(a, b) Repair of pulmonary laceration. Main sketch: wedge excision with stapler
If you decide to also access the opposite thoracic cavity, you can proceed by transecting the sternum. Remember always to ligate the internal mammary arteries. Sometimes due to severe hypovolemia, they are not actively bleeding during the operation just to start to bleed in the postoperative care unit.
36.5 Injuries to the Lung Parenchyma
On performing surgery on the chest, it is advisable to isolate the respective lung by inserting a double-lumen endotracheal tube.
When treating bleeding from the lung parenchyma, always try to use the technique with the least possible physiological insult. The inflated lung can easily be injured if you handle it forcefully. Always use a big gauze and your palms when handling the lungs. If needed, divide the inferior pulmonary ligament by concurrently palpating and freeing the ligament between your thumb and index finger by a gentle rolling action. Avoid excessive pulling and jerking.
Superficial parenchymal lacerations are preferably managed but not obligatory with the lung isolated and deflated by clamping the hilum. This avoids any unnecessary tears of the friable parenchyma during suturing. The laceration depending on the extent can be repaired with either pledgetted 4/0/Prolene SH (larger needle) or a running suture in two layers, firstly a horizontal mattress followed by an ‘over-and-over’ suture. Open superficial missile tracts with electrocautery and ligate individual vessels individually with ties or Ligaclips depending on their size. Open bronchioles are ligated for control. Do not close and liberally irrigate. You can also manage peripheral injuries with a stapled wedge resection either with GIA (newer products available are also reinforced with pericardium – this adds to the integrity of the stapled surface and reduces the incidence of air leaks postoperatively especially if your patients will be ventilated receiving the additional insult of positive pressure ventilation) or TA stapler . Avoid the use of staplers with a fully inflated lung. Ask the anaesthetist to stop ventilating the lung; apply pressure to partially deflate it, and then staple. Then check the staple line for bleeding and air leaks, and if necessary reinforce it with a figure-of-eight suture of Prolene (less friction in the easily lacerated lung parenchyma). An alternative to this technique is to use two soft bowel clamps wedged on either side of the part of the lung to be resected. A mattress suture is used under the clamp and the repair is then completed by a continuous locking stitch at the resected end (Fig. 36.2).
Wedge excision using soft bowel clamps
Deep parenchymal laceration can be controlled by a non-anatomic exposure of the laceration tract by tractotomy. Insert clamps or the limb of a linear stapling device (GIA) along the tract and divide it (Fig. 36.3). Before using the staplers, ask the anaesthetist to stop ventilating the lung and apply pressure to partially deflate it. If the vessels or small bronchi are not effectively included in the suture line, oversew them by figure-of-eight monofilament sutures such as polypropylene. Always be aware that when the lung reinflates, the staples may give way. In those cases, overrun the suture line with a continuous locking suture. Beware of placing superficial sutures in deep lacerations that are bleeding, as this can lead to an intrapulmonary haematoma, infection and air embolism.
(a, b) Insert: bullet track in pulmonary tissue. Main sketch: tractotomy using staplers
36.7 Gunshot Injuries
Low energy missile injuries are treated as above, usually necessitating a tractotomy. High-energy missile injuries of the thorax are increasing in frequency with worldwide conflicts. The characteristics of these injuries are different to normal low-velocity handgun injuries and thus should be managed by aggressive intervention. Conservative therapy in these cases has reported high mortality rates. As these injuries result in the release of high kinetic energy, the destructive force produces massive pulmonary disruption with cavitation, haemorrhage and V/Q shunting (Fig. 36.4). Non anatomical lobectomy of the affected lung parenchyma in the presence of physiological instability or anatomical resection if the patient is physiologically stable is the treatment of choice.
Chest x-ray showing a high energy bullet tract causing lung contusion. There is also subcutaneous emphysema present
36.8 Pulmonary Resections
Central injuries may need anatomical lobectomy. Very rarely a pneumonectomy might be needed. The mortality rate in the latter is high.
Intubate with double lumen endotracheal tube if time permits. It is imperative to gain access of the pulmonary vasculature. Remember that both the arteries and veins are fragile and tear easily. Use large gauze on the palms when manipulating the lungs to facilitate traction. Open the adventitial plane anterosuperiorly to isolate either the right or the left pulmonary artery. This is achieved with blunt dissection using an angled Lahey and is encircled with No. 1 tie. This is a life-saving manoeuvre should there be any further injury to the vasculature while mobilising. Isolating the left pulmonary artery is different as one has to dissect inferior to the aortic arch. Look for the left recurrent laryngeal nerve that is in close proximity. Identify the segmental branches, and ligate depending on which lobe is to be resected with a vascular clamp and oversewn with 3-0 monofilament as a running over-and-over stitch, together with two proximal suture ligatures that overlap. The assistant must relax the traction of the lung when these ligatures are being tied. You can alternatively use vascular staples.
Division of the bronchus must be close to the trachea or adjacent lobar bronchus to avoid future formation of a bronchopleural fistula. This can be closed either with staples or sutures. If with sutures, use simple interrupted absorbable sutures of your choice. Try and cover the bronchial stump with a pleural flap or other tissues if possible.