# 60  T_h e thorax

# Anatomy of the lungs

Anatomy of the lungs

The left lung is divided by the oblique fissure, which lies nearer to the vertical than horizontal, so the upper and lower lobes could also be called anterior and posterior. On the right, the equivalent of  the left upper lobe is further divided to give the middle lobe. Each lobe is composed of  segments, with anatom ically defined and named bronchial, pulmonary arterial and venous connections ( Figure 60.1 ). The right main bronchus (RMB) is shorter, wider and nearly vertical compared with the left main bronchus (LMB). As a consequence, inhaled foreign bodies are mor e likely to enter the RMB than the left ( Figure 60.2 ). The trachea and bronc hi have a systemic arterial blood supply delivered by the bronchial arteries, which arise directly from the nearby tho racic aorta. Lymphatic drainage tends to follow the bronchi. Lymph nodes are both named and identified by numbered ‘stations’ and more recently into zones, which are of  importance in stag ing of  lung cancer ( Figure 60.3 ). - 

The assessment of patients requiring lung surgery
•
Surgical oncology as applied to chest surgery
•
Chest wall disorders
•
Posterio
r
A
nterior
Right upper lobe
Posterior
Apical
Anterior
Right lower lobe
Horizontal
/f_i
ssu
re
Apical
Middle lobe
Medial
Posterior
Basal
Lateral
Lateral
Oblique
/f_i
ssure
Anterior
Posterio
r
A
nterior
Left upper lobe
Oblique
/f_i
ssure
Posterior
Apical
Left lower lobe
Anterior
Apical
Superior lingular
Anterior
Basa
l
Inferior lingular
Lateral
Posterior
Figure 60.1
The lobar and segmental divisions of the lungs, right lung
above and left lung below as if viewed from the side.

# BENIGN LUNG TUMOURS

BENIGN LUNG TUMOURS

Benign tumours of  the lung are uncommon and account for fewer than 15% of  solitary lesions seen on chest radiographs. A peripheral tumour usually causes no symptoms until it is large; a central tumour may present with haemoptysis and signs of bronchial obstruction while still small. A tumour is likely to be benign if  it has not increased in size on chest radiographs for more than 2 years or it has some degree of  calcification; however, a tissue diagnosis is usually pursued. Most benign nodules are granulomas (tuberculosis or his - toplasmosis). The most common benign tumour is a hamar - toma, a developmental abnormality containing mesothelial and endothelial elements. Diagnosis (and definitive treatment) is achieved by excision of  the lesion. Any of  the mesodermal elements of  the lung may for m a mesodermal tumour (chon - droma, lipoma, leiomyoma). Deposits of  amyloid may have a similar radiographic appearance to a nodule (pseudotumour).

# CHEST TRAUMA

CHEST TRAUMA

The approach to trauma must be methodical and exact because the signs, particularly in the presence of  other injury , - . - 

(a)
(b)
Figure 60.27
(a)
A large solitary bulla seen on videothoracoscopy.
(b)
The bulla de
/f_l
ated and rolled in preparation for staple resection.
/uni00A0

and ATLS (Advanced Trauma Life Support) must be followed. Thoracic trauma is responsible for over 70% of  all deaths following road tra ffi c accidents. Blunt trauma to the chest in isolation is fatal in 10% of  cases, rising to 30% if  other injuries are present. The indications for emergency room thoracot omy in blunt chest trauma include massive haemothorax, sus pected cardiac tamponade and witnessed cardiac arrest in the resuscitation area. Success rates are low . Penetrating thoracic wounds vary according to the prevalence of  civil violence a mortality rate of  3% for simple stabbing to 15% for gunshot wounds. The indications for emergency room thoracotomy are similar to those for blunt chest trauma. The standard approach is a left anterior thoracotomy , unless the penetrating injury is in the right chest; however, it may be necessary to extend the incision to bilateral thoracotomies or a clam-shell incision.

# DISORDERS OF THE CHEST WALL Tumours of the chest w

DISORDERS OF THE CHEST WALL Tumours of the chest wall

These can be tumours of any component of  the chest wall, i.e. bone, cartilage and soft tissue. They are treated similarly to those that occur at other sites and require specialist surgical - input only if  major resection and chest wall reconstruction are contemplated.

# DISORDERS OF THE PLEURA Pneumothorax

DISORDERS OF THE PLEURA Pneumothorax

Pneumothorax is the presence of  air outside the lung, within the pleural space. It must be distinguished from bullae or air cysts within the lung. Bullae can be the cause of  an air leak from the lung and can therefore coexist with pneumothorax. Spontaneous pneumothorax occurs when the visceral pleura ruptures without an external traumatic or iatrogenic cause. Cases are divided into primary spontaneous pneumo thorax (PSP) and secondary spontaneous pneumothorax (SSP). Pneumothorax can also occur following trauma or iatrogenic injury such as insertion of a central line. Tension pneumo thorax is when (independent of  aetiology) there is a build-up of  positiv e pressure within the hemithorax, to the extent that the lung is completely collapsed, the diaphragm is flattened, the mediastinum is distorted and, eventually , the venous return to the heart is compromised. Surgical emphysema is the pr esence of  air in the tissues. It requires a breach of  an air-containing viscus in communica tion with soft tissues, and the generation of  positive pressure to push the air along tissue planes. The most serious cause is Sven Ivar Seldinger , 1921–1998, Swedish radiologist, introduced the Seldinger technique to obtain safe access to blood vessels and other hollow organs. also occur with asthma or barotrauma from positive-pressure ventilation. A poorly managed chest drain, with intermittent build-up of pressure, allows air to track into the chest wall thr ough the point where the drain breaches the parietal pleura. Primary spontaneous pneumothorax This is a common condition characteristically seen in young people from their mid-teens to late twenties. About 75% of cases are in young men, who tend to be tall and have a family history of  the condition. It is due to leaks from small blebs, vesicles or bullae, which may become pedunculated, typically at the apex of  the upper lobe or on the upper border of  the lower or middle lobes. Secondary spontaneous pneumothorax This occurs when the visceral pleura leaks as part of  an underlying lung disease; any disease that involves the pleura may cause pneumothorax, including tuberculosis, any cavitat - ing lung disease and necrosing tumours. As such it tends to occur in older patients, often with a history of  underlying lung disease such as emphysema. The pneumothorax may be less well tolerated. The risk of recurr ent pneumothorax is increased after the first episode. The best estimates of  recurrence rates are: /uni25CF of  patients who experience a first event, only about one- third experience recurrence; /uni25CF of  those who have a second episode, about one-half  go on to experience a third episode; /uni25CF those who have had three episodes will probably go on to have repeated recurrences. Current recommendations from the BTS are that, in cases of  persistent air leak following drain insertion or failure of  the lung to re-expand, an early (3–5 days) thoracic surgical opinion should be sought. Summary box 60.1 Indications for surgical intervention for pneumothorax include: /uni25CF - /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF Current recommendations ( Figure 60.7 ) focus on the use of  small bore (10–14 /uni00A0 Fr) chest drains, usually of  a Seldinger - type, inserted ideally under ultrasound guidance. However, knowledge of  the role of  the ‘surgical’ chest drain and how to insert it safely is still required. 

Normal
Second ipsilateral pneumothorax
First contralateral pneumothorax
Bilateral spontaneous pneumothorax
Pneumothorax fails to settle despite chest drainage
Spontaneous haemothorax: professions at risk (e.g. pilots,
divers)
Pregnancy



Spontaneous pneumothorax
If bilateral/haemodynamically
unstable proceed to chest drain
signi
/f_i
cant smoking history
NO
Primary
Evidence of underlying
pneumothorax
lung disease on exam
Aspirate
Size >2 cm
YES*
16–18 G cannula
and/or
Aspirate <2.5 L
breathless
NO
Success
(<2 cm and
breathing
improved)
YES
Consider discharge
review in OPD
in 2–4 weeks
*In some patients with a large pneumothorax but minimal
symptoms conservative mangement may be appropriate
Figure 60.7
British Thoracic Society guidelines on the management of spontaneous pneumothorax (2010) (adapted from www.bts.org.uk).
OPD,
/uni00A0
outpatient department.

# Disorders of the diaphragm

Disorders of the diaphragm

Disorders of  the diaphragm can be broadly classified as disor ders of  innervation, leading to paralysis of  the diaphragm, with elevation and reduction of  thoracic volume leading to breathlessness, and disorders of  anatomy , which ar e further categorised into congenital diaphragmatic hernias or acquired hernias, usually secondary to trauma. There are two well recognised congenital sites where abdominal viscera can herniate into the chest ( Figure 60.28 ). /uni25CF The foramen of  Morgagni: a hernia in the anterior part of  the diaphragm with a defect between the sternal and Giovanni Battista Morgagni , 1682–1771, Professor of  Anatomy , Padua, Italy , for 59 years, regarded as ‘the founder of  morbid anatomy’. Victor Alexander Bochdalek , 1801–1883, Professor of  Anatomy , Prague, Czech Republic. Mark M Ravitch , 1910–1989, paediatric surgeon, University of  Pittsburgh, PA, USA. Donald Nuss , contemporary , paediatric surgeon, Norfolk, V A, USA, described this technique in 1987. the transverse colon. /uni25CF The foramen of Bochdalek: through the dome of the dia - phragm posteriorly . Traumatic rupture of  the diaphragm may occur with blunt - trauma. Unless there is severe bleeding or strangulation of  the - viscera it is best managed after an interval. In a severely injured patient being ventilated it can wait until other injuries are dealt with and weaning fr om the ventilator is being considered. , with When the diaphragm is breached, as in anatomical dis - orders, repair either with primary closure or with a mesh is usually possible via a thoracotomy . Diaphragmatic paralysis, particularly idiopathic unilateral paralysis, can be treated by plication, returning the diaphragm to a lower position and impr oving thoracic volume. 

1
4
2
3
Figure 60.28
Diagram of sites of hernias. The usual sites of congenital
diaphragmatic hernia: 1, foramen of Morgagni; 2, oesophageal hiatus;
3, foramen of Bochdalek (pleuroperitoneal hernia); 4, dome.

# FURTHER READING

FURTHER READING

Baas P , Fennell D, Kerr KM et al . Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015; 26 (Suppl 5): v31–9. Batchelor TJP , Rasburn NJ, Abdelnour-Berchtold E et al . Guidelines for enhanced recovery after lung surgery: recommendations of  the Enhanced Recovery After Surgery (ERAS®) Society and the Euro - pean Society of  Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019; 55 (1): 91–115. Brierley J, Gospodarowicz MK, Wittekind C. TNM classification of  ma - lignant tumours , 8th edn. Oxford: Wiley-Blackwell, 2017. BTS Pleural Disease Guideline Group. British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl 2): 1–76. Lim E, Baldwin D, Beckles M et al . Guidelines on the radical man - agement of  patients with lung cancer. Thorax 2010; 65 (Suppl 3): iii1–27. National Institute for Health and Care Excellence. Lung cancer diagno - sis and management . NICE Clinical Guideline 122. London: NICE, 2019. Available from https://www .nice.org.uk/guidance/ng122.

# Haemoptysis

Haemoptysis

Diseases causing repeated haemoptysis include carcinoma, bronchiectasis, carcinoid tumours and some infections. Severe - mitral stenosis is now a rare cause. Patients with repeated - haemoptysis should be investigated, at the very least by chest radiography and bronchoscopy . Haemoptysis following trauma may be from a lung contusion or injury to a major airway . Treatment depends on the underlying cause. Common associated chest symptoms include cough with or without sputum, pain, breathlessness, hoarseness and more general symptoms of  systemic upset, including fatigue and loss of  weight. Occasionally , chest disease may cause palpitations - owing to a trial fibrillation. Any of  these symptoms in associa - tion with haemoptysis requires urgent investigation. Investigation Bronchoscopy Flexible bronchoscopy ( Table 60.4 ) may be performed with the patient awake and the oropharynx anaesthetised with topical lignocaine ( Figure 60.11 ). The bronchoscope is passed - into the nose or mouth and through the vocal folds under direct vision. As the scope is flexible, its tip can be directed into the segmental bronchi with ease. Tissue and sputum samples may be obtained for diagnostic purposes. There is a greater range of movement with this instrument, but the biopsies are relatively small and suction limited. Rigid bronchoscopy requires general anaesthesia in most instances. It is ideal for therapeutic manoeuvres, such as removal of  foreign bodies, aspiration of  blood and thick secre - tions, and intraluminal surgery (laser resection or stent place - ment). The surgeon and the anaesthetist share control of  the airway . The bronchoscope is passed under direct vision into the oropharynx, behind the epiglottis, until the vocal folds are seen and introduced into the trachea. The trac heal rings and the carina should be easily seen. Advancing the bronchoscope into the RMB or LMB reveals the orifices of  the more peripheral bronc hi. Operability of  an endobronchial tumour may be assessed in terms of  its location (e.g. the proximity of  a lesion to the carina). Complications are rare but include bleeding, pneumothorax, laryngospasm and arrhythmia. 

TABLE 60.4
Uses of bronchoscopy.
Diagnostic
Con
/f_i
rmation of disease: carcinoma of the
bronchus; in
/f_l
ammatory or infective processes
Investigative
Tissue biopsy
Preoperative
Before lung resection
assessment
Before oesophageal resection
Persistent haemoptysis
Therapeutic
Removal of secretions
Removal of foreign bodies
Stent placement, endobronchial resection, etc.
-

Rigid bronchoscopy can be combined with endobron chial interventions to tackle airway tumours; these techniques include use of  laser or cryotherapy , with heat or cold respec tively , to excise potentially obstructing endobronchial tumours y patency and breathing. and improve airwa Other techniques of  biopsy of  intrathoracic lesions are often necessary to confirm diagnosis, stage disease and plan treatment. T he options range from percutaneous needle biopsy under radiological control (typically CT scan) to open (V ATS) lung biopsy . Endobronchial ultrasound (EBUS) and naviga tional bronchoscopy are alternative airway techniques used to obtain intrathoracic biopsies. Summary box 60.4 Biopsy hazards /uni25CF /uni25CF /uni25CF Tracheal obstruction may present acutely as a life-threatening emergency or insidiously with little in the way of  symptoms until critical narrowing and stridor occur. The more common causes of  airway narrowing are outlined in Table 60.5 . Treatment depends on the underlying cause. Tracheostomy may be required to overcome the obstruction, but there are few indications to do this as an emergency . Tracheal replacement resection of  up to 6 /uni00A0 cm of  trachea is possible. Sleeve resections of  the major bronchi are also possible. 

(b)
Figure 60.11
(a)
Rigid and
/f_l
exible bronchoscopes.
(b)
View past the
carina into the left main bronchus with a tumour seen in the bronchial
lumen.
Bleeding disorders
Systemic anticoagulation
Pulmonary hypertension
TABLE 60.5
Causes of airway narrowing.
Intraluminal Inhaled foreign body
Neoplasm
Intramural Congenital stenosis
Fibrous stricture (post intubation or tuberculosis)
Extramural Neoplasm (thyroid cancer, secondary deposits)
Aortic arch aneurysm

# INTRODUCTION Anatomical development of the lungs

INTRODUCTION Anatomical development of the lungs

The lungs are derived from an outpouching of the primitive foregut during the fourth week of  intrauterine life. This bud becomes a two-lobed structure, the ends of  which ultimately become the lungs. The lobar arrangement is defined early and is fairly constant but anomalies of  fissures and segments leading to anatomical variation in the adult are common. The primitive lungs drain into the cardinal veins, which ultimately become the pulmonary veins draining into the left atrium. Variability in venous drainage is very common and is usually of  little functional significance. At the most severe end of  the spectrum is total anomalous drainage, which pr esents in early infant life because oxygenated blood is all directed back to the right heart.

# Inhaled foreign bodies

Inhaled foreign bodies

This is a fairly common occurrence in small children and is often marked by a choking incident that then apparently passes. Surprisingly large objects can be inhaled and become lodged in the wider calibre and more vertically placed RMB. There are three possible presentations: 1 asymptomatic; 2 wheezing (from airway narrowing) with a persistent cough and signs of  obstructive emphysema; 3 pyrexia with a productive cough from pulmonary suppu - ration. Either flexible or more often rigid bronchoscopy is required to remove the foreign body .

# Inserting and managing a chest drain

Inserting and managing a chest drain

An intercostal tube connected to an underwater seal is central to the management of chest disease; however, the management of  the pleura and of  chest drains can be troublesome, even in experienced hands. The safest site for insertion of  a drain ( Figure 60.8 the triangle that lies: /uni25CF anterior to the mid-axillary line; /uni25CF above the level of  the nipple; /uni25CF below and lateral to the pectoralis major muscle. This will ideally find the fifth space. The technique includes the following. /uni25CF Meticulous attention to sterility throughout. /uni25CF Adequate local anaesthesia to include the pleura. /uni25CF Sharp dissection to cut only the skin. /uni25CF Blunt dissection with artery forceps down through the muscle layers; these should only be the serratus anterior and the intercostals. /uni25CF An oblique tract, so that the skin incision and the hole in the parietal pleura do not overlie each other and the drain is in a short tunnel, which reduces the chance of entraining air. /uni25CF A drain for pneumothorax and haemothorax should aim towards the apex of  the lung. A drain for pleural e ff usion or empyema should be nearer the base. The drain should pass over the upper edge of  the rib to avoid the neurovas - cular bundle that lies beneath the rib. ) is in /uni25CF The retaining stitch should be secure but should not oblit - erate the drain. /uni25CF A vertical mattress suture is inserted for later wound clo - sure. This is vital for pneumothorax management but should be omitted if  the drain is for empyema (provided there is adherence of  the pleura) because that tract should lie open. /uni25CF Connect the drain to an underwater seal device which functions as a one-way valve. /uni25CF After completion, check that the drain has achieved its objective by taking a chest radiograph. It is preferable not to apply suction to the drain or clamp it. The danger is that the clamp may be applied for trans - port and forgotten. Dangers of  disconnection and siphoning are small or best averted in other ways apart from clamping. 

Age >50 and
YES
Secondary
pneumothorax
or x-ray?
YES
>2 cm or
breathless
NO
Aspirate
YES
Size
16–18 G cannula
1–2 cm
NO
Aspirate <2.5 L
NO
Success
YES
NO
(size now
<1 cm)
Admit
Chest drain
High-
/f_l
ow oxygen
size 8–14 Fr
(unless suspected oxygen sensitive)
Admit
Observe for 24 hours

(a) ) (c) (d) (b A bubbling drain should (almost) never be clamped. Remove the drain when it no longer has a function. Summary box 60.2 Suction on a pleural tube /uni25CF /uni25CF /uni25CF 

Triangle of
‘safety’
Mid-axillary
line
Figure 60.8
Insertion of chest drain:
(a)
triangle of safety;
(b)
pleura;
(d)
suture placement;
(e)
gauging the distance of insertion;
central trochar and positioning of drain;
(h)
underwater seal chest drain bottle.
Be aware! Inserting the drain, and not the suction, is the life-
saving manoeuvre
If the lung is reluctant to expand, the suction deviates the
mediastinum
If the lung is fragile, it may worsen an air leak

# Introduction

## Introduction

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# Investigation of the respiratory system

Investigation of the respiratory system

Pulmonary function tests (PFTs) are useful in determining the functional capacity of  the patient and the severity of  pulmonary disease, and in predicting the response to various treatments. The tests range from simple clinic or bedside measurements to those only available in specialist centres. Spirometry is the most commonly performed PFT and measures specifically the amount (volume) and/or speed (flow rate) of  air that can be inhaled or exhaled. It is reported in both absolute values and as a predicted percentage of  normal. Normal values vary , depending on gender, race, age and height. The most common parameters measured in spirometry are defined below and illustrated in Figure 60.5 . Basil Martin Wright , 1912–2001, member of  the scientific sta ff of  the Medical Research Council Research Centre, Northwick Park Hospital, Harrow , UK. Peak expiratory flow rate Peak expiratory flow rate (PEFR) is measured by a Wright peak flow meter or a peak flow gauge. This is the maximum airflow velocity achieved during an expiration delivered with maximal force from the total lung capacity . It is a reliable and reproduc - ible test but has the disadvantage of  being e ff ort dependent, and it may therefore be a ff ected by abdominal or thoracic wound pain. PEFR measurements are often used in managing asthma, but there are many other causes of  low PEFR such as a pr oblem with large airway patency . Forced expiratory volume in 1 second The forced expiratory volume in 1 second (FEV ) is the amount 1 of  air forcibly expired in 1 second. It is low in obstructive lung disease and may be normal in patients with poor gas exchange. Forced vital capacity The forced vital capacity (FVC) is the volume of  air forcibly displaced following maximal inspiration to maximal expiration. The FEV and the FVC can be measured using a Vitalograph, 1 

Postoperative
Perioperative
dyspnoea
death
Dynamic lung volumes,
Thoracoscore
transfer factor
+/– split function testing
Yes
Offer surgery as part of
multimodality management

(b) and a ratio (FEV /FVC) can be calculated ( Figure 60.5 1 low ratio indicates obstruction and the test should be repeated after bronchodilators. A normal ratio (FVC and FEV reduced 1 to the same extent) indicates a restrictive pathology . There are two physiological categories of  lung disease: obstructive and restrictive ( Table 60.1 ). In obstructive condi tions such as asthma or emphysema, the flo w of air in and out of  the lungs is impaired. In restrictive disease, such as lung fibrosis, the lungs have lost size or elasticity , becoming ‘sti ff ’ so that they do not fill or expand properly . Diffusion capacity The di ff usion capacity (DLCO) is a measurement of  the lung’s ability to transfer gases and is often referred to as the ‘trans fer factor’. It cannot be performed at the bedside, requires the patient’s current haemoglobin level and is a test of  the integrity of  the lung’s alveolar–capillary surface area for gas ex change. In lung diseases that damage the alveolar walls, such ). A ↓↓ ↓ - ↓↓ ↓ ↓ ↓↓ as emphysema, or that thicken the alveolar membrane, such as lung fibrosis, it may be reduced. In patients who require - surgery to remove part of  their lung, for example for lung cancer, measurement of  DLCO is an important determinant of  ‘fitness’ for surgery and it should be measured formally as part of  a lung function test. 

4
4
3
3
q
2
2
Volume (litres)
1
1
1
0
2 3 4 5 6 0
Normal
Obstructive
Tidal volume
Total lung
capacity
(TLC)
Normal
Figure 60.5
Spirometry.
(a)
Spirogram tracings obtained from a Vitalograph:
vital capacity (FVC) 3.8 litres, FEV
/FVC 82%;
(ii)
obstructive defect, reversible asthma,
1
FEV
/FVC 40%; q after a bronchodilator, FEV
2.5 litres, FVC 3.5 litres, FEV
1
1
2.0
litres, FEV
/FVC 90%. No change with bronchodilators.
(b)
1
from Gray HH. Pulmonary embolism.
Medicine International
1993;
4
3
2
p
1
1
2 3 4 5 6
1
0
2 3 4 5
6
Time (seconds)
Restrictive
VC
TLC
Vital
capacity
(VC)
VC
TLC
Obstructive
Restrictive
(i)
normal forced expiratory volume in 1 s (FEV
) 3.1 litres, forced
1
p
before a bronchodilator, FEV
1.4 litres, FVC 3.5 litres,
1
/FVC 71%;
(iii)
restrictive defect,
/f_i
brosing alveolitis, FEV
1.8 litres, FVC
1
1
Changes in lung volume in obstructive and restrictive lung disease. (Reproduced
21
: 477, by kind permission of the Medicine Group (Journals)
/uni00A0
Ltd.)
TABLE 60.1
Spirometry values in obstructive and
restrictive lung diseases.
Obstructive pattern
Restrictive pattern
PEFR
Normal or
FEV
Normal or
1
FVC
Normal or
FEV
/FVC
<70
>80
1
FEV
, forced expiratory volume in 1 second; FVC, forced vital
1
capacity; PEFR, peak expiratory
/f_l
ow rate.

Oxygen saturation (S O ) refers to the degree of  oxygen p 2 molecules (O ) carried in the blood attached to haemoglobin 2 molecules (Hb). It is a measure of how much oxygen the blood is carrying as a percentage of  the maximum it could carry . The common method of  monitoring the oxygenation of  a patient’s haemoglobin is through a pulse oximeter. Blood gases The S O measured non-invasively with a pulse oximeter p 2 measures only oxygenation, not ventilation, and provides no information regarding a patient’s carbon dioxide or bicarbon ate levels, blood pH or base deficit. This requires arterial blood sampling or ‘blood gases’ ( Table 60.2 ). The FEV and DLCO are often used to predict the risk 1 of  postoperative dyspnoea after lung resection. The predicted postoperative values can be calculated by considering the vol ume of  lung, more specifically the number of  bronchopulmo nary segments, expected to be removed at surgery . For example if  five segments of  the left upper lobe are to be removed, the postoperative predicted FEV in a patient with a preoperative 1 FEV of  2.5 litres (85% predicted) is ((19 /uni00A0 – /uni00A0 5)/19) /uni00A0 ×/uni00A0 2.5 = 1 1.84 litres and ((19 /uni00A0 – /uni00A0 5)/19) /uni00A0×/uni00A0 85% = 62.6% predicted. This assumes that all bronchopulmonary segments are function ing (e.g. not collapsed) and contribute equally to lung func tion. Although an optimum cut-o ff of  postoperative predicted FEV of  40% is widely cited, there are currently limited data 1 to provide guidance on this figure to help predict an acceptable degree of  postoperative dyspnoea and quality of  life. Patients should still be o ff ered surgical resection if  the predicted risk of postoperative dyspnoea is moderate or high, as long as they are aware of  and accept the risks of  dyspnoea and associated complications. Exercise testing Other functional assessments, including the shuttle walk test, 6-minute walk test, stair climbing coupled with other tests such as oxygen saturations, as well as cardiopulmonary exercise testing (CPET), could be considered for patients at moderate or high risk of  postoperative dyspnoea and may help predict surgical outcome after lung resection. In patients with moder ate to high risk of  postoperative dyspnoea, using a shuttle walk test distance of  >400 /uni00A0 m and CPET of >15 /uni00A0 mL/kg/min are cut-o ff values for good function. Ernest Henry Starling , 1866–1927, Professor of  Physiology , University College, London, UK. The key to many aspects of practical chest surgery is an under - standing of  the pleura and of  the mechanics of  breathing. Management of  the essentially healthy pleural space is logical and simple and needs minimal technology . On the other hand, when pleural disease is advanced, for example when there is gross pleural sepsis surrounding a leaking and trapped lung, management is di ffi cult and the patient ma y require prolonged care with repeated interventions. The physiology of pleural fluid - The turnover of  fluid in the human pleural space is about 1–2 /uni00A0 litres in 24 hours, with only 5–10 /uni00A0 mL of  fluid present at any one time as a film, about 20 /uni00A0 /uni03BC m thick, between the visceral and parietal pleura. The mechanisms and equations given are simplifications but serve to explain the clinical conditions encountered. The fluid is produced from the capillaries of  the parietal pleura as a transudate, according to the Starling capillary loop pressures. Howe ver, there is a further negative force in the pleura. The elastic content of  the lung causes it to recoil and collapse if  not held open by the negative pressure in the pleura. This elastic recoil exerts about 4 /uni00A0 mmHg of  negative pressure and favours accumulation of  fluid. The secreting forces add up to about 11 /uni00A0 mmHg in health. Pleural fluid is mainly reabsorbed (about 90%) by the visceral pleura, whose capillaries are part of the pulmonary circulation. The principal force in absorption of pleural fluid is oncotic pressure (approximately 25 /uni00A0 mmHg) - minus the di ff erence in mean capillary hydrostatic pressure of - the pulmonary capillary (8 /uni00A0 mmHg). Thus, the overall absorb - ing pressure is 25 /uni00A0 – /uni00A0 8 = 17 /uni00A0 mmHg, producing a net drying e ff ect (17 /uni00A0 – /uni00A0 11) of  about 6 /uni00A0 mmHg ( Figure 60.6 ). Gas in the pleural space There is normally no free gas in the pleural space because - the same physiological mechanism that absorbs air from a - pneumothorax prevents any gas accumulating. The partial pressures (water as saturated vapour pressure) of  the gases in venous/end-capillary blood are: /uni25CF P O 40 /uni00A0 mmHg 5.3 /uni00A0 kPa 2 /uni25CF P CO 46 /uni00A0 mmHg 6.1 /uni00A0 kPa 2 /uni25CF P N 573 /uni00A0 mmHg 76.4 /uni00A0 kPa 2 /uni25CF P H O 47 /uni00A0 mmHg 6.3 /uni00A0 kPa 2 These partial pressures add up to less than atmospheric pressure (760 /uni00A0 mmHg). Free gas is therefore absorbed into the blood and lost to the atmosphere thr ough the lungs, with the gases moving in relation to their solubility (carbon dioxide quickest and nitrogen slowest) and relative concentrations in the pleural space and the blood. This does not favour nitrogen, which constitutes about 80% of  atmospheric air. Breathing oxygen accelerates nitrogen removal by reducing the content - of  nitrogen in the blood and increasing the gradient for its absorption. Nitrous oxide anaesthesia is dangerous in the pres - ence of  a pneumothorax; nitrous oxide is very soluble and, although not normally present in the pleural space, it will be 

TABLE 60.2
Arterial blood gases: ‘normal values’.
pH
7.35–7.45
PaCO
4.5–6
/uni00A0
kPa (35–50
/uni00A0
mmHg)
2
PaO
11–14
/uni00A0
kPa (83–105
/uni00A0
mmHg)
2
Standard bicarbonate 22–28 mmol/L
Anion gap 10–16 mmol/L
Chloride 98–107 mmol/L

(b) rapidly transported into the space if  the patient is given nitrous oxide to breathe. 

Produced at a rate of:
and reabsorbed:
0.6
mL/kg per hour
or 1000 mL
80–90% into
per day
pulmonary capillaries
10–20% (plus protein)
into lymphatics
Capillary
hydrostatic
+32
+8
pressure
Colloid
–25
–5 –25
pressure
4
Elastic recoil
Net drying effect 6 mmHg
Figure 60.6
(a)
Production and absorption of pleural
/f_l
uid.
(b)
pleural physiology. (See the text for an explanation of this simplistic
physiological model.)

# LUNG TRANSPLANTATION (see Chapter 92 )

LUNG TRANSPLANTATION (see Chapter 92 )

Lung transplantation is an established therapy for those with end-stage parenchymal or pulmonary vascular disease; it is limited by the number of  donor lungs available.

# Learning objectives

Learning objectives

To understand: The anatomy and physiology of the thorax • Investigation of chest pathology • The role of surgery in pleural disease •

# Lung abscess

Lung abscess

The causes of  lung abscess are shown in Table 60.8 . The chest radiograph shows a cavity with a fluid level or in mycetoma a fungal ball. Most acute abscesses resolve with appropriate antibiotic therapy and postural drainage. Surgery is avoided. Small radiologically sited drains are used sometimes in the intensive care unit. 

Speci
/f_i
c pneumonia
Streptococcal
Staphylococcal
Pneumococcal
Klebsiella
spp.
Anaerobic
Bronchial obstruction
Carcinoma
Carcinoid
Foreign body
Postoperative atelectasis
Chronic respiratory sepsis
Sinusitis
Tonsillitis
Dental infection
Septicaemia
Penetrating lung injury

# MAJOR THORACIC SURGERY

MAJOR THORACIC SURGERY

The British Thoracic Society (BTS) recommends a tripartite risk assessment model for patients undergoing lung resection, considering the risk of  operative mortality , risk of perioperative myocardial events and risk of  postoperative dyspnoea ( Figure 60.4 ).

# MEDICAL CONDITIONS FOR WHICH SURGERY MA Y BE REQUI

MEDICAL CONDITIONS FOR WHICH SURGERY MA Y BE REQUIRED Bronchiectasis

Bronchiectasis is chronic irreversible dilatation of  the medium- sized bronchi, which may occur following a suppurative pneumonia or bronchial obstruction. It is the pathological end stage of  a range of  conditions. If  generalised it is almost never considered for surgical resection. Cases caused by whooping - cough and measles are decreasing in frequency in resource- rich countries.

# Mechanics of breathing

Mechanics of breathing

The intercostal muscles contract, causing the ribs to move upwards and outwards, thereby increasing the transverse and anteroposterior dimensions of  the chest wall. Along with - the diaphragm, which contracts simultaneously and flattens, increasing the vertical dimension of  the chest cavity , these muscles are the muscles of  respiration. In addition, the acces - sory muscles of  respiration – the neck and spinal muscles such - as sternocleidomastoid – may be used particularly during heavy breathing, such as when exercising or during periods of  illness such as a pneumonia (lung infection). As the volume increases, the intrathoracic pressure falls and air flows in until the alveolar pressure is the same as the atmospheric pressure. The only force used in normal expiration is the elastic recoil of  the lung. Ability to cough comfortably to clear retained secretions is an essential part of  recovery from surgery . In a vigorous cough, probably the only muscle in the body that is r elaxed is the dia phragm; as the abdomen and chest wall and accessory muscles contract, the limbs are braced and the sphincters are tightened. When the intrathoracic and abdominal pressure is built up, the glottis is opened and the diaphragm is forced up as a piston, or like the plunger of  a syringe, to expel air at high velocity . 

Lingula
Apical lower
Apical
Middle
lower
lobe
Basal
Basal
lower
lower
Figure 60.2
Surgical anatomy of the bronchial tree. To surgically
remove the right lower lobe and conserve the middle lobe, the sur
geon must be prepared to dissect and separately divide the apical
bronchial segment (red line).
1
Supraclavicular zone
Station 1: low cervical, supraclavicular
sternal notch
4
Upper zone
Station 2: upper paratracheal
Station 3: prevascular/retrotracheal
10
Station 4: lower paratracheal
Subcarinal zone
11
Station 7: subcarinal
8
Hilar/interlobular zone
Station 10: hilar
Station 11: interlobar
Lower zone
Station 8: paraoesophageal
Station 9: pulmonary ligament
Figure 60.3
Lymph node stations related to the bronchial tree are particularly important in the staging of lung cancer,
with N1 nodes (10–14) and N2 nodes (2–9) shown. AP , anteroposterior.

# NEOPLASMS OF THE LUNG

NEOPLASMS OF THE LUNG

-

# Other conditions of the mediastinum

Other conditions of the mediastinum

Many of  the primary tumours such as neurogenic tumours and germ cell tumours can present as cysts or have a cystic quality . In addition, the mediastinum can contain other cysts, often with an embryological aetiology . Thymic, pericardial, bronchogenic and foregut cysts can all present asymptom - atically or with local compression ( Figure 60.26 ). Surgical excision is recommended if  the diagnosis is unclear or the patient has symptoms.

# Other diseases of the chest wall

Other diseases of the chest wall

- Congenital abnormalities are often incidental findings on chest radiography (e.g. bifid rib), but there are some important exceptions. Cervical rib and thoracic outlet syndrome This rib is usually represented by a fibrous band originating from the seventh cervical vertebra and inserting onto the first thoracic rib. It may be asymptomatic, but because the subclavian artery and brachial plexus course over it a variety of  symptoms may occur. The lower trunk of  the plexus (mainly T1) is compressed, leading to wasting of  the interossei and altered sensation in the T1 distribution. Compression of  the subclavian artery may result in a poststenotic dilatation with thrombus and embolus formation. The diagnosis, assessment and surgery are fraught with uncertainties and are best left to those with a well-developed interest in this problem. Pectus excavatum The sternum is depressed, with a dish-shaped deformity of  the anterior portions of  the ribs on one or both sides. Whether it causes cardiopulmonary issues through compression remains unclear but certainly the disfigurement can lead to significant psychological concerns. It can be repaired either as an open procedure (modified Ravitch procedure), which involves resect - ing the a ff ected costal cartilages and mobilising the sternum, or as a minimally invasive technique, the Nuss procedure. A metal bar is placed behind the sternum to hold this central panel in its new position; the bar has to be removed after a period of time ( Figure 60.29 ). Pectus carinatum (pigeon chest) In this condition the sternum is elevated above the level of the ribs and treatment is o ff ered for aesthetic reasons. It often comes to light during the growth spurt at adolescence when, of course, the teenager is particularly sensitive about appearance. Most patients are asymptomatic and the only justification for treatment is on cosmetic grounds. Some surgeons make a very good case for this but the risk of  morbidity and of  a less than perfect result must be clearly spelt out to the patient and his/ her parents. Surgery (modified Ravitch) involves mobilising the sternum with the costal cartilages so that the sternum can be flattened to a more anatomical position. Surgery is best left until the late teens, when further growth of  the chest wall is unlikely . Alternatively , an external orthotic brace can be worn in young patients with a pliable chest wall to remodel the chest shape over time. 

Figure 60.29
(a)
Insertion of a preformed bar placed thoracoscopically
beneath the pectus excavatum.
(b)
Chest radiograph following inser
tion of a metal bar bracing the sternum forward (the Nuss procedur
-
e).

# Pleural effusion

Pleural effusion

Pleural e ff usion can be readily understood with reference to the physiological mechanisms governing the flux of  pleural fluid given above. Pleural e ff usions are divided into exudates and transudates, depending on protein content (more [exudates] or less [transudates] than 30 /uni00A0 g/L), and characterised further according to glucose content, pH and lactate dehydrogenase content. The following are the most common ways in which the pleural fluid balance is disturbed. Malignant pleural effusion Pleural e ff usion is a common complication of  cancer. This may be due to: /uni25CF lung cancer; /uni25CF pleural involvement with primary or secondary malignancy; /uni25CF mediastinal lymphatic involvement. Lung cancer There may be direct involvement of  the parietal and/or - visceral pleura, collapse of  the lung parenchyma and spread to the mediastinal lymphatics, or a combination of  these, causing pleural fluid accumulation. It is usually regarded as a feature that puts lung cancer beyond surgical cure. Pleural malignancy The only primary malignancy of  the pleura seen with any regularity is malignant mesothelioma. This is a consequence of asbestos exposure, with few exceptions. The peak of  asbestos importation into the UK was from 1960 to 1975, with the inci - dence initially rising but more recently stabilising (2015–2017), with a fall in incidence projected in the future. Mesothelioma commonly presents with breathlessness because of  pleural e ff usions, pain and systemic features of  malignancy . Di ff use - seeding of  the parietal and visceral pleura is a common pattern any origin. Mediastinal lymphatic involvement In many instances, particularly in breast cancer, there is no evident disease in the pleura. The disease is in the mediastinal lymphatics, which are obstructed, and this upsets the balance of  physiological forces that control pleural fluid. Surgery for patients with malignant pleural effusion The surgeon has two roles: to make the diagnosis and to achieve e ff ective palliation by draining the fluid and pleurodesis. Diagnosis Pleural biopsy can be obtained by a range of techniques, with V ATS being the most common. An unequivocally positive biopsy is useful, but a negative biopsy may be a sampling error. Summary box 60.3 Biopsy of the pleura /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Pleural infection and empyema Empyema is the end stage of  pleural infection from any cause. It most commonly results from infection of the underlying lung, involving pneumonia or a lung abscess, but can occur as a complication of  any thoracic operation. It is seen if  a traumatic haemothorax becomes infected or in the course of management of  pneumothorax or pleural e ff usions. It may be associated with pus under the diaphragm ( Table 60.3 pathological diagnosis requires the presence of  thick pus with a thick cortex of  fibrin and coagulum over the lung. When empyema presents de novo it usually follows pneumo nia, and three phases are described: 1 In the exudative phase, there is a protein-rich (>30 /uni00A0 g/L) e ff usion. If  this becomes infected with the organisms from the lung (typically Streptococcus milleri and Haemophilus influ enzae in children), the scene is set for empyema. At this stage antibiotics may be all that is required. Aspiration or drainage to dryness in addition is preferred. 2 Over subsequent days, the fluid thickens to what is known as the fibrinopurulent phase. Drainage at this stage is prudent as antibiotics on their own are unlikely to be curative. 3 The organising phase causes the lung to be trapped by a thick peel or ‘cortex’ for which surgical management may be required. Leon David Abrams , 1923–2012, cardiothoracic surgeon, the United Birmingham Hospitals, Birmingham, UK. 

Cytological examination of the pleural
/f_l
uid (low yield)
Abrams’ needle (low yield in malignancy)
Computed tomography (CT)-guided needle biopsy of a
suspicious area
VATS biopsy
Open surgical biopsy
formation.
Pulmonary infection
Unresolved pneumonia,
bronchiectasis, tuberculosis,
fungal infections, lung abscess
Aspiration of pleural effusion
Any aetiology
Trauma
Penetrating injury, surgery,
oesophageal perforation
Extrapulmonary sources
Subphrenic abscess
Bone infections
Osteomyelitis of ribs or vertebrae

# Primary lung cancer

Primary lung cancer

- Lung cancer is one of the most common cancers throughout the world. In the UK, there are approximately 45 /uni00A0 000 new cases a year. From the time of  diagnosis, 60% of  patients are dead within 1 year and only 15% survive 5 years, making lung cancer the most common cause of cancer death. Survival is dependent on the stage that the patient presents with lung cancer. The number of  lung cancer operations performed in the - UK has significantly increased over the last 10 years. The pro - portion of  lung cancers in which resection is attempted varies ut, in most resource-rich countries, is over 30%. Most patients b o ff ered lung cancer surgery are in the early stages. The tho - king in a cancer team has a role in diagno - racic surgeon wor sis, staging and palliation, in addition to curative resection in appropriate cases. Cigarette smoking is undoubtedly the major risk factor for developing bronchial carcinoma and accounts for 85–95% of  all cases. To a lesser extent, atmospheric pol - lution and certain occupations (mining of radioactive ore and chromium) contribute. For practical purposes, lung cancers are divided into small cell lung cancer and non-small cell lung cancer (NSCLC), which are seen in a ratio of  about 1:4. /uni25CF The pattern of  disease, the prognosis and the results of treatment for small cell (also known as oat cell) carcinoma di ff er from all other types su ffi ciently for these to be man aged di ff erently from the outset on the basis of  the histo logical classification. /uni25CF Subdivisions of  NSCLC according to histological charac teristics are much less important, but pathological staging is critical to treatment and outcome. Histological classification of lung cancer Small cell lung cancers were known as oat cell cancers because of  the packed nature of  small dense cells. They are a type of  neuroendocrine tumour (NET) and represent about 20% of  all lung cancers. They tend to metastasise early to lymph nodes and by blood-borne spread. The median survival is measured in months. The tumours are very responsive to chemotherapy such that median survival may be doubled (although it is still short) but they are rarely , if  ever, cured. Surgery is rarely o ff ered unless in very limited stage disease. Non-small cell lung cancers : adenocarcinoma is now the most common of  the NSCLC types, having overtaken squamous cancer. The increasing incidence is partly due to an increasing incidence in women and may be the result, in part, of  a move towards lower tar cigarettes that are inhaled more deeply to get the same e ff ect. Squamous carcinoma typically appears as a cavitating tumour. Large cell undi ff erentiated is a discrete histological type of NSCLC and is included within NETs. NETs of the lung are a group of  lung cancers that include small cell cancer and large cell undi ff erentiated lung cancer, but also include other less aggressive tumour types, including typical carcinoid and atypical carcinoid tumours. These occur in the major (cen tral) bronchi and 20% are found peripherally . They are char acteristically slow growing and highly vascular. Most behave in a benign way; however, approximately 15% metastasise. The patient often presents with a history of  recur rent pneumonia or haemoptysis, but carcinoid syndrome is rare unless there are extensive pulmonary or hepatic metastases. Surgical excision is preferred because the prognosis following complete resection is excellent (>90% 10-year survival). Accurate diagnosis and staging of  the tumour are vital if surgery is to be considered. Clinical features Clinical features of  lung carcinoma depend on: /uni25CF the site of  the lesion; /uni25CF the invasion of  neighbouring structures; /uni25CF the extent of  metastases. Henry Khunrath Pancoast , 1875–1939, Professor of  Radiology , University of  Pennsylvania, Philadelphia, PA, USA, described this condition in 1932. Lee M Eaton , 1905–1958, neurologist who was a professor at the Mayo Clinic, Rochester, MN, USA. Edward H Lambert , 1915–2003, Professor of  Physiology , University of  Minnesota, MN, USA. Eaton and Lambert described this condition in a joint paper in 1956. loss, dyspnoea and non-specific chest pain. /uni25CF Haemoptysis occurs in fewer than 50% of  patients pre - senting for the first time. /uni25CF Cough, or a changed cough, is a common presentation but non-specific in this population. /uni25CF Severe localised pain suggests chest wall invasion with the - infiltration of  an intercostal nerve. Invasion of  the apical - area may involve the brachial plexus, leading to Pancoast’s syndrome. - /uni25CF Dyspnoea or breathlessness may come from loss of  func - tioning lung tissue, lymphatic invasion or the development of  a large pleural e ff usion. /uni25CF Pleural fluid is an ominous feature and the presence of blood in a pleural e ff usion suggests that the pleura has been directly invaded. /uni25CF Clubbing and hypertrophic pulmonary osteoarthropathy occasionally accompany some lung cancers and may re - solve with excision of  the primary lesion. /uni25CF Invasion of  the mediastinum may result in hoarseness (because of  recurrent laryngeal nerve involvement), dys - phagia (because of  the involvement of, or extrinsic pres - sure on, the oesophagus) and superior vena caval obstruc - tion. /uni25CF Small cell carcinoma is associated with the development of myopathies, including the Eaton–Lambert syndrome, which is similar to myasthenia gravis. Treatment of lung cancer Careful investigation is required to determine which tumours are operable and will benefit from a major thoracic resection. The internationally agreed tumour–node–metastasis (TNM) staging system gives prognostic information on the natural history of  the disease. Tumours graded up to T3, N1, M0 can be encompassed within an anatomical surgical resection and have a much improved prognosis when treated surgically so the - tumour must be staged accurately before resection. Increas - - ingly , for higher stage tumours a multi- or trimodality approach is being o ff ered where patients have chemotherapy , with or followed by radiotherapy follow ed by surgery . A number of non-tumour-related factors, including the general fitness of  the patient and the results of  lung function tests, help to determine the appropriate treatment. In patients with incurable disease, treatment is palliative to maximise quality of  life. Survival Carcinoma of  the bronchus generally has a low survival rate after diagnosis. Important factors in determining prognosis are the size of  the tumour (T status), the spread or stage of the cancer as determined by the TNM classification, the histological type of  the tumour and the general condition of the patient. Early detection and surgical resection o ff er the best hope for cure. Increasing emphasis in recent years has been on the early detection of  lung cancer, with guidance on symptoms and signs of  potential lung cancer that require urgent chest radiograph and referral to a lung cancer team. Non-invasive investigations Chest radiography A chest radiograph will detect most lung cancers but some, particularly early curable tumours, are hidden by other struc tures. Secondary e ff ects such as pleural e ff usion, distal collapse and raised hemidiaphragm may be evident ( Figure 60.12 Computed tomography CT is the first investigation in suspected lung cancer. The surgeon needs to know whether the primary is resectable (T /uni00A0 stage) and which, if  any , lymph nodes are involved (N stage). Lymph nodes more than 2 /uni00A0 cm in diameter are likely to be involved in the disease (70%) ( Figure 60.13 ) and those less than 10 /uni00A0 mm in the shorter axis are unlikely to be involved. Remote metastases to the liver, adrenal glands or elsewhere may be detected. Positron emission tomography The patient is given radiolabelled fluorodeoxyglucose (FDG), which is taken up by all metabolising cells but more avidly by cancer cells. The FDG enters the Krebs cycle but cannot complete it and accumulates in proportion to the glucose avidity of  the cells. High accumulation is associated with lung cancers and secondaries. Infection or other inflammation, and lymphadenopathy secondary to it, are also FDG avid. Sputum cytology Sputum cytology may reveal malignant cells but the false- negative rate is high. Invasive investigations Once lung cancer is suspected, diagnosis and further staging are sought. The choice of  investigation depends on the position of  the primary tumour in the lung (peripheral or central) and the clinical stage of  the cancer (presence of  enlarged lymph nodes or metastasis). Bronchoscopy Flexible bronchoscopy is usually performed under sedation, particularly in patients with more centrally placed lung cancers. It allows assessment of  the segmental airway , cytological testing through brushing and washing of  the concerned segmental bronchi and transbronchial needle aspiration (TBNA). Endobronchial ultrasound EBUS allows bronchoscopic assessment of suspicious medi astinal lymph nodes with an ultrasound probe incorporated into the tip of  the bronchoscope to aid TBNA ( Figure 60.14 Johann Friedrich Horner , 1831–1886, Professor of  Ophthalmology , Zurich, Switzerland, described this syndrome in 1869. Sir Hans Adolf  Krebs , 1900–1981, Professor of  Biochemistry , University of  Oxford, Oxford, UK. - ). Endoscopic ultrasound (EUS) is a similar technique that, by passing the probe down the oesophagus, allows fine-needle aspiration (FNA) of  less approachable mediastinal lymph nodes. Navigational bronchoscopy Navigational bronchoscopy provides a virtual three- dimensional map of  the lung using radiological guidance during a flexible bronchoscopy , which can guide the physician to target, locate and perform an anatomically precise lung biopsy , place markers for radiation therapy and/or facilitate - surgical removal of  a small peripheral lung lesion or use thermal ablative techniques for peripheral lung lesions. ). 

Figure 60.12
Chest radiograph of carcinoma of the lung. This patient
has a large mass in the right upper lobe, causing Horner’s syndrome,
a Pancoast tumour.
Figure 60.13
Paratracheal lymphadenopathy shown on a computed
tomography scan.

Computed tomography-guided biopsy Percutaneous CT-guided FNA may give a good yield of  cells for cytological examination. Alternatively , a core of  tissue can be obtained for formal histology . These techniques are best for larger and more peripheral lesions. Pneumothorax is common (10%) but rarely requires intercostal tube drainage. The contraindications include poor respiratory reserve, when even a small pneumothorax would be hazardous. Surgical diagnosis and staging Mediastinoscopy , mediastinotomy , V ATS or thoracotomy lymph node/lung biopsy are aimed at establishing a tissue diagnosis and assessing the degree of  spread (staging), which determines resectability . Histological proof  of  the status of mediastinal nodes may be important to avoid unnecessary thoracotomy for incurable cancers and, conversely , to avoid denying surgery to patients whose lymph nodes are enlarged but benign. Mediastinoscopy Following an incision in the neck and careful blunt dissection in front of  the trachea, access to the paratracheal and subcarinal nodes via mediastinoscopy is achieved and biopsies taken ( Figure 60.15 ). These techniques may also be used in the diagnosis of  other mediastinal conditions, including: /uni25CF lymphoma; /uni25CF anterior mediastinal tumours; /uni25CF thymoma; /uni25CF sarcoid, tuberculosis or any other cause of  lymphadenop athy . VATS mediastinal lymph node and lung biopsy For inaccessible mediastinal lymph nodes, or when diagnosis of  the lung tumour has not been possible through radiological or bronchoscopic techniques, V ATS allows diagnosis of  the tumour and staging of  the mediastinum and gives the oppor tunity to assess the likely operability of  the lung cancer. 

Figure 60.14
Endobronchial ultrasound allows accurate detection of
enlarged mediastinal lymph nodes for diagnosis and staging of lung
cancer.
Figure 60.15
Mediastinoscopy. The mediastinoscope slides down
immediately in front of the trachea, behind the aortic arch, and behind
and between the great vessels of the head and neck.

# Primary tumours of the mediastinum

Primary tumours of the mediastinum

Thymoma, neurogenic tumours, germ cell tumours and lymphoma are the usual primary tumours of  the mediastinum. /uni25CF Thymoma . This is the most common mediastinal tumour, accounting for 25% of  the total, and is derived from the thymus gland ( Figure 60.23 ). Thymomas vary in behaviour from benign to aggressively invasive, as reflected in the Masoaka classification system used to stage thymo mas and more recently the TNM classification. They are often related to myasthenia gravis, a neuromuscular condi tion that can have a high associated incidence of  thymomas, and inter estingly may respond to excision of  the thymus gland even when the gland has no associated thymoma present. T he only reliable indicator of  malignancy is cap sular invasion. Diagnosis and treatment are best achieved by complete thymectomy , which for large tumours (>5 /uni00A0 cm) Akira Masoaka , 1930–2014, Professor of  Surgery , Nagoya, Japan. or if  tumour invasion is suspected a median sternotomy is performed. If  the thymoma is small or when the patient has myasthenia gravis and the thymus is being excised as a treatment, various less invasive approaches can be con - sidered, including a V ATS approach or a transcervical approach with or without an additional V ATS procedure. /uni25CF Germ cell tumour . The anterior mediastinum is the most common site of extragonadal germ cell tumours. They account for 13% of  all mediastinal masses and cysts and contain elements from all three cell types (mesoderm, endoderm and ectoderm). They tend to present in young ) adults and 75% are benign and cystic, although they may cause compression of neighbouring structures; hence, dermoid cysts are best excised. Malignancy is suspected if elevated levels of  serum alpha-fetoprotein, human chorionic gonadotropin and carcinoembryonic antigen are detected. After initial treatment with chemotherapy , a patient with tumour marker normalisation and a persistent mass on CT may be considered for surgical resection. If tumour markers fail to normalise, further chemotherapy is usually o ff ered. /uni25CF Lymphoma . Lymphoma is a common cause of  a mediast - inal mass lesion, particularly in the anterior mediastinum, and can lead to superior vena cava obstruction or other symptoms of  local compression. The main treatment is ely required apart from chemotherapy , and surgery is rar obtaining tissue for diagnosis. /uni25CF Mesenchymal tumours . Lipomas are common in the - anterior mediastinum. Other mesenchymal tumours are very rare. - /uni25CF Thyroid . Ectopic thyroid (and parathyroid) tissue may be found in the anterior mediastinum but usually the mass is an extension of  a thyroid lesion (retrosternal goitre). Exci - sion of  retrosternal thyroids may be required if  there is lo - - cal airway compression and stridor and can be performed via a transcervical incision, but occasionally median ster - notomy may be required. 

Figure 60.23
Computed tomography scan showing a thymoma pre
-
senting as a mediastinal mass.

/uni25CF Neurogenic tumours . These may derive from the sympathetic nervous system or the peripheral nerves and are more prevalent in the posterior mediastinum. They may be painful but are more often discovered acciden tally on routine chest radiography and can be quite large ( Figure 60.24 ). They include neuroblastoma in childhood, and Schwannomas and neurofibromas in adults, which are usually benign. Phaeochromocytoma arises fr om the sym pathetic chain and produces the characteristic endocrine syndrome. Excision of  neurogenic tumours is generally recommended, particularly if  the patient is developing symptoms. This can be performed through a thoracotom though for smaller tumours a V ATS approach can be used ( Figure 60.25 ). /uni25CF Enlarged mediastinal lymph nodes are commonly involved by metastatic tumour, mimicking a primary mediastinal lesion. Symptoms are generally secondary to compression or invasion of  a structure within the mediastinum. Surgery such as mediastinoscopy is reserved for diagnosis only . Theodor Schwann , 1810–1882, Professor of  Anatomy and Physiology , successively at Louvain (1839–1848) and Liège, Belgium (1849–1888). 

Figure 60.24
Computed tomography scan showing a right-sided
paravertebral neurogenic tumour.
Figure 60.25
Video-assisted thoracoscopic surgery (VATS) image of
a neurogenic tumour attached to the posterolateral chest wall prior
to excision.
Figure 60.26
Computed tomography scan of the chest showing a
bronchogenic cyst splaying the carina.

# Pulmonary sequestration

Pulmonary sequestration

This describes a section of  non-functional lung separated from the normal bronchial connection with other abnormalities of development, which often include a direct systemic arterial supply from the aorta. V enous return is to the pulmonary veins in the majority of  cases. The segment becomes cystic and infected, resulting in the common appearance of  a solid lung mass that may be homogeneous or heterogeneous, occasion ally with cystic changes on CT scan. Interlobar sequestration occurs within the lung substance. It may present with recurrent chest infections and/or haemoptysis. Patients with extralobar sequestration are usually asymptomatic because air spaces are not present, and therefore it usually presents as an incidental finding. Theodor Albrecht Edwin Klebs , 1834–1913, Professor of  Bacteriology , successively at Prague, Czech Republic; Zurich, Switzerland; and The Rush Medical College, Chicago, IL, USA. Developmental lung cysts have a tendency to become infected. Acquired lung cysts may contain air or fluid and may be single or multiple. Pulmonary hydatid disease is a cause in endemic areas. Air cysts (bullae) may be spontaneous but may be secondary to emphysematous degeneration ( Figure 60.27 ).

# Risk of operative mortality

Risk of operative mortality

The Thoracic Surgery Scoring System (Thoracoscore) is the most widely used model to assess the risk of  operative mortality in thoracic patients. Risk is calculated based on nine variables – age, sex, American Society of  Anesthesiologists score, perfor - mance status, dyspnoea score, priority of  surgery , extent of surgery , malignant diagnosis and composite comorbidity score. It is currently the most robust model available to estimate the risk of  death when considering patients f or thoracic surgery . 

-

# Risk of perioperative myocardial event

Risk of perioperative myocardial event

History , physical examination and resting electrocardiogram (ECG) form the basics of  assessing perioperative cardiovas - - cular risk. Patients who are found to have an active cardiac condition should be evaluated by a cardiologist and optimised (medical, revascularisation or cardiac surgery) before thoracic surgery . Sur gery should be avoided within 30 days of  myocar - dial infarction. 

2
14
3
Peripheral zone
Station 12: lobar
12
13
Station 13: segmental
7
Station 14: subsegmental
11
Oesophagus
9
AP zone
Station 5: subaortic
6
Station 6: para-aortic
5
Left pulmonary artery



Risk assessment for surgery
Postoperative
cardiac event
ACC/AHA risk
strati
/f_i
cation
+/– cardiology review
Address potentially modi
/f_i
able risk factors and reassess
Does the patient accept the risk in each category +/– potential impact on lifestyle?
No
Exclude surgery from multimodality
management
Figure 60.4
Tripartite risk assessment. ACC, American College of Cardiology; AHA, American Heart Association.

# Risk of postoperative dyspnoea

Risk of postoperative dyspnoea

Any patient undergoing general anaesthesia requires some assessment of  respiratory function. This may be a clinical appraisal of  fitness, but more detail is necessary for patients who are undergoing lung resection.

# Surgical approach to lung cancer resection

Surgical approach to lung cancer resection

Thoracotomy Although the most frequent indication for thoracotomy is lung cancer, all surgeons dealing with trauma should be able to perform a thoracotomy if required. The standard route into the thoracic cavity is through a posterolateral thoracotomy . The incision is used for access to the: /uni25CF lung and major bronchi; /uni25CF pleura; /uni25CF thoracic aorta; /uni25CF oesophagus; /uni25CF posterior mediastinum. A double-lumen endotracheal tube is used to allow ven - tilation of  one lung while the other is collapsed, to facilitate surgery and to protect the non-operated lung and retain con - trol of  ventilation ( Figure 60.16 ). The patient is turned to the - - 

Tracheal
in
/f_l
atable cuff
Bronchial
in
/f_l
atable cuff
Figure 60.16
The double-lumen tube permits separate ventilation of
the right and left lungs.

lateral position with the a ff ected side up ( Figure 60.17 incision passes 1–2 /uni00A0 cm below the tip of  the scapula and extends posteriorly and superiorly between the medial border of  the scapula and the spine. /uni25CF The incision is deepened through the subcutaneous tissues to the latissimus dorsi. This muscle is divided with coagu lating diathermy , taking care over haemostasis. /uni25CF A plane of  dissection is developed manually , deep to the scapula and serratus anterior. The ribs can be counted down from the highest palpable rib (which is usually the second) and the sixth rib periosteum is scored with the dia thermy near its upper border. A periosteal elevator is used to lift the periosteum o ff the superior border of  the rib or, alternatively , the intercostal muscle is cut with diathermy just above the rib ( Figure 60.18 ). /uni25CF This reveals the pleura, which may be entered by blunt dissection. A rib spreader is inserted between the ribs and opened gently to prevent fracture. In an emergency thoracotomy for penetrating wounds of the heart, a more anterior approach is used and no specialised supporting equipment is required ( Figure 60.19 ). The incision is taken down to the fourth or fifth rib with a scalpel, and the pleural cavity is opened using scissors. This gives rapid access to the left pleural cavity in cases of massive left haemothorax and the pericardium if  cardiac tamponade is suspected. A left anterior thoracotomy can be quickly converted to a clamshell or bilateral thoracotomy if  necessary . Analgesia is an important aspect of  postoperative care, and the process may be started prior to thoracotomy with an epi dural catheter placed by the anaesthetist or intraoperatively by infiltrating the intercostal nerves in the region of  the incision with a long-acting local anaesthetic or increasingly via a surgi- ). The cally sited paravertebral catheter. Various strategies have been developed to deliver analgesics postoperatively to facilitate a normal breathing pattern. Video-assisted thoracoscopic surgery (VATS) Various approaches utilising thoracoscopic techniques can - be used to gain access to the chest cavity and facilitate lung - - 

Double-lumen tube to protect the
underlying lung
Elbows are placed at 90° to
upper arms
Incision curves below angle
of scapula
Underlying leg bent
for stability
Upper leg cushioned
Figure 60.17
Correct positioning for thoracotomy.
B
5
C
6
A
7
Latissimus dorsi
8
9
muscle
Serratus anterior
muscle
Figure 60.18
Incision and layers encountered during posterolateral
thoracotomy. A, The latissimus dorsi is divided in line with the skin
incision. B, If the serratus anterior is divided, it should be close to
its attachment to ribs 6, 7 and 8. It can be left intact and mobilised
along its inferior border. C, The intercostal muscles are stripped off the
upper border of the rib.
A sandbag or
dense pillow to
roll the patient
30º
Arm for
anaesthetist’
s
Incision in 5th
access
intercostal
space
Arm back
Figure 60.19
Emergency left anterior thoracotomy for access to the
heart. This requires no special supports or devices.

lung resections with dissection of  the hilar structures and full lymph node staging commonly performed through one- (uniportal), two- or three-port V ATS incisions. The technique avoids rib-spreading and appears to reduce postoperative pain and length of stay and aids a speedier recovery , particularly in frail patients. Robotically assisted thoracic surgery (RATS) In this approach, the thoracoscopy is done using a robotic system with three-dimensional vision. The surgeon sits at a control panel in the operating room and moves robotic arms to operate through several small incisions in the patient’s chest. RATS is similar to V ATS in terms of  less pain, less blood loss and a shorter recovery time ( Figure 60.20 ). For the surgeon, the robotic system may provide more manoeuvrability and more precision when moving the instru ments than standard V ATS. It may have advantages when performing more comple x lung resections such as segmentec tomies or mediastinal tumours (thymectomy). Surgical management of lung cancer The principle of  surgery is to remove all cancer (the primary and the regional lymph nodes) but to conserve as much lung as possible. The selection of  patients in terms of  the stage of  the lung cancer and fitness to undergo such surgery is paramount. Surgery with curative intent is o ff ered to patients with early stage lung cancer (T1–3, N0–1) ( Table 60.6 ). Assessment of a patient’s fitness to undergo lung cancer resection involves considering premorbid conditions, which can be aided using risk scores such as Thoracoscore, cardiovascular function and lung function; see BTS guidelines in Assessment of fitness for major thoracic surgery and UK National Institute for Health and Care Excellence (NICE) guidelines in Table 60.7 Lung function, in particular, will aid the surgeon in selecting the type of  procedure o ff ered and the likelihood of  breathless ness or dyspnoea following lung resection. - Choice of lung resection Segmentectomy and wedge resection - Segmentectomy and wedge resections are performed in patients with small tumours (1–2 /uni00A0 cm) that are predominantly ground glass, not solid (lepidic) and with borderline fitness, through thoracotomy or increasingly by V ATS or RATS. Each lobe of the lung has segments, which allows anatomical dissection and ligation of  the segmental pulmonary artery , vein and bronchus (segmentectomy) ( Figure 60.2 ) or non-anatomical excision can be performed (wedge resection) combined with removal of regional lymph nodes. Lobectomy Lobectomy remains the treatment of choice for patients with early-stage lung cancer. The surgery can be performed via thoracotomy or V ATS. Following dissection of  the fissure and hilar structures, the branches of  the pulmonary artery and . veins to the lobe are isolated and ligated. The bronchus is usually stapled but can be sewn. - The patient does not routinely need intensive care and postoperative ventilation is best avoided. The 30-day mortal - ity rate is 1–2%, with morbidity such as chest infection or car - diac arrhythmia at around 10%. The average length of  stay is around 5–7 days. Pneumonectomy Pneumonectomy is removal of  a whole lung and has a higher mortality rate (5–8%). As such the number of  pneumonec - tomies performed in the UK has fallen and now makes up less than 5% of lung cancer surgery . The surgeon must be satisfied that the patient is fit to tolerate this procedure from the preoperative work-up. This procedure is reserved for either centrally placed tumours involving the main bronchus or those that straddle the fissure. Bronchoplastic lung resections Increasingly , owing to the associated complications and higher mortality of  a pneumonectomy , preservation of  lung tissue is being considered but without compromise of  the surgical resection margins. Sleeve lung resections involve removing a central tumour that is invading a major bronchus, such as the LMB or RMB, together with the lobe of  the lung involved, 

TABLE 60.6
UK National Institute for Health and Care
Excellence (NICE) recommendations for surgery for non-
small cell lung cancer (NSCLC).
Surgery with curative intent for NSCLC
Offer patients with NSCLC who are
/f_i
t for surgery open or
thoracoscopic lobectomy as the treatment of
/f_i
rst choice. If
complete resection is possible, consider segmentectomy or
wedge resection for patients with smaller tumours (T1a–b, N0, M0)
and borderline
/f_i
tness
Offer more extensive surgery (bronchoangioplastic surgery,
bilobectomy, pneumonectomy) only when needed to obtain clear
margins
Perform hilar and mediastinal lymph node sampling or
en bloc
resection for all patients undergoing surgery with curative intent
For T3 NSCLC with chest wall involvement, aim for complete
resection by extrapleural or
en bloc
chest wall resection
For people with operable stage IIIA–N2 NSCLC who can have
surgery and are well enough for multimodality therapy, consider
chemoradiotherapy with surgery
Figure 60.20
A thoracic surgeon performing robotically assisted
thoracic (RATS) lung resection remotely from an operating console.

with reanastomosis of  the cut major bronchus to the remaining lobar bronchus. Complications of lung resection /uni25CF Bleeding . Bleeding should be avoidable by the use of a careful surgical technique but may be severe in the pres ence of  dense adhesions. /uni25CF Respiratory infection . Many of these patients are ex-smokers and therefore basal collapse and hypoxaemia are common postoperatively . /uni25CF Persistent air leak . Chest drains are placed at the time of  surgery to deal with the air leak. Rarely , the air leak persists and the remaining lung does not expand. Re-thoracotomy may then be necessary to seal the leak. /uni25CF Bronchopleural fistula . This is a serious complica tion. Following pneumonectomy , the space left behind is initially filled with air. This is slowly reabsorbed and the space fills with tissue fluid. The fluid level rises until the air is finally reabsorbed ( Figure 60.21 ). Dehiscence of  the bronchial stump leads to the development of  a br oncho pleural fistula and the fluid in the space (which is almost inevitably infected) is expectorated in large quantities. This complication has a high morbidity and mortality rate. The patient is nursed sitting up and turned so that the a ff ected space is dependent; this is to pr event infected fluid from entering the remaining lung while arrangements are made to site a pleural drain. This should be connected to an underwater seal but not suction. Bronchopleural fistulae are unlikely to resolve spontaneously and management is highly specialised. Postoperative care Enhanced recovery after surgery (ERAS) is a strategy that seeks to reduce patients’ perioperative stress response, thereby reducing potential complications, decreasing hospital length of  stay and enabling patients to return more quickly - to their baseline functional status. These principles have been applied to patients having lung cancer surgery . Postoperatively , patients have limited respiratory reserve following lung resec - tion, so infection and fluid overload are to be avoided. Once air leaks have settled, the drains are removed. Mobilisation, breathing exercises and regular physiotherapy are begun as soon as the patient’ s condition permits. Postoperative pain - It is important to deal with postsurgical pain e ff ectively so that a normal breathing pattern and gas exchange are achieved in the early postoperative period. Four strategies are routinely used in combination: - 1 paravertebral/extrapleural or epidural catheter-delivered local anaesthetic; 2 intercostal nerve blocks; 3 PCA with intravenous boluses of  opiates; 4 background oral analgesia with paracetamol and/or non-steroidal anti-inflammatory drugs. Long-term postsurgical pain can be reduced by careful attention to detail during the operation. Sources of avoidable chronic pain include rib fracture and the entrapment of  inter - costal nerves during wound closure . 

treatment with curative intent (including surgery).
Perioperative mortality Consider global risk score, such as Thoracoscore Ensure patient is aware of risk before consenting
Cardiovascular function Assess risk factors and cardiac functional capacity Avoid surgery within 30 days of MI
Lung function
Perform spirometry, measure TLCO if
disproportionate breathlessness or other lung
pathology, perform segment count and assess
exercise tolerance
Consider shuttle walk testing (cut-off 400
/uni00A0
m)
and cardiopulmonary exercise testing (cut-off
15
/uni00A0
mL/kg/minute) if moderate to high risk of
postoperative dyspnoea
FEV
, forced expiratory volume in 1 s; MI, myocardial infarction; TLCO, transfer factor for carbon monoxide.
1
From NICE Clinical Guideline 122, available from:
www.nice.org.uk/guidance/ng122.
Optimise primary cardiac treatment and begin secondary
cardiac prophylaxis as soon as possible
Offer surgery if two or fewer risk factors and good
cardiac functional capacity
Seek cardiology review if active cardiac condition, three
or more risk factors or poor cardiac functional capacity
Consider revascularisation before surgery in stable
angina
Continue anti-ischaemic treatment in perioperative
period. Discuss perioperative platelet treatment if patient
has a coronary stent
Offer surgery if normal FEV
and good exercise tolerance
1
or FEV
or TLCO below 30% and patient accepts the
1
risks of dyspnoea
Offer radiotherapy with curative intent if lung function
poor but patient is otherwise suitable for radiotherapy
with curative intent and volume of irradiated lung is small

For all malignancies, the lung is the most common site of metastases that often develop through haematogenous spread. The presence of  metastases is regarded as a sign of  advanced disease and few curative treatment options exist; however, surgical resection of  lung metastases may result in a survival advantage, particularly with metastases from solid tumours such as colorectal cancer, though the evidence still remains uncertain. The selection criteria often used when considering lung metastasectomy include control of  primary tumour; no evidence of  metastases outside the lung; possibility of  complete resection utilising lung-sparing techniques; and acceptable operative risks with adequate pulmonary function. Various approaches can be considered, though V ATS is increasingly favoured over thoracotomy owing to reduced postoperative pain and length of  stay , and therefor e speedier recovery . The disadvantage of V ATS is the inability to palpate and evaluate the lung in its entirety to locate other nodules deeper within the lung parenchyma, particularly those not identified on prior CT imaging. The main principle when resecting lung metastases is to utilise lung-sparing techniques as much as possible, e.g. wedge resections rather than lobec - tomy , because it is likely that later reoperations to resect new metastases may be necessary . Long-term outcome depends on the primary tumour type, with germ cell tumours having the best outcome. Patients with epithelial tumours (carcinomas) generally hav e a 30–40% 5-year survival, as reported in several r etrospective series. 

(b)
(c)
Figure 60.21
Chest radiographs
(a)
pre- and
(b)
post-pneumonec
tomy, with rising
/f_l
uid level
(c)
in the left haemothorax.

# Surgical management of pleural effusions and infec

Surgical management of pleural effusions and infections

Thoracoscopy or video-assisted thoracoscopic surgery (VATS) The direct-vision thoracoscope has been used for many years, but its use was limited mainly to performing biopsies. Since the advent of  video-assisted thoracoscopy ( Figure 60.9 ) the surgeon’s hands are now free because the camera is attached to the thoracoscope, which can be operated by an assistant with the image displayed on a screen. The surgeon is able to manipulate instruments with both hands to perform a variety of  procedures. The number of  ports required depends on the type and complexity of  the surgery . The patient is usually positioned with the diseased side uppermost, having had a double-lumen endotracheobronchial tube (ETT) placed by the anaesthetist to allow for single-lung ventilation. The principal ). The - - 

Figure 60.9
V i d e o - a s s i s t e d  t h o r a c o s c o p i c  s u r g e r y  ( V A T S )  u t i l i s e s
modern thoracoscopic instruments and digital technology and avoids
large incisions.

postoperative pain and a more rapid recovery . VATS drainage, pleural biopsy and talc pleurodesis V ATS drainage, pleural biopsy and talc pleurodesis is increas ingly performed for the management of  patients with an undi agnosed or malignant pleural e ff usion. It can be performed using a single port and allows direct visualisation of  the pleural cavity for complete drainage, multiple pleural biopsies and excellent talc insu ffl ation to achieve pleurodesis. VATS debridement of empyema Pleural infection, particularly early in its evolution, requires drainage, but once the fluid component becomes fibrinopu rulent and loculated it requires surgical debridement, which can often be achieved through a V ATS approach. The lung is isolated through the use of  a double-lumen tube, the patient is positioned disease side up and the pleural cavity is entered. T he fluid and debris are vigorously debrided, freeing the lung and allowing for re-expansion. At the end of  the case, carefully positioned chest drains are placed to allow for dependent drainage. Following the procedure, the patient requires good analge sic control, typically using patient-controlled analgesia (PCA), and physiotherapy to help fully re-expand the lung prior to final removal of  chest drains. Decortication If  the lung fails to re-expand after drainage of the empyema, the more radical operation of  decortication may be required ( Figure 60.10 ). The fibrous cortex or peel from the entrapped underlying lung is removed so that the lung can expand to obliterate the pleural space. This is usually performed through a posterolateral thoracotomy , though in selected cases it can be performed as a V ATS procedure. It requires careful dissection to remove the parietal and visceral cortex, taking care not to damage the visceral pleura, so allowing the lung to re-expand fully . 

Figure 60.10
Chest computed tomography scan showing an empy
ema with a grossly thickened pleura (arrow).

# Surgical management of pneumothorax

Surgical management of pneumothorax

Pleurectomy and pleurodesis Surgery for pneumothorax can be performed by video-assisted thoracoscopic surgery (V ATS) or as an open procedure (thora cotomy). The object of  the exercise is threefold: /uni25CF to deal with any leaks from the lung; /uni25CF to search for and obliterate any blebs and bullae; /uni25CF to make the visceral pleura adherent to the parietal pleura so that any subsequent leaks are contained and the lung cannot completely collapse. Pleural adhesion is achieved in one of  three ways: 1 pleurectomy : systematically stripping the parietal pleura from the chest wall; 2 pleural abrasion : a scourer is used to scrape o ff the slick surface of  the parietal pleura; 3 chemical pleurodesis : usually talc is used and is insuf flated into the chest cavity . ) (f ) ( g) (e (h) 

penetration of the skin, muscle and pleura;
(c)
blunt dissection of the parietal
(f)
digital examination along the tract into the pleural space;
(g)
withdrawal of

# THE DIAPHRAGM

THE DIAPHRAGM

The diaphragm is the fibromuscular structure separating the thorax from the abdomen.

# THE MEDIASTINUM

THE MEDIASTINUM

The mediastinum refers to the central area in the chest between the thoracic inlet and the diaphragm, between the right and left pleural surfaces, and which extends from the inner aspect of  the sternum to the vertebral column. It contains the heart, great /uni00A0 vessels, trachea and oesophagus and is arbitrarily subdivided into compartments (superior, inferior, anterior, middle and posterior). Many of the regional lymph node chains draining the chest and its organs are also found 

-

in the mediastinum. Various surgical procedures to approach structures, and particularly lymph nodes, in the mediastinum are performed, usually as diagnostic procedures. The surgical approach when mediastinal tumours require resection depends on the anatomical location of  the tumour ( Figure 60.22 and includes median sternotomy for anterior mediastinal pathology , thoracotomy or V ATS for posterior mediastinal pathology and transcervical (neck incisions) for superior mediastinal pathology . The middle mediastinum can usually be approached through thoracotomy or V ATS. Increasingly , a robotic or RATS approach is used, particularly for anterior mediastinal tumours such as thymomas. 

mediastinum
mediastinum
Thymoma
Lymphoma
Lymphoma
Thyroid
Germ cell tumour
Parathyroid
Middle
mediastinum
Cystic lesions
Lymphoma
Mesenchymal
tumours
Posterior
mediastinum
Neurogenic
tumours
Cystic lesions
Mesenchymal
tumours
Figure 60.22
Mediastinal pathology. Subdivisions of the mediastinum
with the most common mediastinal masses.

# Treatment

Treatment

- Removal of  the bronchiectatic part of  the lung for bleeding, recurrent infection or copious symptoms can be very e ff ective when the disease is localised. y ,

# Tuberculosis

Tuberculosis

Surgery is rarely indicated for tuberculosis in resource-rich countries but, when it is, it must be combined with adequate antitubercular chemotherapy or the benefit of  surgery will be lost. Summary box 60.5 Tuberculosis: indications for surgery /uni25CF /uni25CF /uni25CF /uni25CF Diagnosis Surgical procedures may be necessary to establish the diag nosis if  suspected clinically but sputum or pus cultures are persistently negative. Complications such as an aspergilloma in a chronic cavity causing life-threatening haemoptysis may require lobectomy 

Suspicious lesion on chest radiograph in which neoplasia
cannot be excluded
Chronic tuberculous abscess, resistant to chemotherapy
Aspergilloma within a tuberculous cavity
Life-threatening haemoptysis