Open surgical approach and technique in left pneumonectomy

The classic posterolateral thoracotomy remains an important incision to any surgeon for lung resections. It allows inspection, complete mobilization of the lung and hilum and access to mediastinal structures. For pneumonectomy, the key-step is the circumferential hilar dissection, exposing the hilar structures, resect lymph nodes and assess resectability in cancer operations. The dissection starts at the level of the left pulmonary artery (PA) and proceeds posteriorly and inferiorly. Suspension of the posterior mediastinum provides excellent exposure of the left main bronchus and the inferior pulmonary vein, while at the same time protects the recurrent nerve and the esophagus. The dissection circumvents the ligament and continues anteriorly, until the superior pulmonary vein is identified and the hilar loop is completed. Isolation of each structure by blunt or even finger dissection commences, and a vascular tape is applied for gentle retraction. The PA is divided first, followed by the inferior and superior pulmonary veins. Either non-absorbable monofilament sutures or staplers may be equally used for the transection of each structure. We suggest initial clamping and then proximal and distal transfixion of the vessels rather than simple ligation if sutures are to be used. Special attention should be paid to the transection of the bronchus, as this step is usually responsible for late complications. The bronchus should be dissected free, up to the level of the carina, retracted, clamped and divided, leaving the shortest possible stump. Either double horizontal mattress sutures or stapler provide equally safe result. The procedure is completed with extended lymph node dissection and air leak assessment.