Right upper lobectomy

Pneumonectomy is an effective treatment for certain intrapulmonary or bronchial diseases. Depending on the nature, extent of the lesion and the patient's lung function, all lungs on one side (ie, pneumonectomy) can be removed; partial lung resection (including lobectomy, segmentectomy, or wedge resection) can also be performed; Lung lobe, or lung lobe plus lung segment (or wedge) resection; sometimes can be used for one or two (or staging) bilateral lung lobe or segmentectomy. For some patients, the mediastinal lymph nodes, pleural wall layer or part of the diaphragm are often removed while the lung or whole lung is being removed. In principle, the scope of lung resection should be sufficient, so that the lesions in the lungs are completely removed, and no recurrence can be left; but as little as possible, the normal lung tissue should be preserved as much as possible to maintain better lung function. Treatment of diseases: bronchial tuberculosis Indication 1. Pulmonary laceration: severe lung laceration, can not be repaired, should be used for local lobectomy or pneumonectomy. 2. Bronchopulmonary tumors: The opinions on the scope of resection of malignant tumors have not been consistent. Most people believe that as long as there is no distant metastasis, the lymph nodes of one or two lobe and hilar, paratracheal and subcarinal lobe where the tumor is located are removed. The same effect as pneumonectomy can be obtained, but the surgical damage and complications can be reduced, and the postoperative lung function can be preserved more. For metastatic cancer that is confined to one leaf, or if the nature of the tumor is undetermined and cannot be ruled out as a benign tumor or tuberculoma, lobectomy should be performed. In summary, when considering the scope of resection, the type, location, metastasis, respiration, circulatory function, and patient's tolerance to surgery should be fully estimated. Such as lung cancer patients have cachexia, severe chest pain, fever; X-ray examination showed that the protuberance has been widened, the cancer shadow and the chest wall or mediastinum have been connected, no gap, or see pleural effusion; bronchoscopy see protuberance Widening and fixation, the tumor is less than 2cm from the bulge; the lactate dehydrogenase is more than 400 units, and the possibility of surgical resection is small, or can not be removed. If lung cancer has distant metastasis, or has invaded the phrenic nerve, recurrent laryngeal nerve and mediastinal vessels, contraindications are contraindicated. 3. Tuberculosis: Surgical treatment of tuberculosis is an integral part of the comprehensive treatment of tuberculosis and is only suitable for some patients with tuberculosis. Appropriate timing should be chosen and must be closely coordinated with other therapies to reduce treatment time, expand treatment coverage, and reduce recurrence rates. When selecting a treatment, the patient's general condition, type of disease, progression of the disease, and response to previous treatments must be fully considered and carefully determined based on the positive and lateral radiographs of the x-ray within the last 3 weeks. Under normal circumstances, patients with tuberculosis should first undergo a certain period of drug treatment, such as the lesion can not be cured, but suitable for surgery, that is, surgery should be timely, do not wait until all anti-tuberculosis drugs are ineffective after trial, so as not to miss the opportunity. In addition, when considering the surgical method, it is necessary to estimate the surgical effect, the burden of the patient, the degree of loss of lung function, and the possibility of recurrence of the residual lung lesion, and the safest, simplest, and effective surgery. At present, the risk and complications of pneumonectomy have been greatly reduced, but those who are not suitable for pneumonectomy should not be forced to use it. (1) Tuberculosis ball: The diameter is more than 2cm, and the drug treatment does not disappear after more than 6 months. Even if the center finds liquefied cavity or has an expanding trend, it should be removed. If the nature of the spherical lesion is not certain, it should not be waited for, and the surgery should be performed immediately. (2) Cheese lesions: cheese lesions or a pile of cheese lesions greater than 2cm, drug treatment for 6 months to more than 1 year is invalid, continue to sterilize, surgery should be considered. (3) Cavity: due to bronchial tuberculosis caused by granulation hyperplasia or scarring caused by stenosis, the distal cavity forms a tension cavity; or because of the long time of the lesion, the fibrous tissue around the cavity proliferates, forming thick-walled cavities, should be removed. Generally, the cavity is still not closed after the drug is actively treated for 6 months to 1 year. Regardless of whether or not the sputum is sterilized, surgery should be considered to avoid hemoptysis and dissemination in the future. (4) bronchial tuberculosis: active treatment of drugs for 6 months to more than 1 year of ineffective, even due to stenosis (or complete obstruction) caused by atelectasis; or due to extensive wall destruction, the formation of bronchiectasis, should be removed. (5) Destroy the lung: All or most of the lungs of one or one lobe are destroyed, forming cheese lesions, cavities, lung atrophy, fibrosis, bronchiectasis, emphysema, etc., should be considered for resection. If there are lesions such as cheese lesions, tuberculoma or cavities on the contralateral side, surgical problems should be carefully studied. (6) After the surgical collapse therapy, the cavity is still not closed in June to 1 year, and the acid-fast bacteria positive or intermittent positive is detected. When the patient's general health condition permits, the lung resection can be performed again. 4. Bronchiectasis: Bronchial angiography confirms the limitation of the lesion. If there are obvious symptoms, the diseased lung segment, lung lobe or whole lung should be surgically removed. If the symptoms are not obvious, surgery is not necessary. Such as bilateral bronchus have localized lesions, and the scope is small, can be resected, first cut the heavier side of the lesion; if there are still symptoms after surgery, confirmed by contrast from the contralateral side, and then the second surgery . The scope is too broad, and those who have no chance of surgery can only use body position drainage and Chinese and Western medicine treatment. 5. Lung abscess: After active medical treatment for more than 3 months, clinical symptoms and x-ray films are not improved, should be used for lobectomy or pneumonectomy. Because the range of inflammation is often extensive, it is not appropriate to consider the removal of the lung segment to avoid residual lung disease. For some extremely weak patients, the symptoms of poisoning are serious, can not tolerate lung surgery and the lesions are located in the superficial part of the lungs, and can be used for incision and drainage. 6. Others: Congenital pulmonary cysts, pulmonary bullae or pulmonary isolation, if symptoms appear, should be used for lung, lung or partial resection. All types of patients above should be tested for lung function before deciding on a pneumonectomy. If the preoperative lung capacity and maximum ventilation account for more than 60% of the predicted value, the lung surgery is safer, and those who are below 60% should be treated with caution. In addition, if the patient has chronic heart and renal insufficiency, it will be difficult to tolerate surgery. Preoperative preparation 1. For patients with lung resection, the history of respiratory diseases should be inquired in detail, respiratory function should be checked, and pulmonary function tests should be performed if necessary to correctly estimate postoperative respiratory function. 2. Tuberculosis patients, especially those with irritating cough and sputum acid-fast bacteria, should be examined by bronchoscopy to determine whether the mucosa of the bronchial stump to be resected is normal, so as to avoid bronchial tuberculosis due to residual endobronchial tuberculosis. Serious complications such as pleural fistula and empyema. 3. For patients with pulmonary suppuration (including bronchiectasis), positional drainage should be strengthened, and appropriate antibiotics should be used according to the results of sputum culture and antibiotic susceptibility test, and the daily sputum should be minimized (preferably at 50 ml). the following. Surgical procedure 1. Although only the upper lobe is removed, all the adhesions of the right lung and the pleura should be separated to facilitate the expansion of the lung. The right lung is pulled down, the mediastinal pleura around the upper part of the hilar is cut, the mediastinal connective tissue is separated at the lower edge of the superior vein into the superior vena cava, and the vagus nerve branch and accompanying small blood vessels are cut and ligated to reveal the right pulmonary artery trunk and The branch of the anterior segment of the upper tip divides, ligates, sews and cuts the branch of the anterior segment. 2. The tip and anterior segments of a small number of patients are separated from the trunk and should be cut off separately. The branch of the pulmonary vein is located on the anterior side of the anterior tip of the anterior segment, affecting the operation of the anterior segment of the apex. The apical vein can be cut first, or the artery can be treated after cutting the superior vein. The upper lobe is pulled upward, the middle and lower leaves are pulled downward, and the inter-leaf pleura is cut near the junction of the upper, middle and lower lobe. The anterior segment of the right upper lobe can be exposed 1 to 3, respectively, and ligated. Stitching and cutting. Sometimes the posterior segment of the artery can come from the dorsal artery of the lower lobe and should be ligated and cut. Pulmonary insufficiency between the upper and middle lobe, or adhesion is very tight and can not be separated, can be separated in the sheath along the main trunk of the pulmonary artery, can reveal the posterior segment of the upper lobe artery. 3. If it still cannot be revealed, the upper bronchus can be cut off from the posterior side, and the distal bronchus is clamped with tissue clamps, and then pulled downward (to simultaneously inflate the middle and lower leaves to see the interlobular fissure). , cut, sutured, along the main trunk of the pulmonary artery for intrathecal separation, you can see the posterior segment of the artery, and then ligation, suture and cut. In the anterior aspect of the hilar and the posterior aspect of the phrenic nerve, the right superior pulmonary vein is exposed, and the superior vein is separated (be careful not to damage the posterior arterial trunk when separating), and the middle vein is retained. According to the length of the upper venous trunk, a ligation or a ligation of the tip, the anterior and posterior segment of the vein, and the suture are cut. 4. The upper bronchus is located on the posterior side of the right pulmonary artery. After separation with a small gauze ball and a curved hemostatic forceps, the upper bronchial artery is sutured. On the separated bronchi, first gently clamp a bronchial forceps, inflate the lungs with an anesthesia machine, and prove that the right upper lobe is clamped, clamp the bronchial forceps, pull the line, cut and suture the bronchial stump, and remove the disease. lung. After examination for no leaks or bleeding, the suture was covered with connective tissue around the mediastinal pleura or azygous vein.