Tutorial
Intrapericardial pneumonectomy
Intrapericardial pneumonectomy is a major thoracic surgical procedure that is employed to resect locally advanced bronchogenic carcinoma.
The right-side and left-side procedures differ slightly due to the anatomical differences of the two pulmonary hila and adjacent mediastinal structures. The common beginning of the operation is the longitudinal opening of the pericardium behind the phrenic nerve. On the left side, the pulmonary artery is dissected under the aortic arch and the ligamentum arteriosum is divided. The superior and inferior pulmonary veins are then dissected and prepared intrapericardially, and finally the bronchus is prepared posteriorly to the hilum. On the right side, the pulmonary artery is dissected from the superior vena cava and the procedure follows as on the left side.
The mortality rate for intrapericardial pneumonectomy is in the range of 5–10% and the complication rate is about 20%.
Intrapericardial pneumonectomy is a major thoracic surgical procedure that is employed to resect locally advanced bronchogenic carcinoma or, less frequently, other thoracic neoplasms that deeply infiltrate into the pulmonary hilum and/or mediastinum.
The main bronchus must be thoroughly explored by bronchoscopy to rule out any infiltration beyond resectability. The procedure is usually performed through posterolateral or lateral thoracotomy, an approach by which the pulmonary hila and lateral aspect of the mediastinum are best exposed. For some specific indications it can also be performed by median or transverse sternotomy. Using this approach the exposure of the pulmonary artery is facilitated, but especially on the left side the exposure of the inferior pulmonary vein can be difficult. Intrapericardial pneumonectomy differs slightly between left side and right side approaches due to the anatomical differences in the two pulmonary hila and adjacent mediastinal structures.
1 - Left intrapericardial pneumonectomy: Opening the pericardium (0:00)
The technique described here is performed through a lateral thoracotomy either on the left or on the right side. After a left intrapericardial thoracotomy has been performed in the 5th intercostal space, the lateral aspect of the mediastinum is approached. The pericardium is suspended by a clamp behind the phrenic nerve at the level of the superior pulmonary vein. The pericardium is then incised and the incision is continued upward toward the pulmonary artery, using scissors, and then downward toward the inferior pulmonary vein with an electric scalpel.
2 - Left intrapericardial pneumonectomy: Preparation of the pulmonary artery (0:28)
The pulmonary artery, the pulmonary veins, and the heart are inspected and palpated to ascertain the extension of the tumor; the pericardial fluid is collected for subsequent cytological examination. The pulmonary artery is then approached first; it is dissected in and out of the pericardium and encircled by an umbilical tape.
3 - Left intrapericardial pneumonectomy: Dissection of the sub-aortic window (0:46)
The lung is then retracted downward and the subaortic window is approached. In this area, which is potentially infiltrated by the tumor, care must be taken to identify the ligamentum arteriosum, which must be divided, and the left recurrent laryngeal nerve, which must be protected. The vagus nerve lies posteriorly in the operative field. If the tumor is present in this area, it must be resected en bloc with the pulmonary hilum, following a subadventitial plane on the hollow side of the aortic arch.
4 - Left intrapericardial pneumonectomy: Dissection of the pulmonary veins (1:12)
After the preparation of the upper portion of the pulmonary hilum is completed, the superior and inferior pulmonary veins are approached. The superior pulmonary vein is dissected, separating its posterior wall from the bronchus, while the inferior pulmonary vein is prepared after sectioning the pulmonary ligament. The vascular elements of the hilum are now under control, and the resection phase can begin; the bronchus can be prepared either at this point or after all the vascular elements have been divided.
5 - Left intrapericardial pneumonectomy: Suture & division of the pulmonary artery (1:25)
An SCW45 vascular stapler with a vascular cartridge is applied to the pulmonary artery and the vessel is sutured and divided.
6 - Left intrapericardial pneumonectomy: Suture & division of the superior pulmonary vein (1:36)
The superior pulmonary vein is sutured and divided using an SWC45 vascular stapler loaded with a vascular cartridge; the bronchus is dissected behind the stump of the vein.
7 - Left intrapericardial pneumonectomy: Suture & division of the inferior pulmonary vein (1:49)
Suture and division of the inferior pulmonary vein using an SWC45 vascular stapler loaded with a vascular cartridge.
8 - Left intrapericardial pneumonectomy: Suture & division of the left main bronchus (2:01)
The bronchus is approached; it is elevated by retracting the whole lung up, and all adhesions are divided using a TX30 linear stapler loaded with a green (4.5 mm) cartridge. At this point the position of the endobronchial tube must be checked and the tube is eventually withdrawn if needed.
9 - Left intrapericardial pneumonectomy (2:08)
The pulmonary hilum after the lung is removed and the pericardial opening are shown.
Right intrapericardial pneumonectomy
On the right side the procedure is similar to that of the left, except there are important differences concerning the anatomy of the right pulmonary artery and its relationship to the main bronchus and superior vena cava.The incision of the pericardium follows the same patterns as on the left side, but on the right the superior vena cava is retracted medially and the pulmonary artery is prepared either behind the cava or, if the tumor does not give enough space, medially to the vein, between the superior vena cava and the ascending aorta.
10 - Right intrapericardial pneumonectomy (2:18)
The pulmonary artery is sutured and divided behind the superior vena cava and below a hypertrophic azygos vein; the left atrium is sutured and sectioned after the confluence of the two pulmonary veins (the two veins are sutured together); the bronchus is sutured and the lung is removed. Note the hypertrophic azygos vein.
The rest of the procedure is similar to that for the left side.
Completing the procedure
After the procedure the pericardial defect can be left open, or it can be closed by interrupted sutures to prevent cardiac herniation if the anatomy requires it. Also, the bronchial stump can either be left as is or protected by a tissue flap according to the surgeon’s preference.
The techniques for intrapericardial pneumonectomy vary on the left and on the right side. Accordingly, the technique for lymphadenectomy varies on the two sides.
Since intrapericardial pneumonectomy is performed mostly for cancer, lymphadenectomy plays an important role. On the right side radical lymphadenectomy should incorporate hilar (stations 10 and 11), paraesophageal (station 8), pulmonary ligament (station 9), subcarinal (station 7), and paratracheal (stations 4 and 2) nodes. On the left side, in addition to these stations, the pre- and para-aortic and pulmonary windows nodes (stations 3, 5 and 6) should be resected.
The protection of the bronchial stump is also an important issue. The bronchus can either be left uncovered or protected by mediastinal tissue, intercostal muscle or omental flap. This is left to the surgeon’s preference and depends on the presence of coexisting risks, for example preoperative induction chemo- or chemoradiotherapy.
The mortality rate after intrapericardial pneumonectomy is in the range of 5–10% and the complication rate is about 20% . Among medical complications, the most frequent are tachyarrhythmias, which appear in about 20% of patients. The most dreaded complication, specific to this operation, is cardiac herniation through the pericardial opening. Care must be taken to close a pericardial defect if this is anatomically relevant. This can be done by direct suture when possible or by the use of a patch (bovine pericardium or PTFE). Other post-pneumonectomy complications are similar to those occurring after standard pneumonectomy.
- Rice TW. Techniques of pneumonectomy. Standard Pneumonectomy. Chest Surg Clin N Am 1999;9:353–368.
PubMed Abstract - Bernard A, Deschamps C, Allen MS, Miller DL, Trastek WF, Jenkins GD, et al. Pneumonectomy for malignant disease: factors affecting early morbidity and mortality. J Thorac Cardiovasc Surg 2001;121:176–182.
PubMed Abstract | Publisher Full Text
This tutorial was originally published by EACTS with Oxford University Press and has been adapted to fit our new MMCTS templates.
Authors
Erino A. Rendinaa, Federico Venutab, and Mohsen Ibrahima
Author Affiliations
aDivision of Thoracic Surgery, Sant’Andrea Hospital, University La Sapienza, Via di Grottarossa a 1035, 00189 Rome, Italy
bUniversity of Rome, Division of Thoracic Surgery, Policlinico Umberto l, V. le del Policlinico b 155, 00100 Rome, Italy
Corresponding Author
Phone: +39 06 8034 5650
Email: erinoangelo.rendina@tin.it
Keywords
© The Author 2006. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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