Pneumonectomy

What is a Pneumonectomy?

Definition: A pneumonectomy is a surgical procedure that involves the removal of the entire lung. See Figure 1. Lung cancer is the most common reason for this procedure. This procedure is typically done if the tumor is close to the center of the chest and therefore other types of lung resection, such as lobectomy, cannot be completed. It is important that all diseased tissue be removed from the body and sometimes this cannot be done unless the entire lung is removed. Pneumonectomy is the removal of the entire lung, right or left.

A pneumonectomy can only be completed through a thoracotomy incision. A thoracotomy is a surgical procedure in which a large cut is made between the ribs to see and reach the lung. This type of incision is made on either the right or left side of the chest, depending on which lung is to be removed. A thoracotomy requires rib spreading and a large 4- to 6-inch incision to gain access to view and treat the lungs. See Figure 2. A thoracotomy is performed for treatment of disease (typically lung cancer) and allows the surgeon to visualize, biopsy or remove tissue. During the operation, the affected lung will be collapsed, and the attached blood vessels and bronchus (airway that supplies the lung with oxygen) will be divided with a special stapling device. The diseased lung can then be removed through the incision.

Preparation for Surgery

Most importantly, if you currently smoke, we strongly recommend that you stop at least three weeks prior to your scheduled procedure. Your risk of post-operative complications is drastically increased if you continue to smoke up until the day of your surgery.

You will most likely be required to have some testing completed prior to your lung resection surgery. Some of these tests include a breathing test (pulmonary function test), EKG (heart tracing), cardiac stress test, echocardiogram, and blood work.

You will not be able to have anything to eat starting at midnight before your operation. You can have clear liquids, such as water or black coffee, up until 2 hours prior to your procedure. You will be given a pamphlet with more details regarding this. If you take medications routinely at home, we will discuss which of these you can take before your operation and which you cannot. Prior to your surgery, after you have been put to sleep, a catheter will be inserted into your bladder to monitor your urine output during and after the surgery.

Pain management is achieved with a combination of intravenous and oral pain medications. The surgeon will also place a nerve block in the chest wall area that ideally lasts for three days after surgery. A thoracotomy incision is typically very painful but with this type of pain control, most patients receive adequate relief of pain. You will be transitioned to pain medication by mouth as you prepare for discharge from the hospital.

After your Surgery

After your surgery has been completed, you will be taken to the intensive care unit (ICU). The nursing staff will monitor your vital signs (blood pressure, breathing rate, oxygen levels, heart rate) and make sure that you are comfortable. You will wake up with 1-2 chest tubes in place. Patients will remain in the ICU for the first night following surgery. Typically, patients undergoing pneumonectomy are transferred out of the ICU the day after surgery. You will then be brought to the step-down unit (2 South) for the rest of your hospital stay.

You will be given supplemental oxygen to help you breathe. You will also be receiving fluids through your IV. You will be able to drink and eat as soon as you can tolerate. The urinary catheter will typically remain in place until the removal of the epidural catheter. The chest tubes will remain in place for 24-48 hours. You will be getting many chest x-rays while you are in the hospital, so expect to be awoken early in the morning for this to be completed. You will be instructed on breathing exercises to prevent any chest infections. You will also be encouraged to walk in the hallway and exercise your legs to prevent any blood clots from forming. Walking is very important, and you will be encouraged to get out of bed the same day as your surgery.

Pain Control: Following your procedure you should expect to have pain, particularly with this type of incision. The rib spreading that is needed to gain access inside the chest is typically what causes the most discomfort in the post-operative period. You will have an epidural catheter placed in your back prior to your surgery to help with pain control after your surgery. We will also control your pain with a multi-modal regimen including Tylenol, Gabapentin (helps nerve pain), and Celebrex (anti-inflammatory). You will also be given a narcotic pain medication as needed. We try and keep IV pain medication to a minimum, but each patient is different, and we will adjust pain medications as needed.

General Care: You will be expected to start walking usually the night of surgery. The incision site dressings will be removed in the office at your follow-up appointment. Once your chest tubes are removed, you can shower daily and are encouraged to do so. The hospital stay for patients who undergo a pneumonectomy is typically 3 to 5 days.

Going Home: You may require home oxygen use temporarily. This will be determined at the time of discharge. You may go home with a small chest drain that will be removed in the outpatient clinic. We will discuss with you activity level, lifting restrictions, driving, and when you may return to work. Walking is highly encouraged. You may also climb stairs.

Risks and Possible Complications

With any surgical procedure, there are certain risks. These risks will depend on your health before undergoing the operation. Your surgeon will discuss these risks with you in detail.

Sore throat: It is normal to have a sore throat following surgery. It is a result of being under anesthesia and from having a breathing tube during the operation. This should get better shortly after surgery.

Changes in blood pressure/heart rate: Sometimes heart rhythm abnormalities occur after major surgery. The most common heart arrhythmia is atrial fibrillation. You will be given a beta-blocker medication, Metoprolol, in the hospital and at discharge to prevent any irregular heart rhythms or heart rates. This is usually stopped two weeks after discharge. If you are already on a beta-blocker, it is important that you take it the morning of surgery. After discharge, we encourage you to check your heart rate and blood pressure daily before taking your beta-blocker medication, Metoprolol.

Coughing up blood (Hemoptysis): It is normal to cough up small amounts of blood tinged sputum (usually the size of a quarter) for the first few days after lung resection surgery. Any blood tinged sputum after pneumonectomy needs to be communicated to your surgeon.

Chest infection/Pneumonia: Breathing exercises, walking, getting out of bed and adequate pain control will reduce the risk of a chest infection. Your chance of pneumonia is 80% higher if you are a current smoker. If you do develop pneumonia, you may need treatment with an antibiotic and your hospital stay may be longer.

Bronchopleural fistula: This is an opening between the bronchus (airway) that was divided during the surgery and the pleural space. This is a serious complication following a pneumonectomy and often requires another surgical procedure to close the fistula.

Heart attack or stroke: This can occur during or after any surgery, the risk is higher in patients with a cardiac history or undiagnosed cardiac disease. For this reason, every patient will have a cardiac work-up completed prior to your procedure.

Discharge

Your follow-up will be scheduled prior to you leaving the hospital, you will be seeing an advanced practice provider at your initial post-operative visit. You will be asked to get a chest x-ray completed at Medical Imaging of Fredericksburg prior to your appointment (that same day).