Pneumopexy After Open Right Upper Lobe Lobectomy

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This video shows a pneumopexy performed after an open right upper lobectomy. The patient had a past medical history of insulin-dependent diabetes, valley fever, and a 25 pack/year smoking history. 

A CT scan at an outside hospital revealed a 5.7 cm cavitary right upper lobe mass and mediastinal adenopathy. After multiple biopsies, she was confirmed positive for adenocarcinoma, and a PET scan indicated a bit of activity in the mass with an SUV max of 6.9. Shortly after, the patient was seen in the authors’ clinic for pulmonary function testing and completed a course of new adjuvant chemoimmunotherapy. After some preoperative planning, it was determined that the best course of action was to proceed with a right upper lobectomy via a thoracotomy incision. Additionally, fixation of the right middle lobe and right lower lobe was performed to help prevent torsion. 
 
The axial cuts of the patient's preoperative imaging, including PET scan and CT scans, showed the right upper lobe mass. Additionally, the coronal cuts showed the same mass.  

This segment of the video begins at the conclusion of the case after the right upper lobectomy had already been performed. The right middle and right lower lobes were reinflated to establish the natural position. After adequate positioning was confirmed, the right middle lobe and right lower lobe were aligned along the major fissure. The surgeons then stopped ventilating the right lung and fired a stabler across this wedge of tissue using an endo GIA purple load. A decision to pexy was made for several reasons, including the amount of dissection required around the hilar structures for lymph node harvest, as well as the patient's complete major fissure. Both of these factors increased the risk for lung torsion.  

In this case, one more purple load of the endo GIA stapler was used to completely wedge out this section of tissue. The patient recovered as expected postoperatively.  
 
Immediately postoperatively and on postoperative day one, the patient did not have an air leak present. The chest tube was then removed after being placed on water seal on postoperative day two. The patient was discharged on postoperative day five. She has since been seen in clinic and is doing well, having returned to her baseline function.  

Lung torsion is a rare but serious complication following various lung resections and open thoracotomies.  
 
Currently, there is a lack of publications on proper right middle low pexy technique, and this video serves as technical instruction on how to correctly align and ensure torsion prevention.  

References

1. Wong PS, Goldstraw P. Pulmonary torsion: a questionnaire survey and a survey of the literature. Ann Thorac Surg. 1992 Aug;54(2):286-8. doi: 10.1016/0003-4975(92)91386-n. PMID: 1637221.
2. Eriguchi D, Imai K, Kajiwara N, Ikeda N. Surgical technique for preventing lung torsion after right upper and lower bilobectomy. Interdiscip Cardiovasc Thorac Surg. 2023 May 4;36(5):ivad069. doi: 10.1093/icvts/ivad069. PMID: 37158570; PMCID: PMC10198701.
3. Le Pimpec-Barthes F, Arame A, Pricopi C, Riquet M. Prevention of middle lobe torsion or bronchial plication using anti-adhesive membrane: a simple, safe and uncomplicated technique! Eur J Cardiothorac Surg. 2011 Jun;39(6):1059-60. doi: 10.1016/j.ejcts.2010.09.033. Epub 2010 Nov 5. PMID: 21115359.
4. Uramoto H, Takenoyama M, Hanagiri T. Simple prophylactic fixation for lung torsion. Ann Thorac Surg. 2010 Dec;90(6):2028-30. doi: 10.1016/j.athoracsur.2010.07.040. PMID: 21095357.

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