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PNEUMONECTOMY It is a surgical procedure to remove a lung. INDICATIONS: Bronchietasis Resistant pneumonia Broncho pleural fistula Lung abscess or hemorraghe TB Malignancy COPD ARDS Interstitial lung disease PRE OP PREPARATION: Assessment: Detailed history Baseline spirometry Respiratory mechanics Lung parenchymal function Cardiopulmonary reserve assessment History: Age Functional status Dyspnoea , cough Smoking Drug use , radiation exposure Chest pain , recent infections Metastatic disease Immobility / venous insufficiency Physical examination: o o o o o o o o o Appearance , anthropometry Cyanosis , clubbing Tracheal position Chest wall abnormality Oropharyngeal crowding and dentition Respiration Auscultation Cardiac assessment Abdomen Investigation: ECG,Echo Chest Xray CBC Sputum culture , gram stain LFT,PFT,RFT Coagulation profile Assess for co morbidities: Pre op optimization: 1. 2. 3. 4. 5. 6. 7. Stop smoking Pre op exercise – weight management Medication – antibiotics , mucolytics, antacids Chest physio Pre op education Psychological preparation Pulmonary care training – spirometry Nursing care - pre op: 1. Nursing assessment 2. Informed consent 3. NPO – 8hrs, bowel and bladder preparation 4. 5. 6. 7. 8. 9. Premedications ,stop antiplatelets , anticoagulants as ordered Skin preparation Removal of jewellery , dentures , contact lens , spectacles Site marking Betadine baths Blood products – arrange as ordered TYPES: simple Removal of affected lung extrapleural Removal of affected lung , part of diaphragm , the parietal pleura, and pericardium on that side , lining are replaced by gortex, usually done for mesothilioma OPERATIVE STEPS - EXTRA PLEURAL TYPE: 1. After induction of GA , a double lumen ET tube is placed and positioned 2. An NG tube is inserted to facilitate palpitation of esophagus , during posterior extra pleural dissection 3. Patients are monitored with arterial line , CVP, foley catheter 4. A thoracic epipleural catheter is placed preop for post op pain management 5. Lateral decubitus position 6. A standard posterior lateral throacotomy 7. Serratus muscle is saved and retracted medially 8. Chest is entered over the unressected 6th rib 9. After division of intercostals muscle , an extrapleural plane is developed superior and inferior to the throacotomy incision.Superior component of dissection is carried out first. Medially the dissection is carried out from apex down to azygos vein. Medial pleura is dissected free from SVC and azygos vein.The pericardium at the level of azygos vein is opened to determine myocardial involvement, if no involvement pericardiotomy is extended anteriorly and inferiorly to encompass the tumor. 1. The dissection of pericardium is completed at the pericardiopleural attachment 2. The diaphragm is excised starting at anterior margin in the circumferential fashion 3. Diaphragm is divided over IVC and dissection is carried posteriorly leaving a line of tissue. 4. Lung is retracted medially and complete and complete mediastinal lymphadenectomy done and thoracic duct is ligated to prevent post op chylothorax 5. Pulmonary artery and veins are ligated and divided.After vessels are divided , pericardium is opened posteriorly to hilum which completes pericardial resection 6. Main stem bronchus is dissected free from peribronchial tissue and stapled.En bloc specimen – lungs, parietal pleura , pericardium and diaphragm is sent for HPE 7. After hemostasis is obtained , a tissue flap to cover bronchial stump.Azygos vein ligated and divided at SVC. 8. Pericardium is reconstructed with a patch to prevent cardiac herniations(bovine patch). 9. Diaphragmatic defect is closed with PTFE patch CONVENTIONAL PNEUMONECTOMY: GA is given, posteriolateral throacotomy incision. Extends from the point below the shoulder blade around the side of body along the curvature of the ribs at the front of the chest. Surgeon removes part of 5th rib in order to have a clearer view , then deflates collapsed lung, ties off the major blood vessel, clamps the main bronchus , cuts through the bronchus , removes the lung , staples the end of the bronchus that has been cut. Chest drains are inserted and chest is closed COMPLICATIONS: Bleeding Mediastinal shift Pulmonary edema Bronchopleural stump rupture POST OP NURSING CARE: Vital parameter setting Contionus cardiac monitoring Respiratory status and neuro status NPM till extubation Fluid restriction, I/O chart , U/O ,drains Chesrt xray , CBC,RFT Adequate analgesia ABG Antibiotics as per policy Dressing Chest physio Hygiene