Thoracic Surgery General Management I

Author: Brian Mitzman, MD
Institution: University of Utah
Date Reviewed: March 2025
Original Case: Stephen Yang, MD; Johns Hopkins University
Learning Domain: General Thoracic Surgery
Learning Objective: Lung anatomy and management
PowerPoint File: File TS01 - Gen Management I.pptx

 

Discussion Questions

  • Most common anomalies of the lung?
    • Encountered during bronchoscopy?
    • During lobectomy of individual lobes?

 

Standard Anatomy - Boyden Classification

Bronchopulmonary segments shown.  Each tertiary bronchus is numbered with respect to its position in the matching numbered bronchopulmonary segment.
a) Right lung (lateral view) / b) Right lung (medial view)
c) Left lung (lateral view) / d) Left lung (medial view)
e) Segmental or tertiary bronchi

     

 

Case #1

A 25 yo M sustains a bullet wound that enters the anterior right chest below the nipple and exits below the tip of the right scapula.

  • What potential organs are injured?  
  • What tests or procedures would be done to exclude injuries?

 

Discussion

  • Potential organs injured:  lung, esophagus, diaphragm, liver, airway, heart, pericardium
  • Work up:  FAST, CT chest/abdomen with oral and IV contrast, esophagram, endoscopy (bronchoscopy, esophagoscopy) – depending on situation and acuity

 

Case #2

  • A 68 yo F undergoes an uncomplicated VATS LLL lobectomy  
  • She is on sips of liquids overnight  
  • During the first POD1, the chest tube output was 350 cc and serosanguinous
  • On POD2, you note that the chest tube output has increased to 750 cc during the 24 hours before and looks turbid
  1. What is the cause? 
  2. How do you work this up and the treatment?  

 

Discussion

  • Differential: Lymphatic leak, chyle leak, esophageal leak
  • Workup: Send fluid for triglyceride, chylomicrons, amylase
  • Management: Make strict NPO vs chyle-leak diet

 

Case #2 Outcome

  • TG 735 in the chest tube fluid
  • PT made NPO > 700 cc/day for ensuing 4 days
  • Now what?

 

Case #2 Outcome

  • Percutaneous lymphoscintigraphy showed normal anatomy and leak in subcarinal area
  • Output slowed after test to 200/day
  • Started on PO diet but output increased to 900 cc cloudy fluid
  • Now what?

Thoracic Duct Lymphangiogram

 

Case #2 Outcome

  • PT given regular diet, NPO after midnight
  • Right VATS thoracic duct ligation at T10 and T11 level
    • Can give intraoperative heavy cream to exacerbate leak for localization
  • Drainage stopped intraoperatively
  • PT d/c home POD8

 

Case #3

  • You are doing a lingulectomy for a small peripheral 1.5 cm NSCLC. 
  • You have already divided the lingular PA and PV branches, and already stapled off the bronchus.
  • You reinflate the lung briefly to decide where to divide the lung parenchyma, but find that the lingula still inflates partially.
  • Why is this so?

 

Pulmonary Collaterals:  Pores of Kohn

  • Interalveolar connections, Canals of Lambert
  • Develop after birth
  • Account for:
    • Ventilation across segments and fissures
    • Failure of endobronchial valves
    • Local recurrence after wedge resection

 

Case #4

  • During a difficult left lower lobectomy dissection, you decide to open the pericardium to gain control of the PV.
  • You find only one branch emanating from the LA.
  • Now what?

 

Common PV Trunk

  • L>R
  • Reported 14% cases
  • Always Identify both SPV and IPV
  • If accidentally divided, convert to open, reanastomose to LA (not completion pneumonectomy)

     

 

Case #5

  • A 30-year-old woman presented with a history of two episodes of “pneumonia” and a three-year history of streaky hemoptysis.  
  • PMH is unremarkable and she is a non-smoker.  
  • Bronchoscopy reveals erythema of the left lower lobe bronchus and cytologic specimens were negative for malignant cells.  
  • A CT was obtained (shown).
  • What is the diagnosis and treatment? 


 

Case #5 Outcome

  • Diagnosis of pulmonary sequestration - what type?
  • Taken to OR for left VATS resection of sequestrated lung  
  • Feeding aortic artery found in inferior pulmonary ligament
  • Discharged POD 4
Intralobar SequestrationExtralobar Sequestration
Shares visceral pleura of normal lungLocked up within own pleural membrane separate from normal lung
Pulmonary venous drainageCongenital systemic venous drainage
Incidence 75%Incidence 25%
Symptoms due to associated anomalies 11%; 85% are asymptomatic60% symptomatic
20% asymptomatic
Recurrent respiratory infectionInfections rare
Malformations with a portion of lung parenchyma separate from normal lobe.
No normal communication with tracheobronchial tree and blood supply from systemic artery (aorta)
Congestive heart failure
Surgical resection for symptomatic lesions

 

Case #6

What is this anatomic anomaly?

 

     

 

Case #7

  • A 25 year old woman presented with a history of progressive SOB over 3 years.  Inhalers do not help her diagnosis of asthma.
  • CXR and CT are shown.
  • Her past medical history is unremarkable and she is a non-smoker.
  • What is the diagnosis and treatment? 

 

Case Outcome

  • Diagnosis of congenital lobar emphysema                 
  • FEV1 68% predicted, DLCO 86% predicted
  • Ventilation perfusion scan showed matched defect to RLL
  • Underwent right thoracotomy, RLL lobectomy
  • Discharged POD 4

 

Learning Points

  • Common anatomic pulmonary arterial anomalies most often in LUL, followed by unusual segmental abnormalities in the RUL post segment, superior segments and lingula
  • Lymphoscintigraphy can be therapeutic 50% in stopping chyle leaks
  • Pulmonary sequestrations are most common in the left side 
  • Be aware of other congenital disorders:  CAM