Lobectomy

Surgical approach

• Indications: lung cancer (most common), bronchiectasis, TB/fungal disease, benign tumours, trauma
• Approaches
  • VATS/robotic lobectomy: 2–4 ports ± utility incision; less pain/LOS, but still major physiological insult
  • Open thoracotomy (posterolateral): rib spreading; more pain, higher respiratory compromise
• Key surgical steps (typical)
  • Lateral decubitus; single-lung ventilation; collapse operative lung
  • Hilum dissection: pulmonary vein branch, pulmonary artery branches, lobar bronchus divided and stapled
  • Fissure completion (staplers), specimen retrieval
  • Mediastinal lymph node sampling/dissection (oncology cases)
  • Air leak test; haemostasis; intercostal drain(s) placed; lung reinflated
• Intraoperative events that affect anaesthesia
  • Need for lung isolation/OLV; periods of hypoxia; CO2 insufflation occasionally in VATS
  • Major bleeding risk (pulmonary artery injury), arrhythmias with hilar manipulation
  • Bronchial stump leak/air leak; conversion VATS → thoracotomy

Anaesthetic management (headline)

• Type of anaesthesia
  • General anaesthesia with lung isolation is standard
  • Regional techniques are adjuncts for analgesia (thoracic epidural, paravertebral, erector spinae plane, serratus anterior plane)
• Airway
  • Double-lumen tube (DLT) most common; bronchial blocker alternative (difficult airway, tracheostomy, paediatrics, need to remain intubated post-op with single-lumen tube)
  • Fibreoptic bronchoscopy to confirm position after intubation and after lateral positioning
• Duration
  • Typically 2–4 hours (longer if complex dissection, adhesions, pneumonectomy conversion, robotic set-up)
• How painful?
  • Thoracotomy: very painful (rib spreading, intercostal nerve injury) → high risk of splinting/atelectasis
  • VATS: moderate–severe; still benefits from regional analgesia and multimodal regimen
• Monitoring/lines (typical)
  • A-line (beat-to-beat BP, ABGs), large-bore IV access; consider CVC if poor access/vasoactive infusions/major bleeding risk
  • Temperature, urinary catheter for longer cases; consider cardiac output monitoring selectively

Preoperative assessment and optimisation

• Goals: assess operability (cardiorespiratory reserve), predict post-op lung function, plan OLV strategy and analgesia, reduce PPCs
• History/examination
  • Symptoms: dyspnoea, exercise tolerance (stairs/shuttle), cough/sputum, haemoptysis, wheeze, chest pain
  • Smoking history; COPD/asthma; OSA; previous thoracic surgery/radiotherapy (adhesions, difficult OLV)
  • Cardiac: IHD, HF, AF; pulmonary HTN; prior chemo (cardiotoxicity e.g., anthracyclines)
• Investigations
  • Spirometry: FEV1, FVC; consider bronchodilator optimisation
  • DLCO (gas transfer): strong predictor of perioperative risk
  • ABG if severe disease/hypercapnia suspected; CXR/CT; ECG; echo if indicated
  • Cardiopulmonary exercise testing (CPET) if borderline: VO2peak and anaerobic threshold (AT)
• Predicted postoperative function (ppo)
  • Estimate using segment counting or perfusion scan: ppo = preop value × (remaining functional segments/total functional segments)
  • Interpretation (typical thresholds used in practice): ppoFEV1 or ppoDLCO < 30% predicted = high risk; 30–40% = increased risk; > 40% generally acceptable with other factors considered
• Functional risk markers (commonly used)
  • CPET: VO2peak < ~10 ml/kg/min or AT < ~11 ml/kg/min suggests high risk; VO2peak > ~15 ml/kg/min lower risk (interpret alongside clinical context)
  • Stair climb: poor performance suggests higher risk (rough guide only)
• Optimisation
  • Smoking cessation (ideally ≥4 weeks), bronchodilators/inhaled steroids as indicated, treat infection, chest physio, prehabilitation
  • Anaemia correction, nutrition, glycaemic control; VTE risk assessment

Anaesthetic technique: induction, maintenance, and positioning

• Induction
  • Standard IV induction; consider haemodynamic stability (thoracic epidural may reduce SVR); avoid excessive opioids if aiming for early extubation
  • Muscle relaxation to facilitate DLT placement and surgical exposure
• Airway/lung isolation choices
  • Left DLT often preferred (more forgiving anatomy); right DLT if left main bronchus pathology/left pneumonectomy etc.
  • Bronchial blocker: useful with difficult airway, existing ETT, or need for post-op ventilation without DLT exchange; slower collapse, harder suctioning
• Positioning (lateral decubitus)
  • Check DLT position after turning; protect pressure points; axillary roll; secure head/neck; ensure dependent arm perfusion
  • Ventilation-perfusion: dependent lung better perfused; aim to ventilate dependent lung during OLV
• Maintenance
  • Volatile or TIVA acceptable; avoid high FiO2 for prolonged periods if possible (absorption atelectasis), but prioritise oxygenation
  • Neuromuscular monitoring; depth of anaesthesia monitoring may help with low-flow/OLV and haemodynamic stability

One-lung ventilation (OLV): physiology and management

• Key physiology
  • Shunt increases as non-ventilated lung still perfused; HPV reduces shunt by diverting blood to ventilated lung
  • Factors that inhibit HPV: high volatile concentrations, alkalosis, high pulmonary artery pressures, vasodilators; hypoxia and hypercapnia augment HPV (within limits)
• Ventilation strategy during OLV (typical)
  • Protective ventilation: tidal volume ~4–6 ml/kg predicted body weight, plateau pressure ideally < 25 cmH2O, driving pressure minimised
  • PEEP to dependent lung (often 5 cmH2O, titrate to oxygenation/compliance); avoid excessive PEEP that increases dead space or diverts perfusion
  • Permissive hypercapnia may be acceptable if haemodynamics and ICP allow; avoid severe acidosis
• Managing hypoxaemia during OLV (stepwise)
  • 1) Increase FiO2 to 1.0; check circuit, haemodynamics, Hb, and SpO2 trace
  • 2) Confirm lung isolation and DLT/blocker position with fibreoptic bronchoscopy; suction secretions; ensure operative lung fully collapsed
  • 3) Optimise ventilation: recruitment manoeuvre to dependent lung then titrate PEEP; adjust VT/RR to avoid high pressures
  • 4) Apply CPAP (e.g., 1–5 cmH2O) to non-dependent lung if surgeon allows; or intermittent two-lung ventilation
  • 5) Consider differential lung ventilation, pulmonary vasodilator avoidance, treat bronchospasm, and discuss temporary surgical pause
• Fluid strategy
  • Aim for euvolaemia; avoid liberal fluids (risk of post-resection pulmonary oedema/ARDS), but maintain perfusion and renal function
  • Use balanced crystalloid; blood products guided by losses/viscoelastic testing where available; consider vasopressors early rather than fluid loading

Analgesia (thoracotomy and VATS)

• Principles
  • Effective analgesia reduces splinting, improves cough/physio, reduces PPCs and chronic post-thoracotomy pain
• Regional options
  • Thoracic epidural (TEA): excellent dynamic analgesia; risks: hypotension, urinary retention, motor block, epidural haematoma/infection; caution with anticoagulation
  • Paravertebral block/catheter: comparable analgesia with less hypotension; risk: pneumothorax, vascular puncture, LA toxicity
  • Erector spinae plane (ESP) catheter: easier/safer plane block; variable efficacy; useful when TEA contraindicated
  • Serratus anterior plane/intercostal blocks: helpful for VATS port pain; shorter duration unless catheter used
• Systemic multimodal
  • Paracetamol + NSAID (if renal function/bleeding risk acceptable) + opioid (PCA) as rescue; consider ketamine infusion (opioid-sparing), magnesium, lidocaine infusion (unit dependent)
  • Avoid excessive sedation; prioritise early mobilisation and effective cough

Postoperative care and complications

• Immediate post-op priorities
  • Oxygenation/ventilation, analgesia, chest drain management, haemodynamic stability, temperature, nausea control
  • Plan destination: PACU with enhanced monitoring vs HDU/ICU depending on reserve, extent of resection, intra-op events
• Respiratory complications
  • Atelectasis, pneumonia, bronchospasm, prolonged air leak, pneumothorax, respiratory failure
  • Post-resection pulmonary oedema/ARDS: uncommon but severe; associated with pneumonectomy > lobectomy, high fluids, high airway pressures, right-sided resections
• Cardiovascular complications
  • Atrial fibrillation (common after thoracic surgery), myocardial ischaemia, hypotension (epidural/bleeding), pulmonary embolism
• Surgical complications relevant to anaesthesia
  • Bleeding (pulmonary artery), bronchopleural fistula, chylothorax (thoracic duct injury), recurrent laryngeal nerve injury (hoarseness/aspiration risk)
• Extubation considerations
  • Aim for extubation in theatre if: good gas exchange on two-lung ventilation, normothermia, haemodynamic stability, adequate analgesia, acceptable airway pressures, minimal bleeding
  • Consider post-op NIV/CPAP in selected patients (COPD/OSA) with careful monitoring and surgical agreement