Rare surgical indications

Less common, but not negligible, are operations in the thorax in case of failure or insufficient initial therapy. Surgery may be necessary in cases of recurrent fluid accumulating in the narrow gap between the lung and the chest (recurrent pleural effusion), insufficiently treatable, narrowly defined adhesions of the lung tissue (bronchiectasis), pulmonary tuberculosis that does not heal despite treatment with antibiotics, and also in cases of a recurrent purulent cavity formation within the lung tissue that cannot be treated over a longer period of time (recurrent lung abscess). The same applies if a lung collapses due to the removal of the attachment forces that normally hold the lung to the thorax and thus ensure its development, and if there is an accumulation of air outside of one lung (spontaneous pneumothorax), as well as in the first occurrence when other therapy alternatives prove ineffective or in the case of chronic suppuration of the tissue surrounding the lung (pleural empyema).

Therapy

In the case of lung diseases that require surgical treatment, the surgical area is already precisely limited by the disease.Although the scope of the surgical interventions is therefore the same in each case, the individual treatment techniques differ greatly from one another and must of course be adapted to each case, disease and patient. In principle, open surgery (thoracotomy) can be distinguished from minimally invasive video-assisted thoracoscopy (VATS). In open surgery, access to the operating area is usually gained through an incision of a few centimeters on the lateral chest wall.

In some cases, however, a complete opening of the thorax from the front center is necessary in order to view and treat larger areas. The VATS, on the other hand, works with a camera that is inserted under anesthesia through a small skin incision between the ribs to the surface of the lung, giving the surgeon a clear view. Via a second and possibly third access, various instruments that are ultimately used can then be brought into the field of vision and operation.

Of course, both types offer certain advantages and specific risks. In general, it can be said that minimally invasive procedures achieve the more cosmetically pleasing results and the patient can recover more quickly after the operation because the wounds are smaller, usually less painful and therefore less troublesome. The disadvantage of this procedure, however, is just that: Smaller incisions and small surgical instruments mean that only minor procedures are possible, which also have to take place relatively close to the patient’s body surface.

Often only a few centimeters of depth can be reached. In addition, it is often more difficult for the surgeon to clearly see and assess the area to be treated. Therefore, in many cases of lung diseases that require surgical treatment, the decision will still be made against the minimally invasive and in favor of open surgery.

Within this procedure, many different surgical procedures are conceivable: Depending on the clinical picture and condition of the patient, all variants are conceivable, from the complete removal of a lung (pneumectomy), to the separation of part of the affected lung (lobectomy), to the removal of several smaller lung segments (segment resection). For some special cases, specialized treatment procedures have also been established, such as the removal of the skin lying on the lung tissue (pleurectomy) or the introduction of a special talcum powder (talcum) into the cavity between the lung and the chest, which is intended to achieve a bonding of both components (pleurodesis). A thorough lung function test is essential before every operation in order to assess whether the patient could survive the operation in question and whether sufficient well-working lung tissue is still available to supply his body with oxygen after the surgical intervention.

In addition, there is always the question of whether an operation is still feasible. For example, for carcinoma or tumor removal, several important criteria must be met, including the fact that neither half of the lung may be affected by the disease and that the foreign body must be clearly defined and thus easily removable. If one or more of these criteria do not apply, one assumes a situation that is difficult or even impossible to operate on, in which other (non-operative) treatment or even purely palliative care is indicated.

For the diagnosis and doubtless detection of lung diseases that require surgical treatment, several partly complementary, partly overlapping examinations and methods are available. The first step in the case of an unclear clinical suspicion of a lung disease is an x-ray of the chest (thorax), which is taken in two planes both from the front and the side as standard. The images of the computer tomograph (CT) are important for closer examination and differentiation, but also for the preparation and planning of surgery.

In some cases (e.g. children or special problems) magnetic resonance imaging (MRT) is also conceivable. However, the possible invasive diagnostic procedures are lung-specific: With the help of an endoscope, the respiratory tract can be examined up to the individual bronchial tubes (bronchoscopy) or the lung as a whole (thoracoscopy, see VATS).The great advantage of these examinations is the possibility to take a sample (biopsy) of suspicious tissue areas at any time, which can then be pathologically examined and classified, and the direct imaging of the lung without falsifying projections or complex reconstruction on the computer. However, these examinations cannot be carried out without anesthesia, which is why the risk increases with such invasive examinations.

If an infectious disease of the lung is suspected, microbiological diagnostics must always be initiated. For this purpose, culture media are inoculated in the laboratory with samples of the sputum the patient has coughed up, or any flushing liquid that may be present, which should flush the bronchial tubes freely. Of course, this also applies to the now rare case of pulmonary tuberculosis.

Which type of examination is ultimately chosen depends on the type of suspected disease, the experience of the physician and, to a certain extent, the standard guidelines of the hospital in question. The possible prognosis or the treatment intention (cure or relieve pain?) also determines the extent of the apparative diagnostics.

For this reason, several different diagnostic paths are almost always possible, but they can all come to the same result. As a rule, a combination of the available options will be used in order to be able to represent and assess the patient’s lungs and chest as clearly and accurately as possible. Based on this, the optimal treatment – whether with or without surgery – can then be determined together with the patient, depending on the diagnosis and type of disease, and taking into account his or her wishes and ideas.