Lobectomy

• What is a Lobectomy?
• When is a Lobectomy Used as Treatment?
• When is a Lobectomy Not Used as Treatment?
• What is Involved in a Lobectomy?
• What to Expect Before and After a Lobectomy
• What are the Possible Side Effects of a Lobectomy?

What is a Lobectomy?

A lobectomy is the surgical removal of one lobe of the lungs, usually to remove a lung cancer. A bilobectomy is the removal of two lobes, and a pneumonectomy is the removal of an entire lung. Lobectomy is usually used for the treatment of non-small cell lung cancers, especially if caught early enough that they have not spread very far. Lobectomy is a major operative procedure, and there are risks involved. These, along with the benefits and the method of the procedure, should be discussed in detail with a surgeon before the operation takes place.  

As shown in the diagram above, the lungs are actually made up of several sub-sections known as ‘lobes’. Lobes are big areas of lung tissue divided by lines or ‘fissures’. The right lung has three lobes, called the superior (meaning top), inferior (meaning bottom) and middle lobes. The left lung only has two lobes, the superior and inferior, partially because there is less room due to the presence of the heart in the left side of the chest. In a lobectomy, the surgeon will try and remove only one of these lobes, allowing the rest to remain functional. Removal of two lobes of the lung is called a ‘bilobectomy’ and removal of an entire lung is called a pneumonectomy.

When is a Lobectomy Used as Treatment?

A lobectomy is usually used for treatment of non-small cell lung cancers (NSCLC), especially those that are caught early. The amount of lung that needs to be removed to prevent the spread of these tumours is affected by the location of the tumour as well as whether or not there are any ‘hilar lymph nodes‘ (that lie between the lobes) involved. Whether the surgeon decides to remove one lobe, two lobes or an entire lung will depend on the site of the tumour, the size of the tumour as well as the presence of any lymph nodes that appear to have tumour cells in them. If there are hilar nodes involved then a pneumonectomy may be necessary. Decisions may also depend on the general state of a person’s health, as a healthier patient may be able to cope with surgery better than someone who is very unwell.

When is a Lobectomy Not Used as Treatment?

Lobectomy is not suitable therapy for all lung cancers. For example if the cancer was caught very, early when it is small and has not spread, and if the patient is too weak to get through a lobectomy, then removal of an even smaller section of lung called a ‘segment’ may be used. The type of cancer is also important in deciding whether lobectomy is a suitable treatment or not. Lobectomy may not be as appropriate for the treatment of small-cell cancers, as they require far more aggressive treatment. Advanced lung cancers that have spread to other parts of the body may not be suitable candidates for lobectomy either, as there may not be sufficient benefit from it. However for some patients, especially those with isolated metastases (areas of spread) in their brain or adrenal glands, surgery may still have some benefit.

What is Involved in a Lobectomy?

A lobectomy will be done under general anaesthesia. The exact details of where a surgeon will make an incision will depend on the location and size of the tumour. The surgeon will have to isolate the lobe of the lung by removing its blood supply as well as the bronchi (the airways that feed into the lobe) before the lobe itself is able to be removed. During the procedure, the surgeon may want to take what is known as a ‘frozen section’ from a lymph node, or an area surrounding the tumour. A frozen section is basically a relatively quick sample of tissue that can be examined by the pathologists on the spot so that they can assess whether or not the tumour has spread to the tissue that the surgeon has sampled. This can also be done to make sure that there is a good margin of healthy tissue that has been removed from the area around the tumour, ensuring all the tumour has been taken out.

What to Expect Before and After a Lobectomy

Before a lobectomy details about the procedure, the benefits, and the risks should all have been explained to you by your surgeon. If you have any questions regarding the operation you should feel free to ask them, as the more you know then the less worried you will be regarding the surgery. To decide whether lobectomy is the correct procedure, several investigations will have to be done to examine both the lesion itself as well as your general health. An X-ray and CT of the chest will help to assess the size, location and operability of the lesion. An ECG to assess the function of your heart will give the doctor a good idea of how your heart will cope with the strain of the operation and the suitability of a lobectomy. Lung Function Tests will give the doctor an idea about how well the rest of the lung is working. They need to know that they rest of the lungs are strong enough to take over the function of the removed lobe. For information about further tests for lung cancer not directly related to lobectomy, see the section on NSCLC. After the operation there will usually be a ‘drain’ attached to the site of the operation. This drain is a tube that sits in the operative site and will remove any blood or other fluid that may otherwise cause breathing problems. This will be removed once fluid has stopped draining. The doctors, nurses and physiotherapists on the ward will probably try and get you moving as soon as possible. This is because it not only helps your lungs to get better, but also stops the blood from pooling in your leg veins and helps prevent deep vein thrombosis. X-rays of your chest should be taken regularly while in hospital to make sure that they are inflating correctly, and there are no abnormalities. After the surgery you will be kept in hospital for observation until the doctors are satisfied that you are ready to leave. The length of stay in hospital varies from person to person, but should not be rushed.

What are the Possible Side Effects of a Lobectomy?

A lobectomy is a major operation and while everything is done to try and prevent complications, it is inevitable that they will occasionally occur. The mortality rate for a lobectomy is between 3 and 4%, which is significantly lower than for a pneumonectomy which is between 6 and 8%. Possible complications following a lobectomy include:

• Cardiac arrhythmias: the heart beats irregularly and stops pumping blood as efficiently
• Bleeding
• Infection
• Bronchopleural fistulae: a connection forms between the lung and the surrounding area leading to air leakage
• Respiratory Insufficiency: if the rest of the lung cannot compensate for the loss of the lobe
• Pulmonary Embolism: a blood clot ca
  n lodge in the vessels of the lung, causing an area to lose blood supply
• Deep Vein Thrombosis: lying in bed for long periods after surgery can cause blood to pool in the veins of the legs and clot, causing a DVT
   

References

1. Ginsberg RRJ, Rubinstein LLV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. The Annals of thoracic surgery. 1995;60(3):615-22; discussion 22.
2. McLatchie G, Leaper D. Oxford Handbook of Clinical Surgery. Second ed. Oxford: Oxford University Press 2002.
3. Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Annals of surgery. 2006;244(3):420-5.
4. Tjandra JJ, Clunie GJ, Kaye AH, et al. Textbook of Surgery. Third ed. Massachusetts: Blackwell Publishing 2006.
5. Vay LW, Doherty GM. Current Surgical Diagnosis & Treatment. Eleventh ed. New York: Lange Medical Books/McGraw-Hill 2003.