Post Operative Management VATS Right Upper Lobectomy

Author: Brian Mitzman, MD
Institution: University of Utah
Date Reviewed: March 2025
Original Case: Junaid Haroon, MD; Rosemary Kelly, MD, Chair, University of Minnesota
Learning Domain: General Thoracic
Learning Objective: RML torsion
PowerPoint File: File TS04 - RML Torsion.pptx

 

Case History

73 yo RIGHT upper lobe nodule (14mm) on screening CT chest

  • PMHx: HTN, Peripheral Arterial Disease, Abdominal Aortic Aneurysm
  • PSHx: Knee surgery
  • Meds: Albuterol, Amlodipine, Lisinopril, Naproxen, Tamsulosin
  • Social: Veteran, current smoker, 75 pack year history, denies ETOH
  • Workup:
    • CT chest: 14mm spiculated nodule
    • PET/CT: SUV 6.5
    • PFTs: FEV1: 76.9%, DLCO: 60%
    • Biopsy: Squamous Cell

 

Pre-Op CT Chest

 

Procedure

  • VATS Right Upper Lobectomy, Mediastinal Lymphadenectomy
  • Complete fissures
  • No intraoperative complications

 

Immediate Post-Op CXR

 

Hospital Course

  • POD 1: Clinically stable
    • Afebrile
    • Saturating 98% on room air
    • In no distress
  • Routine CXR done

 

POD 1 CXR

 

Questions

  1. What do you see on CXR?
  2. Differential?
  3. Next step in care?

 

 

CT Chest

     

     

     

 

Questions

  1. What is your differential after CT Chest?
  2. What other things would you want to look for on the CT Chest that may not be shown?
  3. Plan?

 

Bronchoscopy

  • What are the usual bronchoscopic findings for middle lobe torsion?
  • How do you rule out torsion versus mucous plug?

 

Bronchoscopic view of middle lobe bronchus, after removing mucus

 

Hospital Course Part 1

  • CT Chest:
    • Mucus plugging with collapse of Right middle lobe
  • Bronchoscopy
    • Rt upper lobe bronchial stump intact
    • Rt middle lobe bronchus with mucus plugging
    • Once mucus plug removed, bronchus appeared congested and inflamed
    • Unable to pass scope into slit like opening of middle lobe bronchus

 

Hospital Course Part 2

  • Takeback to OR:
    • RML torsion
    • Right VATS, Right Middle Lobectomy
  • Pathology:
    • RUL: Squamous cell carcinoma, pT1b pN0
    • RML: Vascular congestion, focal alveolar hemorrhage

 

POD 1 CXR S/P Rt Middle Lobectomy 

 

Key Points

  • Differential of CXR
    • Post op pneumonia
    • Mucus plugging
    • Right middle lobe torsion
  • Differential of CT
    • Shows RML collapse/consolidation
      • Technical problem: 1) stapled RML airway, 2) inadvertently took RML nutrient blood supply/ischemia(right middle lobe PA +/- bronchial arteries), 3) RML torsion
      • Non-Technical problem:  1) Atelectasis, 2) pneumonia, 3) RML mucus plugging
  • Plan
    • Treat mucus plugging with bronch, pulmonary toilet.  RML torsion is vascular emergency identified by airway occlusion/collapse, rare to save RML unless identified very quickly and untorsed.  Best to prevent by providing broad base of attachment/fixation.  If not viable on exploration, perform right middle lobectomy.

 

Prevention

If major fissure between middle and lower lobe is complete after an upper lobectomy:

  1. Close observation during reinflation of lung
  2. Middle Lobe Pexy -  with suture, or by stapling parenchymal edge of middle lobe to lower lobe edge
  3. Glue has been reported in the literature (Venuta F et al.  JTCVS 2012;143:240-1)