Right pneumonectomy

Right pneumonectomy is performed for central tumors, often in the setting of regional nodal involvement, and is sometimes indicated for benign disease. Assessment of cardiopulmonary reserve is critical in patient selection and ensuring a good physiologic outcome. An intraoperative assessment is performed before proceeding to ensure an R0 resection is feasible. This often includes a mediastinal nodal dissection and frozen section analysis if the outcome will affect decision making. A “veins first” approach is generally used. Intrapericardial dissection is performed if access to the pulmonary vessels is difficult due to the proximity of tumor or to changes from induction therapy. There are a variety of methods available for bronchial closure and division; selection depends on the proximity of the tumor to the takeoff of the right main bronchus and on the surgeon’s personal preference. Reinforcement of the bronchial stump with vascularized tissues is often appropriate, particularly in the setting of induction therapy. Separation of the bronchial stump from the hilar vessels is recommended in all cases. Use of a pleural drainage tube is not generally agreed upon. If a tube is placed, it should not be put on suction. The tube generally is clamped and left in place only until the surgeon is confident that there is no longer a need for the tube, typically no more than 24 hours. Good perioperative pain control is essential in achieving a smooth postoperative recovery. Some tips and tricks for managing difficult technical challenges are provided.