapeutic plan 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: Especially to recognize anatomical norm variants of the bronchial system, a preoperative bronchoscopy by the surgeon is recommended.
     

Cardiopulmonary Capacity

The assessment of cardiopulmonary capacity 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 capacity (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)
    • If VO2max > 20ml/kg/BW (>75%), surgery up to pneumonectomy is possible from a lung function perspective.
    • If VO2max < 10ml/kg/BW (< 35%), surgery is contraindicated.

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

• Shaving of the left thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously about 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 explained:

• Bronchial stump insufficiency, bronchial fistula requiring intervention, possibly also re-operation
• Postoperative air fistula due to lesions of the lung parenchyma
• 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, particularly the trachea and main bronchi, large vessels, and the esophagus, necessitating corresponding extension of the procedure
• Damage to the phrenic nerve with diaphragmatic elevation 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: In case of oncological diagnosis, definitive radiochemotherapy

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

For standard positioning in minimally invasive thoracic surgical procedures (illustrated here for right-sided operations), the extended lateral position is recommended.

• 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 additionally use a shoulder support.

Finally, it is important to pad pressure-sensitive areas and place 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 any potential obstruction during the subsequent operation.

The arrangement (the image shows a right-sided operation) of the surgeon and assistant ventrally and opposite the OR 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 performed through the anterolateral minithoracotomy.

• Wound protection ring film (wound retractor)
• Standard VATS instrumentation with curved instruments
  • An ultrasonic scalpel can be helpful for bloodless and thus clear preparation.
• Endoscopic stapling device
  • Staple magazines with a curved tip assist in the gentle bypassing of smaller vessels.
  • In emphysematous lung tissue, reinforcement of the staple line 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 Treatment of Acute Perioperative and Posttraumatic Pain.

• Medical Follow-up
  • X-ray control on the operating table
  • Thoracic drainage with suction 20mmHg for approximately 2 days postoperatively, with secretion amount under 250ml/24h and without evidence of an air fistula, 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, taking into account 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

Full diet

• Bowel Regulation

Accompanying opioid analgesia

• Incapacity for Work

Approximately 14 days, considering the type of work and the patient's situation