Open Pneumonectomy in Tubercular Empyema - Operative Steps

Preoperative Considerations

• Anti-tuberculous therapy: Complete or near-complete course before surgery; sputum should ideally be negative or culture-negative
• Airway assessment: Rigid or flexible bronchoscopy to assess the main bronchus and plan the stump level
• Lung function: Predicted postoperative FEV1 must be adequate; low ppoFEV1 significantly increases pulmonary complications
• Nutritional optimization: TB patients often have poor general health; optimize albumin and correct anemia
• Empyema control: If active empyema with frank pus, drainage through the most dependent site is performed preoperatively to reduce contamination risk

Anesthesia and Positioning

1. Double-lumen endotracheal tube (DLT) for single-lung ventilation - mandatory; the side to be resected must be isolated to prevent contamination of the healthy lung, especially in empyema where pleural spillage is likely
2. Lateral decubitus position, operated side up
3. Arterial line, central venous access, epidural or paravertebral catheter for pain control
4. Thoracic epidural analgesia planned from the start

Incision

Extrapleural Dissection (Pleuropneumonectomy) - Key Modification in TB Empyema

1. The extrapleural space is identified as a thickened white layer deep to the intercostal muscle
2. Blunt and sharp dissection develops this plane anterolaterally first, then extended:
   • Superiorly toward the apex (caution: subclavian vessels)
   • Inferiorly toward the diaphragm
   • Laterally toward the spine
   • Medially toward the mediastinum (caution: internal mammary vessels, phrenic nerve, recurrent laryngeal nerve)
3. The entire thickened parietal pleura, pus cavity, and infected lung are mobilized as a single mass
4. If spillage of infected material occurs despite careful dissection, copious saline irrigation with antiseptic solution is performed immediately

The extrapleural approach carries higher rates of post-pneumonectomy empyema (PPE) - reported at 21-46% when the pleural space is infected - but is necessary when the conventional intrapleural plane does not exist. [PMC3322180]

Hilar Dissection

• Divide the inferior pulmonary ligament from below, sweeping upward toward the inferior pulmonary vein
• This mobilizes the lower lobe and exposes the inferior hilum
• Removes station 9 (inferior pulmonary ligament) lymph nodes

• Open mediastinal pleura anterior and posterior to the hilum in the cranial direction
• Identify and preserve the phrenic nerve on the pericardium

• Isolate, clamp, and divide the inferior pulmonary vein
• Stapled division with an Endo-GIA or TA stapler (vascular load) is preferred
• In the absence of space for a stapler, the vein is ligated and oversewn individually

• Divide anteriorly at the hilum
• A large hilar N1 lymph node is often found posterior to the superior vein and should be included in the specimen
• Note: dividing the veins commits the surgeon to completing pneumonectomy - once both veins are divided the main PA must follow

• In TB, the main PA may be shortened, surrounded by calcified nodes, or adherent to the carina
• Carefully remove fibroadipose tissue to reach the arterial sheath
• Pass a vessel loop (tape) around the main pulmonary artery
• Clamp test: After placing the stapler, close but do not fire - wait 1-2 minutes to confirm no hemodynamic instability or desaturation; if unstable, abort resection
• Fire the Endo-GIA with a vascular load to resect the PA
• If anatomy prevents stapling, the PA is clamped centrally (DeBakey), divided, and oversewn with 4-0 Prolene (double-layer closure)

Bronchial Division and Stump Management - Critical Step

1. Dissect connective tissue and lymph nodes from around the main bronchus
2. Divide the bronchus as proximal to the carina as possible - especially on the right, where the right mainstem bronchus is short and the stump pocket is prone to dehiscence (right-sided BPF rates are significantly higher than left)
3. Stapled division: TA or Endo-GIA stapler with a wide (black or purple) load, placed in the "Sweet direction" (perpendicular to the long axis of the bronchus, around the 3rd cartilage counting from the carina as zero)
4. Intraoperative bronchoscopy by anesthesia confirms stapler position and ensures the shortest possible stump
5. If a stapler is not feasible: manual division with a scalpel, closed with interrupted 3-0 Vicryl sutures placed 1-2 mm apart, lubricated with mineral oil; suture tails used to secure the bronchial reinforcement
6. Bronchial stump reinforcement is mandatory in TB (infected field):
   • Pericardial fat pad
   • Intercostal muscle flap (most commonly used - harvested at the start of the procedure before it desiccates)
   • Parietal pleura flap
   • Omental flap on a gastroepiploic pedicle (for high-risk or previously irradiated stumps)
7. Leak test: Check stump with warm sterile water and gentle Valsalva after division

Specimen Removal and Lymphadenectomy

• Specimen (lung ± thickened parietal pleura + empyema contents) removed en bloc
• Systematic lymph node sampling from stations 4 (paratracheal), 7 (subcarinal), 8 (paraesophageal), and 9 (inferior pulmonary ligament)
• In TB, calcified/anthracotic nodes may require sharp dissection; injury to the azygos vein (right) or thoracic duct (posterior mediastinum) must be avoided

Thoracic Duct

• When dissecting posteriorly to mobilize the specimen off the esophagus and spine, the thoracic duct must be identified and preserved
• Fatty tissue posterior to the esophagus (anteromedial to the aorta) is ligated with 0-silk sutures or large clips at multiple points to prevent chylothorax

Chest Closure and Drainage

1. Irrigation: Thorough saline/antiseptic irrigation of the pleural cavity, particularly critical in empyema cases where contamination is anticipated
2. Hemostasis: Check raw pleural surfaces, especially the extrapleural dissection plane
3. A single intercostal drain is placed in the pneumonectomy space
   • Clamped immediately after closure (unlike lobectomy - the space must fill with serosanguineous fluid to prevent mediastinal shift)
   • Released intermittently or periodically to balance mediastinal position (confirmed by postoperative CXR)
   • Some surgeons omit the drain entirely in uncomplicated cases
4. Ribs reapproximated with heavy pericostal sutures
5. Layered closure of muscle and fascia
6. Patient extubated in the operating room if stable

Special Considerations in Tubercular Empyema

Key Complications to Anticipate

• Bronchopleural fistula (BPF) - most feared; right side more common; incidence 9-22% in TB series
• Post-pneumonectomy empyema (PPE) - rate 21-46% when operating through infected space
• Pulmonary artery injury - during calcified nodal dissection; kept at highest vigilance, proximal vascular control must be established before nodal clearance
• Cardiac herniation - rare but if pericardium is widely opened (intrapericardial vessel control), the defect must be repaired
• Chylothorax - from thoracic duct injury during posterior mediastinal dissection

• Fischer's Mastery of Surgery, 8th Edition (Extrapleural Pneumonectomy, Left Pneumonectomy operative steps)
• Murray & Nadel's Textbook of Respiratory Medicine (Surgical options for pleural infection)
• PMC3322180 - Early and Long-term Outcomes of Pneumonectomy for Treating Sequelae of Pulmonary Tuberculosis
• AATS Thoracic Surgery Resident Primer on Pneumonectomy