Upper Lobectomy

Upper Lobectomy Krysten Miller Pennsylvania College of Technology ?IntroductionAn Upper Lobectomy is the removal of the superior lobe from a lung. This occurs when a neoplasm is confined to a specific area and hilar nodes are not involved. This procedure may be done to remove the spread of cancer, abnormal abscess, or infection within the lungs. The lungs are located below the clavicle and above the diaphragm. They consist of five lobes, both sets being separated by fissure. The right side has three lobes known as superior, middle, and inferior. While the left has superior and inferior. The left side only has two lobes because the anatomical position of the heart needs room to rest. Connected to the lungs are ancillary structures, such as, bronchus, pulmonary artery and vein, and lymphatic vessels. These structures enter at the hilum where the lungs are slightly concave. The surgical goal is to remove the neoplasm without harming other structures. Signs/Symptoms/Risks Generally, signs and symptoms may vary depending on the diagnosis. For example, signs and symptoms of TB are pain in chest, fatigue, fever/chills, or mucus and blood in saliva. Whereas signs and symptoms of cancer consist of a reoccurring respiratory infection, chest pain, weakness in the upper body, and trouble swallowing, change in bowel movement (American Cancer Society, 2018). In most cases signs and symptoms are very common and testing will need done for diagnosis. If these signs and symptoms are noticed a doctor should be consulted and a check-up be made. Diagnosis/Alternatives In addition, a neoplasm may be diagnosed through a Computerized Tomography (CT) or a Magnetic Resonance Image (MRI). During a CT scan small lesions may be identified, whereas, MRI may reveal a mass or nodule. If a spot occurs, a tissue biopsy may be done to identify what the mass or lesion may be. Another diagnosis is sputum cytology. During this assessment the sputum is looked under a microscope for cancer cells to be identified (Mayo Clinic, 2018). Once diagnosed alternative therapy may be assessed if surgery is too much to handle. These sources include radiation, chemotherapy, radiosurgery, and drug therapy. Overall, these alternatives use multiple drugs and or high—power of radiation to kill and reduce the neoplasm within the lungs. Alternative medication to help those with signs and symptoms involve acupuncture, hypnosis, massage, meditation, and yoga. These forms of medicine help relax the tissue and relieve pain within the area. When alternatives are not an option, and the aggression is too far surgery is the option. Surgery Set Up To begin, the set up contains a back table and mayo stand. The back table will consist of three sections: drapes, instruments, and sharps. Drapes will be towels and an adhesive back drape. Electrocautery and suction, as well as, other items that need access to the patient may be placed here as well. Instruments are then placed on the field. Two main trays will be placed along with a variety of other tools. A thoracotomy set will include useful instruments that aid in removal of a rib and exposure to repair the underneath organs. A general vascular set will also be available. This set includes additional cardiovascular instruments that may be useful if needed. In addition, various sizes of hemoclips are separate and kept for hold. Once instruments are placed, sharps and basins are then placed. In the top corner an emission basin and bowl are placed for fluids. Sponges in the form of kitners, laps, and 4Ãâ€"4 are placed on the field. A suture counter is then placed in the corner. This is filled with silk suture ties, polypropylene suture, and pledgets. A number 10, 11, and 15 knife blades are then loaded on a handle. Once the back table is complete with all needed instruments the mayo may be addressed. The common instruments include knife, tissue forceps, and metz and scissors to dissect to operative area. Hemostats, Kocher's and Allis's may be place to grab tissue and retract along with hemostasis. Multiple retractors and elevators may be used either sorted on the mayo or back table. Once the sterile field is prepped, the patient is retrieved and prepped. Patient Preparation Following set-up, the patient is brought into the room. They are transferred to the OR bed and position aids are placed. Antiembolitic hoses are placed on the legs to help with blood flow. Aesthesia may apply Swan-Ganz and CVP lines which allow direct contact to the heart (Goldman, 2008). Once general anesthesia is applied with endotracheal intubation, the patient is placed in lateral position with the surgical site up. During this time a catheter may be placed, as these procedures may be length if problems occur. Padded kidney rests or pillows are placed around the torso to stabilize. The unaffected arm is placed on an arm board while the other is rested above on a padded mayo. The lower leg is slightly bent with a pillow placed on top and the top leg laid flat, this is done to keep the patient from rotating. Pads are placed around the ankles and other bony areas for cushion. During this time, it is needed to be confirmed that blood has been ordered and available for this case. Prep/Draping Once the patient is positioned, prepping and draping of the surgical area may begin. When prepping cleansing for a posterolateral incision is made. Starting at the mid-thorax region, extending from the shoulder, to the iliac crest and down bilaterally. Within the prep the axilla region should be included as well. After the prep is dried, drapes may be placed. Folded towels are placed in a square around the incision site. Towel clips are placed at each inside corner to hold the towels together. An adhesive drape is then placed and unfolded across the patient to create the complete sterile field. Two suction tubes should be thrown up at this time along with any other cords that need to be thrown off. Surgery Following draping, a time out may occur and surgery begins. A posterolateral incision is made into the fourth intercostal space of the ribs with a #10 blade. Rib spreaders are placed to open the ribs and the pleura is cut. The anterosuperior portion of the hilar pleura is then incised and then separated making room to open the thorax. Once opened, the likelihood of the rib instruments being reused are slim and may be removed from the surgical field and onto back table (Frey & Ross, 2014). The upper and lower lobe fissure is opened, and dissection down to the pulmonary artery begins. During this time the surgical technologist should keep count of how much irrigation is used for the account of potential blood replacement. If sponges are to be weighed they must be fully saturated before throwing off. The second count may begin at this time. The pulmonary artery and vein branches are identified. Once identified they are separated. The surgical technologist should move quickly to access suture and assess double ligation of artery and vein. They are then divided. Blunt dissection is then used to free the upper lobe bronchus. It is either clamped with a bronchus clamp or a stapler. Sutures and stapler should be prepared prior to the step, bronchus is divided quickly. The clamp or stapler should be placed 2 cm form the main bronchial trunk (Frey & Ross, 2014). Entry to the bronchial tree changes wound class and results in contaminated instruments. At that time contaminated items shall be separated. The bronchus is then closed with a nonabsorbable suture or staples. Closely watching the surgeon and his assistance allows for anticipation at this time. A pleural flap is secured with sutures over the bronchial stump and the remaining lobes are checked for leakage of air. Leakages are checked by filling the thorax with body-temperature irrigation. The wound is irrigated and chest tubes of sort are placed in the thorax. The lines form the tubes must be hooked with a closed drainage unit and immediately turned on to prevent clotting. Final counts are made while tubes are placed. An injection of 0.25% Marcaine is made for postoperative pain control prior to closure. The fascia is closed with a 2-0 Vicryl and the skin is closed with staples. Dressing is a nonadherent contact layer, may vary depending on the doctor preference. The surgical technologist should not break scrub until the patient has left the operating room. Outcome Following surgery, the patient is then transported to the CCU. The endotracheal tube is still attached at this time to check for postop ventilation and proper breathing. The patient will stay in the hospital 7 to 10 days. If no complications they may leave and have a full recovery. Additional treatments may be essential such as chemotherapy and radiation. These treatments can help determine when normal activity can return. If complications occur hospitalization is longer. This may be a surgical site infection, hemorrhage, atelectasis, pneumothorax, embolus, edema, etc. During this time the patient will be monitored and possible emergency surgery may be done. If no complications occur during surgery this is a Class 1: clean procedure. Conclusion To conclude, an upper lobectomy is the surgical removal of a lobe caused by an abnormal growth or infection. It can be diagnosed through imaging or a tissue biopsy. Alternatives before surgery are a variety of drug therapy and active medicines. Once these are out of the question surgery is an option. The patient is then prepped and assessed for surgery. The lobe is removed and the patient is sent to recovery. They will then be hospitalized for 7 to 10 days and sent home if no other complications occur. ? ReferencesFrey, K. B., & Ross, T. (2014). Surgical technology for the surgical technologist: a positive care approach. Clifton Park, NY: Delmar Cengage Learning.Goldman, M. A. (2008). Pocket guide to the operating room. Philadelphia: F.A. Davis Co.Lung WebMD. (2018). Cancer Symptoms: What You Should Know. Retrieved April 22, 2018, from https://www.webmd.com/lung-cancer/understanding-lung-cancer-symptomsAmerican Cancer Society. (2018). Managing Cancer-related Side Effects. Retrieved April 25, 2018, from https://www.cancer.org/treatment/treatments-and-side-effects/physical-side- effects.html