• ERAS medications (including non-narcotic pain medications and DVT chemoprophylaxis) should be given in preoperative holding area.
  • Ensure proper placement of double-lumen endotracheal tube.
  • Appropriately timed prophylactic antibiotic.
  • Avoid use of foley catheter.
  • Radial artery catheter rarely needed.
  • Keep patient normothermic.
  • Lead the “Time Out” which includes 2 patient identifiers, verification of procedure and equipment needed, and the introduction of all team members in the O.R. suite.
     

INCISION, EXPLORATION, & MOBILIZATION

  • 0.5% Marcaine with epinephrine is used for preemptive analgesia in the wounds and for a multilevel intercostal nerve block.
  • After entry into the chest, complete adhesiolysis if needed.
     

  • Perform manual palpation of the entire lung to rule out occult disease and to ensure resectability of primary lesion.

 

  • If not yet performed, completely mobilize the inferior pulmonary ligament.

LYMPH NODE DISSECTION

  • With the inferior pulmonary ligament mobilized, remove any level 9 lymph nodes with the Harmonic 1100 Shears (or similar ultrasonic device).
     
  • Retract the lung anteriorly and complete a posterior lymphadenectomy including stations 7, 8, and 10 with the Harmonic 1100 Shears. 
  • Retract the lung posteriorly and complete the anterior hilar dissection removing level 10 and 4R inferior (on the right side) with the Harmonic 1100 Shears. 

DISSECTING & DIVIDING BLOOD VESSELS

  • For upper and middle lobes, dissect the upper and middle lobe pulmonary vein as it lies more anterior to the artery.

  • For lower lobectomies, the inferior pulmonary vein is found at the base of the inferior pulmonary ligament. 
     

  • Encircle the vein with a suture or vessel loop to aid in manipulation for stapling. 
  • Dissect out the lobar branches of the pulmonary artery and encircle with a suture or vessel loop.
  • Dissect and encircle the lobar bronchus with a suture or vessel loop. 
  • Compress the lobar bronchus with the ECHELON 3000 stapler (Green load).
  • Perform test ventilation to ensure no inflation of target lobe with adequate ventilation to remaining lung.
  • Remove the specimen from the chest in an appropriately sized tissue pouch.
  • Complete the lymphadenectomy by removing level 2R and 4R on the right side, or level 5 and 6 on the left side with the Harmonic 1100 Shears.

AIR LEAK TEST

  • With all staple lines and lung parenchyma under saline, gradually ventilate the lung. Start at an airway pressure of 20cmH2O and increase in increments of 5cmH20 up to 35cmH20 while examining the lung for evidence of an air leak. 
  • If an air leak is detected, repair options include suturing, restapling, or the use of a pneumostatic agent.
  • Suction any remaining irrigation fluid.
  • Place a single chest tube to the apex of the chest and secure.

NOTE: “Debrief” with the O.R. team should verify the procedure performed, estimated blood loss, correct labeling of all pathology specimens, and anticipated postoperative needs.

Potential complications include but are not limited to:

  • Air leak
  • Bleeding
  • Atelectasis
  • Pneumonia
  • Arrythmia
  • Wound infection
     

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