Purpose of a Lobectomy

A lobectomy is done to remove a diseased or damaged portion of the lung, most often due to lung cancer. Specifically, lobectomy is most commonly performed for non-small cell lung cancers (NSCLC) in which the tumor is confined to a single lobe. It differs from a sleeve lobectomy, which is a lung cancer surgery where a lobe and part of the airway are removed.

This procedure is less invasive and conserves more lung function than a pneumonectomy, a surgery that involves removing an entire lung. In contrast, it is somewhat more extensive than a wedge resection, a surgery that removes the tumor and a small amount of surrounding tissue.

Types of Lobectomy

A lobe of your lung can be removed using a few different methods.

Open Lobectomy

A lobe of the lungs is removed through a long incision on the side of the chest (thoracotomy). This involves spreading the ribs apart to get access to the lungs.

This type of surgery is usually performed if your healthcare provider needs to remove larger stage 2 and stage 3 tumors from the lungs and lymph nodes.

Video-Assisted Thoracoscopic Surgery (VATS)

A lobe of the lung is removed through a few small incisions in the chest with the assistance of instruments and a camera.

This procedure is becoming the preferred technique. A VATS lobectomy may be considered for stage 1 or stage 2 non-small cell lung cancer (NSCLC).

When a VATS lobectomy is possible, it may result in fewer complications than an open lobectomy.

Robot-Assisted Thoracoscopic Surgery (RATS)

Similar to VATS but performed with robots, RATS also appears to result in fewer complications and shorter hospitalizations after a lobectomy. It has been used successfully with stage 3 NSCLC, but controversy remains over whether it provides a better outcome.

Potential Risks

A lobectomy is a major surgical procedure and surgical complications are not uncommon. Your healthcare provider will discuss these with you prior to surgery.

Some potential complications include:

• Prolonged air leak, requiring a chest tube to be left in place longer than three to four days. This is the most common complication.
• Infections, such as pneumonia
• Bleeding
• Heart problems, such as a heart attack or irregular heart rhythms
• Blood clots in the legs (DVTs) that may travel to the lungs (pulmonary embolus)
• Bronchopleural fistula, an abnormal passageway that develops between lungs large airways and the space between the membranes that line the lungs

According to some research, the rate for post-operative complications is much higher for traditional open lobectomy. Complications from VATS are estimated to occur between 6% and 34.2% of the time, while that may be as high as 58% with open lobectomy.

Choosing a Surgical Technique

When deciding on the type of lobectomy that is best in your case, your healthcare provider will consider:

• Characteristics of your particular cancer
• Where your tumor is located
• The size of your tumor
• Whether or not your tumor has spread to nearby tissues
• The extent of your pain
• How well your lungs are functioning prior to surgery
• Your general state of health
• Feedback from your healthcare team

A healthcare provider's experience/level of comfort performing each of the procedures will also be part of their calculus.

Size and Location of Tumors

Despite a more rapid recovery, there are times when VATS is not possible. The location of some tumors makes it very difficult to perform VATS, and in these cases, an open lobectomy might be both safer and more likely to remove the whole tumor.

During VATS, if your surgeon realizes that the cancer is too large to be managed via video, or if other concerns arise, he may need to switch procedures and begin an open-chest lobectomy.

Pain

Studies have found that the recovery period following a VATS lobectomy is often shorter, with less post-operative pain than an open lobectomy.
​Post-thoracotomy pain syndrome (also called postpneumonectomy syndrome) is a condition of persistent chest pain occurring months to years after lung cancer surgery.

Following open-chest surgery for NSCLC, pain was reported by 50% to 70% of patients at least two months after the procedure. About 40% of patients still had some degree of pain a year later, with 5% saying the paint was significant.

There are no clear comparative studies of pain for VATS or RATS, but the shorter surgery time and less-invasive nature of the procedures are believed to reduce pain.

Pros of VATS

• Faster recovery: Fewer days with pain, shorter hospital stay
• Severity of pain is less and felt for fewer months
• Less blood loss during video-assisted surgery
• Lower rate of post-operative complications
  
  

Cons of VATS

• Limited to tumors of certain size, location
• Surgeons are often more comfortable with open lobectomy
• May result in an emergency open lobectomy
• Some cancer cells may be missed
  

Surgeon's Experience

• Not all surgeons are comfortable performing VATS and this could play a role in what technique they ultimately recommend.
• Make sure to ask why an open lobectomy is recommended if this is the only choice you are given. You may wish to get a second opinion from a surgeon who is comfortable performing VATS, but keep in mind that even the best surgeons will not perform VATS if the location of a tumor suggests that an open lobectomy may result in a better outcome.
• Many surgeons recommend getting a second opinion at one of the larger National Cancer Institute-designated cancer centers.
• Researchers have found those treated at an academic cancer center have higher survival rates than those treated at a community cancer center, particularly patients who have lung adenocarcinoma. Researching facilities as well as surgeons to find those that meet your needs can, therefore, be important to ensuring the best outcome.

Preparation

Before your surgery, your healthcare provider will review any risks and explain the details of the procedure, whether it is an open lobectomy procedure, VATS, or RATS. It's recommended that you take some time to review the steps to prepare for lung cancer surgery.

Pre-Operative Check

Prior to your lobectomy, your healthcare providers will want to make sure you are as healthy as possible. They will also want to know that you will be able to breathe comfortably after a lobe of your lung is removed. Pre-op procedures may include:

• Having a careful history taken
• Physical exam
• Blood tests
• Breathing tests (pulmonary function tests)

Depending on your age and physical condition, your healthcare provider may also test your heart.

Your healthcare provider will carefully review all of your medications during your pre-operative visit and may recommend stopping some of your medicines for a period of time prior to surgery.

It is helpful if you bring along the bottles containing any prescription and non-prescription medications, as well as any supplements that you use. Some dietary supplements can increase bleeding time and need to be stopped well in advance of surgery.

Smoking Cessation

If you smoke, your surgeon will strongly recommend that you quit as soon as possible. Quitting smoking before surgery can reduce your risk of complications, improve wound healing, and increases the chance that your surgery will be successful.

Increasing the success of lung cancer surgery is only one of the benefits of smoking cessation after a diagnosis of cancer.

Procedure

A lobectomy is performed in the operating room under a general anesthetic, so you will sleep through the procedure. You may be given antibiotics intravenously before or after the surgery.

You will be placed on a ventilator with a breathing tube inserted into your throat, and a catheter may be placed to drain urine during and after the procedure.

Your heart rate, blood pressure, and breathing will be monitored throughout the operation.

If you are undergoing an open lobectomy, an incision will be made on the side of the body where the tissue is being removed. The cut will likely start at the front of the chest around the nipple and wrap around your back to the area under the shoulder blade.

An instrument will be used to spread the ribs apart. The healthcare provider will remove the tissue and close up the incision with stitches or staples.

If you are undergoing a VATS or RATS procedure, three or four small cuts will be made around the area of the lobe. A thoracoscope, a small tube with a light and a tiny camera, can then be inserted into the chest cavity. It sends images to a computer screen to help the surgeon visualize the area.

Surgical instruments are then inserted through the other incisions and used to remove the problematic tissue.

After either surgery, a chest tube will be placed into the surgical area to allow excess fluid and air to drain outside of the chest for a period of time. The surgeon will close the incision(s) with stitches or staples.

Recovery

Following your lobectomy, you will be monitored in the intensive care unit (ICU) for a day or so before going to a regular hospital room.

A respiratory therapist will work with you, asking you to take deep breaths and breathe into an incentive spirometer. The nursing staff will help you get up and move about as soon as you are able.

Barring complications, most people stay in the hospital between four and seven days, depending on the type of lobectomy that was done.

Prognosis

The prognosis following a lobectomy depends on many different factors. Some of these include the stage of your lung cancer—that is, how far it has spread -as well as your general health and whether you have any other lung problems in addition to lung cancer.

The five-year survival rate for lobectomy patients is approximately 70%. When a lobectomy is successfully done for early-stage lung cancer, it offers a chance for long-term survival without recurrence of cancer.

Depending on the characteristics of your cancer, your oncologist may recommend adjuvant chemotherapy following surgery to reduce the risk of recurrence.

You may want to also consider pulmonary rehabilitation. Pulmonary rehabilitation for lung cancer has only recently been instituted at some cancer centers but appears to help with shortness of breath as well as other symptoms.