ASSISTANT : Randall E. Nelson, M.D.
ANESTHESIOLOGIST: Sydney I. Thomson, M.D.
OPERATION:
1. Bronchoscopy.
2. Right thoracotomy with decortication.
3. Segmental resection of posterior segment of right upper lobe.
4. Wedge resection of the apical segment of the right upper lobe.
5. Lymph node biopsy.
6. Intercostal nerve block, multiple.
PREOPERATIVE DIAGNOSES:
1. Severe chronic obstructive pulmonary disease secondary to cigarette smoking, right upper lobe carcinoma proven on
CT localization biopsy.
2. Hypertension.
3. Coronary artery disease, status post coronary artery bypass graft.
4. Benign prostatic hypertrophy with urinary retention.
POSTOPERATIVE DIAGNOSES:
1. Severe chronic obstructive pulmonary disease secondary to cigarette smoking, right upper lobe carcinoma proven on
CT localization biopsy.
2. Hypertension.
3. Coronary artery disease, status post coronary artery bypass graft.
4. Benign prostatic hypertrophy with urinary retention.
5. Total peel over the right lung.
ANESTHESIA: General endotracheal with endobronchial tube and transesophageal echocardiography.
INDICATIONS: The patient is an 80-year-old male who has had a long history of cigarette smoking and has had chronic obstructive pulmonary disease. The patient was found to have a lesion in the right upper lobe and subsequent PET scan showed this to have marked increased uptake but there was no evidence of any tumor in the kidneys, adrenals, the liver or the bones. Mediastinoscopy showed large lymph nodes that had been seen on the CT but they were all lymphadenitis and no evidence of metastatic tumor. Because the patient had significant chronic obstructive pulmonary disease, he was seen in consultation by Dr. Wroblewski who noted that his forced vital capacity was 3.01 liters, his

FEV1 was 1.42 liters, and Dr. Wroblewski and I after discussion felt the patient could tolerate lower lobe cancer which had been shown on needle biopsy to be a non-oat cell but we would try and preserve as much lung as possible. He was placed on bronchodilators and vigorous pulmonary toilet prior to the surgery.
The patient had also been on Coumadin because of chronic atrial fibrillation and this had also been stopped. The patient also had a history of type 2 diabetes and hyperlipidemia. He occasionally uses oxygen at home.
The patient, however, has been fairly active and able to walk long distances at a slow pace without significant dyspnea. The patient also prior to surgery had evidence of benign prosthetic hypertrophy with retention and required catheterization but subsequent urinalysis was negative for any infection. Bronchial washings done previously had shown no evidence of any significant infection.
FINDINGS: At the time of the operation the patient had a peel over especially the right upper lobe and adhesions throughout the chest probably from the needle biopsy and some bleeding within. These were taken down and the lung was decorticated. The patient had a few small lymph nodes in the anterior mediastinum and the hilum and these were dissected out but did not appear to be grossly involved with tumor. There were no obvious abnormalities in the lung able to palpated. In the upper lobe indeed the lesion that was palpable was about 3 cm in diameter in the posterior segment of the right upper lobe. After a segmental resection was done, the margins were clear and the tumor appeared to be probably squamous cell carcinoma.
There was also a papular nodular density in the apex of the lung near the superior portion of the apical segment and because there was suspicion about this, this was also wedged out but this proved to be marked inflammatory tissue with some squamous metaplasia but no obvious cancer was seen on frozen but we will have to wait for permanents.
After the conclusion, half of the right upper lobe remained with the anterior segment and most of the apical segment.
The lung ventilated well and after decortication expanded well. The patient had minimal air leak and initially was able to be extubated and taken to the postoperative anesthesia recovery room in stable condition.

PROCEDURE: The patient was placed on the table in the supine position and after placement of intravenous line and arterial line, general endotracheal anesthesia was induced.
After vigorous bronchial lavage and removal of secretions as outlined in another operative report, the table was positioned appropriately and a subclavian line was placed on the right. A Foley catheter had been placed and 1000 mL of urine had been brought out. The patient was then placed in the left lateral decubitus position with all the padding appropriately and with compression hose on the legs and the right chest was prepped and draped in the usual sterile fashion.
A right lateral thoracotomy was performed and a portion of the latissimus dorsi muscle was opened. The 5th intercostal space was carefully entered. The patient did have adhesions. These were carefully freed up as retractors were placed. An extensive resection of the lung from adhesions of the chest wall was done and these were thin and not thickened at all as would be expected from previous cardiac bypass surgery and associated with the biopsy the patient had. The lung in order to reach the fissure and to be able to do the operation had extensive decortication done. Once this was accomplished attention was then turned to the posterior segment where the lesion was.
Using the pneumatic 64.8-mm cutting and non-cutting staple, it was taken down and separated from the apex. Then going in and ligating the artery as needed, the remainder of the posterior segment was able to be freed up, the artery was ligated and the TL-90 stapler was placed beneath it and going down to the major fissure posteriorly, separated from the right lower lobe.
After the segmental resection was completed with vessels being tied off as needed with #4-0 Vicryl suture, the specimen was removed and sent to pathology after having been marked. This showed carcinoma, most likely squamous cell. The margins were clear. Then going to the apical segment, there was some thickening but deeper than the superior part of the apical segment, was another palpable lesion about 2 cm in diameter and then using the TL-60 stapler this was wedged out in order to make a clear margin. This on frozen section appeared to have squamous metaplasia but no identifiable cancer. Below this the lung with good margins showed emphysematous changes but no

inflammatory changes. The edge of the suture line was then oversewn with interlocking #3-0 chromic suture.
The lymph nodes were sought in the area of the anterior hilum and the mediastinum and these were resected and sent off for pathology as well. The left lower lobe was freed up along the inferior pulmonary ligament and freed up from the diaphragm and it was also decorticated as needed.
After this was done the lung expanded well and the wound was irrigated with copious amounts of warm saline and
Kefzol and saline.
Attention was then turned to the intercostal block. The decortication and pleural resection had been facilitated with the thoracoscope and then using the thoracoscope, an intercostal block was done from the 2nd down to the 8th intercostal spaces after the Marcaine with epinephrine.
Through stab wounds, #36 French and right angle chest tubes were placed and there was no bleeding from this area. They were secured with #0 silk suture and attention was turned to closure and #00 chromic pericostals were placed and tied down. The muscles were reapproximated with #0 Vicryl suture and the subcutaneous tissue was closed with continuous suture of #2-0 Vicryl. The skin was approximated with subcuticular stitch of #3-0 Vicryl.
Chest tubes were put on suction and had minimal amount of air leak. The patient's wounds were dressed and he was then placed in the supine position and medicated and extubated. At the end of the procedure, the sponge, needle, and instrument counts were correct.
ESTIMATED BLOOD LOSS: 200 mL.
BLOOD REPLACEMENT: None.
IV FLUIDS GIVEN: 300 to 400 mL of crystalloid.
DRAINS: Two #36 French chest tubes.