Surgical Respiratory Cases

Question 1

Clinical signs Lobectomy

Answer 1

• Reduced expansion and chest wall deformity
• Thoracotomy scar: same for either upper or lower lobe
• Trachea is central
• Lower lobectomy: dull percussion note over lower zone with absent breath sounds
• Upper lobectomy: may have normal examination or may have a hyper‐resonant percussion note over upper zone with a dull percussion note at base where the hemidiaphragm is elevated slightly

Question 2

Investigation for Lobectomy

Answer 2

• CXR: maybe no overt abnormality apparent other than slight raised hemidiaphragm; remember that the right hemidiaphragm should be higher than the left in health
• CT chest: loss of a lobe with associated truncation of bronchus or pulmonary vessels

Question 3

Indications for lobectomy

Answer 3

• Bronchiectasis
• Early stage I-II NSCLC
• Lung nodules
• TB
• Lung abscess
• Fungal infection
• Massive hemoptysis (aspergilloma, cavity, AV malformation, bronchiectasis)

Question 4

Pneumonectomy

Clinical signs

Answer 4

• Thoracotomy scar (indistinguishable from thoracotomy scar performed for a lobectomy)
• Reduced expansion on side of the pneumonectomy
• Trachea deviated towards the side of the pneumonectomy
• Dull percussion note throughout the hemithorax
• Absent tactile vocal fremitus beneath the thoracotomy scar
• Bronchial breathing in the upper zone with reduced breath sound throughout remainder of hemithorax (bronchial breathing is due to transmitted sound from major airways)

Question 5

Investigations for Pneumonectomy

Answer 5

• CXR: complete white out on side of pneumonectomy
• Pneumonectomy space fills with gelatinous material within a few weeks of the operation

Question 6

Indications for pneumonectomy

Answer 6

Malignant indications:
* pulmonary metastasis (uncommon)
* Non-small cell lung carcinoma
Benign conditions:
* - Chronic infection
multiple abscesses
bronchiectasis
fungal infection
TB
* - Traumatic lung injury
* - Bronchial obstruction with lung damage
* - Congenital lung diseases

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Question 7

Lung transplantation

Signal lung transplant

Answer 7

• Clinical signs:
  thoracotomy scar;
  normal exam on side of scar;
  may have clinical signs on opposite hemithorax
• Indications for ‘dry lung’ condititions: COPD; pulmonary fibrosis

Question 8

Lung transplantation

Double lung transplant

Answer 8

• Clinical signs: clamshell incision – from the one axilla along the line of the lower ribs, up to the xiphisternum to the other axilla
• Indications ‘wet lung’ conditions: CF, bronchiectasis or pulmonary hypertension