Open Pneumonectomy - Operative Steps

Patient Positioning & Approach

Right Pneumonectomy

Anatomical Considerations

• The right main pulmonary artery is longer outside the pericardium than the left, giving more room to work.
• Two-thirds of the main bronchial circumference is cartilage (horseshoe-shaped); the remaining one-third is membranous. Precise stapling orientation is required to prevent bronchial fistula.
• If there is extensive hilar adhesion, the central right pulmonary artery can be accessed between the ascending aorta and superior vena cava.

Operative Steps

• The mechanical weak point of the bronchial stump is the membranous portion; it is important to fold the stump so that the mucous membrane faces inward.
• Reinforce with 2-0 Prolene placed on both sides of the bronchial stump in a Z-direction. Add 2-4 stitches to ensure proper introversion of the stump.

Figure: Division of the right bronchus. The TA stapler is placed in the Sweet direction at approximately the 3rd cartilage ring from the carina.

Left Pneumonectomy

Anatomical Considerations

• The left main bronchus is long, while the left main pulmonary artery is short.
• Resection of the left main bronchus must be done carefully - dividing too far from the carina creates a "dead-end pocket."
• The distance from the main trunk of the pulmonary artery to the pericardium is relatively short, leaving little room to clamp in case of arterial injury.

Operative Steps

Chest Closure and Postoperative Drainage

• After specimen removal, the bronchial stump is tested for air leak underwater.
• The pericardium is inspected; if opened (e.g., for intrapericardial vessel ligation), it is partially reapproximated to prevent cardiac herniation. A pericardial patch may be needed if the defect is large.
• The thoracic cavity is irrigated and a chest drain is placed (often with a balanced drainage system - no suction, to avoid mediastinal shift).
• The thoracotomy is closed in layers: intercostal muscles, serratus anterior, latissimus dorsi, subcutaneous tissue, skin.

Key Technical Points

Indications (Summary)

Right Lung Hilar Anatomy

Overview

Contents of the Right Hilum

Arrangement of Structures

Anterior-to-Posterior Order

Vein → Artery → Bronchus

• Pulmonary veins are the most anterior structures; their course is predominantly inferomedial
• Pulmonary artery lies intermediately; its course is predominantly transverse - it passes anterior to the right main bronchus (in contrast to the left PA, which arches superior to the left main bronchus)
• Bronchus is the most posterior structure; its course is superolateral

Superior-to-Inferior Order

Pulmonary artery (superior) → Upper lobe bronchus → Bronchus intermedius → Superior pulmonary vein → Inferior pulmonary vein (inferior)

• The right upper lobe (eparterial) bronchus arises above the level of the right pulmonary artery - this is why it is called "eparterial" (above the artery). This feature is unique to the right side.
• All other lobar bronchi on both sides are hyparterial (below the artery)

Right hilum (a): pulmonary artery superiorly, pulmonary veins anteroinferiorly, bronchus posteriorly, pulmonary ligament below

Mediastinal surface of right lung (A) showing the hilar arrangement, grooves for SVC and IVC, and the pulmonary ligament

Relations of the Right Hilum

Right vs Left Hilum - Key Differences

Surgical Significance

1. The right PA is anterior to the bronchus - in right pneumonectomy/lobectomy the artery is encountered first at the anterior hilum after the veins are controlled.
2. Azygos vein must be identified (and sometimes divided) to access the right upper lobe hilum superiorly. The right vagus lies between the azygos vein and the trachea - it can be damaged if the azygos is divided carelessly.
3. Right phrenic nerve runs in the mediastinal adventitia of the SVC and pericardial sac - it is in a different tissue plane from the lung root and must not be included in lung retraction.
4. Esophagus lies directly posterior to the hilum; the pulmonary ligament's mediastinal side is immediately anterior to the esophagus inferiorly.
5. Eparterial bronchus means the right upper lobe bronchus is at risk during any hilar dissection at the superior aspect - it must be separately identified and preserved (or specifically targeted) during upper lobectomy.
6. In the right upper lobe, the pulmonary vein is located most anterior to the pulmonary artery and bronchi at the hilum; the upper lobe vein arises from the same branch as the middle lobe vein (shared superior pulmonary vein trunk).