doi:10.1510/mmcts.2004.000091
Intrapericardial pneumonectomy Erino A. Rendinaa,*, Fedrico Venutab, Mohsen Ibrahima a
Division of Thoracic Surgery, Sant’Andrea Hospital, University La Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy b
University of Rome, Division of Thoracic Surgery, Policlinico Umberto l, V.le del Policlinico 155, 00100 Rome, Italy Intrapericardial pneumonectomy is a major thoracic surgical procedure which is employed to resect locally advanced bronchogenic carcinoma. The procedure differs slightly in the left side than in the right side due to the anatomical differences of the two pulmonary hila and adjacent mediastinal structures. The common beginning of the operation is the longitudinal opening of the pericardium behind the phrenic nerve. On the left side, the pulmonary artery is dissected under the aortic arch and the ligamentum arteriosum is divided. Subsequently, the superior and inferior pulmonary veins are dissected and prepared intrapericardially and finally the bronchus is prepared posteriorly to the hilum. On the right side, the pulmonary artery is dissected from the superior vena cava and the procedure follows as on the left side. The mortality of intrapericardial pneumonectomy is in the range of 5–10% and the complication rate is about 20%.
Keywords: Pneumonectomy; Lung cancer Introduction Intrapericardial pneumonectomy is a major thoracic surgical procedure which is employed to resect locally advanced bronchogenic carcinoma or less frequently other thoracic neoplasms which deeply infiltrate into the pulmonary hilum and/or mediastinum. The main bronchus must be thoroughly explored by broncoscopy to rule out any infiltration beyond respectability. The procedure is usually performed through posterolateral or lateral thoracotomy, an approach by which the pulmonary hila and lateral aspect of the mediastinum are best exposed. For particular indications it can also be performed by median or transverse sternotomy. By this approach the exposure of the pulmonary artery is facilitated, but especially on the left * Corresponding author: Tel.: q39-06-8034 5650; fax q39-06-8034 5003. E-mail: [email protected] 䉷 2006 European Association for Cardio-thoracic Surgery
side the exposure of the inferior pulmonary vein can be difficult. Intrapericardial pneumonectomy differs slightly in the left side than in the right side due to the anatomical differences of the two pulmonary hila and adjacent mediastinal structures.
Surgical technique The technique described herein is performed through lateral thoracotomy either on the left or on the right side. Left intrapericardial pneumonectomy After thoracotomy has been performed in the 5th intercostal’s space, the lateral aspect of the mediastinum is approached. The pericardium is suspended by a clamp behind the phrenic nerve at the level of the superior pulmonary vein. The pericardium is then incised and the incision is continued upward toward 1
E.A. Rendina et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000091
Video 1. Left intrapericardial pneumonectomy. Opening of the pericardium; the pericardium is incised behind the phrenic nerve starting cranially by the scissors and proceeding downward by the electric scalpel.
Video 5. Left intrapericardial pneumonectomy. Suture and division of the pulmonary artery; an SCW45 vascular stapler (MMCTSLink 34) with a vascular cartridge is applied to the vessel and the artery is sutured and divided.
Video 2. Left intrapericardial pneumonectomy. After opening the pericardium, the pulmonary artery is prepared first. The vessel is dissected and encircled by an umbilical tape.
Video 6. Left intrapericardial pneumonectomy. Suture and division of the superior pulmonary vein by an SWC45 vascular stapler loaded with a vascular cartridge; the bronchus is dissected behind the stump of the vein.
The pulmonary artery, the pulmonary veins and the heart are inspected and palpated to ascertain the extension of the tumor; the pericardial fluid is collected for subsequent cytological examination. The pulmonary artery is then approached first (Video 2), it is dissected in and out of the pericardium and encircled by an umbilical tape. Video 3. Left intrapericardial pneumonectomy. Dissection in the sub-aortic window. This area is dissected taking care to identify and divide the ligamentum arteriosum and to identify and protect the left recurrent laryngeal nerve which lies in the operative field.
The lung is then retracted downward and the subaortic window is approached (Video 3). In this area, which is potentially infiltrated by the tumor, care must be taken to identify the ligamentum arteriosum, which must be divided, and the left recurrent laryngeal nerve which must be protected. The vagus nerve lies posteriorly in the operative field. If the tumor is present in this area, it must be resected en bloc with the pulmonary hilum, following a sub-adventitial plane on the hollow side of the aortic arch.
Video 4. Left intrapericardial pneumonectomy. Dissection of the superior and inferior pulmonary veins; the two veins are dissected free and encircled by umbilical tapes.
After the preparation of the upper portion of the pulmonary hilum is completed, the superior and inferior pulmonary veins are approached (Video 4). The superior pulmonary vein is dissected separating its posterior wall from the bronchus, while the inferior pulmonary vein is prepared after sectioning the pulmonary ligament.
the pulmonary artery and downward toward the inferior pulmonary vein (Video 1).
The vascular elements of the hilum are now under control, and the resection phase can begin; the bronchus can be prepared either at this point or after all
2
E.A. Rendina et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000091 The bronchus is subsequently approached; it is elevated by retracting the whole lung up, and all adhesions are divided. At this point the position of the endobronchial tube must be checked and the tube is eventually withdrawn if needed. Subsequently the TX30 linear stapler (MMCTSLink 85) is applied (Video 8), the bronchus is divided and the lung is removed (Video 9). Video 7. Left intrapericardial pneumonectomy. Suture and division of the inferior pulmonary vein by an SWC45 vascular stapler loaded with a vascular cartridge.
Video 8. Left intrapericardial pneumonectomy. Suture and division of the left main bronchus by a TX30 linear stapler (MMCTSLink 85) loaded by a green (4.5 mm) cartridge.
Video 9. Left intrapericardial pneumonectomy. The pulmonary hilum after the lung is removed and the pericardial opening are shown.
Video 10. Right intrapericardial pneumonectomy. The pulmonary artery is sutured and divided behind the superior vena cava and below a hypertrophic azygos vein; the left atrium is sutured and sectioned after the confluence of the two pulmonary veins (the two veins are sutured together); the bronchus is sutured and the lung is removed. Note the hypertrophic azygos vein.
the vascular elements have been divided. The pulmonary artery (Video 5), the superior pulmonary vein (Video 6) and the inferior pulmonary vein (Video 7) are then sutured and divided by a mechanical stapler.
Right intrapericardial pneumonectomy On the right side the procedure is similar to that of the left, except there are important differences especially concerning the anatomy of the right pulmonary artery and its relationship to the main bronchus and superior vena cava. The incision of the pericardium follows the same patterns as on the left side, but on the right the superior vena cava is retracted medially and the pulmonary artery is prepared either behind the cava or, if the tumor does not give enough space, medially to the vein, between the superior vena cava and the ascending aorta. The pulmonary veins are prepared and encircled by umbilical tapes individually, or, as shown in Video 10, the left atrium is prepared and sutured after the confluence of the two pulmonary veins. The rest of the procedure is similar to that of the left side. After the procedure the pericardial defect can be either left open, or closed by interrupted sutures to prevent cardiac herniation if the anatomy requires it. Also, the bronchial stump can be either left as is, or protected by a tissue flap according to the surgeon’s preference.
Results As previously reported, the techniques for intrapericardial pneumonectomy vary on the left and on the right side. Accordingly, the technique for lymphoadenectomy varies on the two sides. Since intrapericardial pneumonectomy is performed mostly for cancer, lymphoadenectomy plays an important role: on the right side radical lymphoadenectomy should incorporate hilar (stations 10 and 11) paraesophageal (station 8), pulmonary ligament (station 9), subcarinal (station 7) and paratracheal (stations 4 and 2) nodes. On the left side in addition to these stations, also the pre- and para-aortic and pulmonary windows nodes (stations 3, 5 and 6) should be resected. The protection of the bronchial stump is also an important issue: the bronchus can be either left uncovered, or protected by mediastinal tissue, intercostal muscle or omental flap. This is left to the surgeon’s preference and to the presence of coexisting risks, like for 3
E.A. Rendina et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000091 example, preoperative induction chemo or chemoradiotherapy. The mortality of intrapericardial pneumonectomy is in the range of 5–10% and the complication rate about 20% w1,2x. Among medical complications, the most frequent are tachyarrhythmias which appear in about 20% of the patients. The most dreaded complication, specific to this operation, is cardiac herniation through the pericardial opening. Care must be taken to close the pericardial defect if this is anatomically relevant. This can be done by direct suture when possible or by the use of a patch (bovine pericardium or PTFE).
4
Other post pneumonectomy complications are similar to those occurring after standard pneumonectomy.
References w1x Rice TW. Techniques of pneumonectomy. Standard Pneumonectomy. Chest Surg Clin N Am 1999;9:353–368. w2x Bernard A, Deschamps C, Allen MS, Miller DL, Trastek WF, Jenkins GD, Pirolero PC. Pneumonectomy for malignant disease: factors affecting early morbidity and mortality. J Thorac Cardiovasc Surg 2001;121:176–182.
Intrapericardial pneumonectomy Erino A. Rendinaa,*, Fedrico Venutab, Mohsen Ibrahima a
Division of Thoracic Surgery, Sant’Andrea Hospital, University La Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy b
University of Rome, Division of Thoracic Surgery, Policlinico Umberto l, V.le del Policlinico 155, 00100 Rome, Italy Intrapericardial pneumonectomy is a major thoracic surgical procedure which is employed to resect locally advanced bronchogenic carcinoma. The procedure differs slightly in the left side than in the right side due to the anatomical differences of the two pulmonary hila and adjacent mediastinal structures. The common beginning of the operation is the longitudinal opening of the pericardium behind the phrenic nerve. On the left side, the pulmonary artery is dissected under the aortic arch and the ligamentum arteriosum is divided. Subsequently, the superior and inferior pulmonary veins are dissected and prepared intrapericardially and finally the bronchus is prepared posteriorly to the hilum. On the right side, the pulmonary artery is dissected from the superior vena cava and the procedure follows as on the left side. The mortality of intrapericardial pneumonectomy is in the range of 5–10% and the complication rate is about 20%.
Keywords: Pneumonectomy; Lung cancer Introduction Intrapericardial pneumonectomy is a major thoracic surgical procedure which is employed to resect locally advanced bronchogenic carcinoma or less frequently other thoracic neoplasms which deeply infiltrate into the pulmonary hilum and/or mediastinum. The main bronchus must be thoroughly explored by broncoscopy to rule out any infiltration beyond respectability. The procedure is usually performed through posterolateral or lateral thoracotomy, an approach by which the pulmonary hila and lateral aspect of the mediastinum are best exposed. For particular indications it can also be performed by median or transverse sternotomy. By this approach the exposure of the pulmonary artery is facilitated, but especially on the left * Corresponding author: Tel.: q39-06-8034 5650; fax q39-06-8034 5003. E-mail: [email protected] 䉷 2006 European Association for Cardio-thoracic Surgery
side the exposure of the inferior pulmonary vein can be difficult. Intrapericardial pneumonectomy differs slightly in the left side than in the right side due to the anatomical differences of the two pulmonary hila and adjacent mediastinal structures.
Surgical technique The technique described herein is performed through lateral thoracotomy either on the left or on the right side. Left intrapericardial pneumonectomy After thoracotomy has been performed in the 5th intercostal’s space, the lateral aspect of the mediastinum is approached. The pericardium is suspended by a clamp behind the phrenic nerve at the level of the superior pulmonary vein. The pericardium is then incised and the incision is continued upward toward 1
E.A. Rendina et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000091
Video 1. Left intrapericardial pneumonectomy. Opening of the pericardium; the pericardium is incised behind the phrenic nerve starting cranially by the scissors and proceeding downward by the electric scalpel.
Video 5. Left intrapericardial pneumonectomy. Suture and division of the pulmonary artery; an SCW45 vascular stapler (MMCTSLink 34) with a vascular cartridge is applied to the vessel and the artery is sutured and divided.
Video 2. Left intrapericardial pneumonectomy. After opening the pericardium, the pulmonary artery is prepared first. The vessel is dissected and encircled by an umbilical tape.
Video 6. Left intrapericardial pneumonectomy. Suture and division of the superior pulmonary vein by an SWC45 vascular stapler loaded with a vascular cartridge; the bronchus is dissected behind the stump of the vein.
The pulmonary artery, the pulmonary veins and the heart are inspected and palpated to ascertain the extension of the tumor; the pericardial fluid is collected for subsequent cytological examination. The pulmonary artery is then approached first (Video 2), it is dissected in and out of the pericardium and encircled by an umbilical tape. Video 3. Left intrapericardial pneumonectomy. Dissection in the sub-aortic window. This area is dissected taking care to identify and divide the ligamentum arteriosum and to identify and protect the left recurrent laryngeal nerve which lies in the operative field.
The lung is then retracted downward and the subaortic window is approached (Video 3). In this area, which is potentially infiltrated by the tumor, care must be taken to identify the ligamentum arteriosum, which must be divided, and the left recurrent laryngeal nerve which must be protected. The vagus nerve lies posteriorly in the operative field. If the tumor is present in this area, it must be resected en bloc with the pulmonary hilum, following a sub-adventitial plane on the hollow side of the aortic arch.
Video 4. Left intrapericardial pneumonectomy. Dissection of the superior and inferior pulmonary veins; the two veins are dissected free and encircled by umbilical tapes.
After the preparation of the upper portion of the pulmonary hilum is completed, the superior and inferior pulmonary veins are approached (Video 4). The superior pulmonary vein is dissected separating its posterior wall from the bronchus, while the inferior pulmonary vein is prepared after sectioning the pulmonary ligament.
the pulmonary artery and downward toward the inferior pulmonary vein (Video 1).
The vascular elements of the hilum are now under control, and the resection phase can begin; the bronchus can be prepared either at this point or after all
2
E.A. Rendina et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000091 The bronchus is subsequently approached; it is elevated by retracting the whole lung up, and all adhesions are divided. At this point the position of the endobronchial tube must be checked and the tube is eventually withdrawn if needed. Subsequently the TX30 linear stapler (MMCTSLink 85) is applied (Video 8), the bronchus is divided and the lung is removed (Video 9). Video 7. Left intrapericardial pneumonectomy. Suture and division of the inferior pulmonary vein by an SWC45 vascular stapler loaded with a vascular cartridge.
Video 8. Left intrapericardial pneumonectomy. Suture and division of the left main bronchus by a TX30 linear stapler (MMCTSLink 85) loaded by a green (4.5 mm) cartridge.
Video 9. Left intrapericardial pneumonectomy. The pulmonary hilum after the lung is removed and the pericardial opening are shown.
Video 10. Right intrapericardial pneumonectomy. The pulmonary artery is sutured and divided behind the superior vena cava and below a hypertrophic azygos vein; the left atrium is sutured and sectioned after the confluence of the two pulmonary veins (the two veins are sutured together); the bronchus is sutured and the lung is removed. Note the hypertrophic azygos vein.
the vascular elements have been divided. The pulmonary artery (Video 5), the superior pulmonary vein (Video 6) and the inferior pulmonary vein (Video 7) are then sutured and divided by a mechanical stapler.
Right intrapericardial pneumonectomy On the right side the procedure is similar to that of the left, except there are important differences especially concerning the anatomy of the right pulmonary artery and its relationship to the main bronchus and superior vena cava. The incision of the pericardium follows the same patterns as on the left side, but on the right the superior vena cava is retracted medially and the pulmonary artery is prepared either behind the cava or, if the tumor does not give enough space, medially to the vein, between the superior vena cava and the ascending aorta. The pulmonary veins are prepared and encircled by umbilical tapes individually, or, as shown in Video 10, the left atrium is prepared and sutured after the confluence of the two pulmonary veins. The rest of the procedure is similar to that of the left side. After the procedure the pericardial defect can be either left open, or closed by interrupted sutures to prevent cardiac herniation if the anatomy requires it. Also, the bronchial stump can be either left as is, or protected by a tissue flap according to the surgeon’s preference.
Results As previously reported, the techniques for intrapericardial pneumonectomy vary on the left and on the right side. Accordingly, the technique for lymphoadenectomy varies on the two sides. Since intrapericardial pneumonectomy is performed mostly for cancer, lymphoadenectomy plays an important role: on the right side radical lymphoadenectomy should incorporate hilar (stations 10 and 11) paraesophageal (station 8), pulmonary ligament (station 9), subcarinal (station 7) and paratracheal (stations 4 and 2) nodes. On the left side in addition to these stations, also the pre- and para-aortic and pulmonary windows nodes (stations 3, 5 and 6) should be resected. The protection of the bronchial stump is also an important issue: the bronchus can be either left uncovered, or protected by mediastinal tissue, intercostal muscle or omental flap. This is left to the surgeon’s preference and to the presence of coexisting risks, like for 3
E.A. Rendina et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000091 example, preoperative induction chemo or chemoradiotherapy. The mortality of intrapericardial pneumonectomy is in the range of 5–10% and the complication rate about 20% w1,2x. Among medical complications, the most frequent are tachyarrhythmias which appear in about 20% of the patients. The most dreaded complication, specific to this operation, is cardiac herniation through the pericardial opening. Care must be taken to close the pericardial defect if this is anatomically relevant. This can be done by direct suture when possible or by the use of a patch (bovine pericardium or PTFE).
4
Other post pneumonectomy complications are similar to those occurring after standard pneumonectomy.
References w1x Rice TW. Techniques of pneumonectomy. Standard Pneumonectomy. Chest Surg Clin N Am 1999;9:353–368. w2x Bernard A, Deschamps C, Allen MS, Miller DL, Trastek WF, Jenkins GD, Pirolero PC. Pneumonectomy for malignant disease: factors affecting early morbidity and mortality. J Thorac Cardiovasc Surg 2001;121:176–182.
