OBSERVATIONS ON TOTAL PULMONARY LOBECTOMYAND PNEUMONECTOMYBY JOHN ALEXANDER, M.D.

OF ANN ARBOR, MICH.FROM THE DEPARTMENT OF SURGERY, UNIVERSITY OF MICHIGAN

DURING the last year or two much interest has been aroused by the in-creasingly frequent and successful surgical removal of a lobe of the humanlung, or even of an entire lung. The technic of total pulmonary lobectomyhas made such rapid advances in recent years that the mortality has beenreduced to less than I5 per cent. in several clinics. Until three years agono patient had survived the period of surgical convalescence following totalpneumonectomy; since then seventeen patients have survived.

Much experimental work during the last twenty years demonstrated thefeasibility of lobectomy and pneumonectomy in animals. Application ofthe same technics to man resulted, however, in such a prohibitive mortalitythat they were virtually abandoned in clinical practice. The persistence ofArchibald, Biondi, Brunn, Churchill, Evarts Graham, Janes, Kuemmell,Lilienthal, Willy Meyer, Samuel Robinson, Sauerbruch, Shenstone, Whitte-more and Zaaijer, among others, who applied themselves to the problemspeculiar to man, is chiefly responsible for the many recent successful opera-tions. Scarcely five years ago it seemed unlikely that total lobectomy andtotal pneumonectomy would ever become sufficiently safe to be acceptablein clinical practice.

LOBECTOMY

There is still a division of opinion among surgeons as to whether a one-stage or a two-stage operation is the better. From the point of view of thepatient's convenience and comfort an operation that is completed at once,and that may not be even temporarily followed by a bronchopleural fistula,is obviously preferable to a two-stage procedure. The choice of an opera-tion of the magnitude of a total lobectomy must, however, be made largelyaccording to the factor of safety.

The one-stage lobectomy operation that has produced the best results isthat which has been developed by Brunn, Shenstone and Janes from the prin-ciples that were established by Garre and Quincke, and by Lilienthal duringtheir pioneering work. Brunn has reported two deaths (25 per cent.) outof eight patients and Shenstone and Janes eight deaths (29.6 per cent.)among twenty-seven patients. Tudor Edwards lost seven (I4.5 per cent.)of his forty-eight patients and Roberts and Nelson two (20 per cent.) of tenpatients. Churchill has had one death (i i . i per cent.) among nine one-stage lobectomies. Archibald has reported three deaths (23 per cent.) among

393

JOhIN ALEXANDER

thirteen patients. The mortality figures given in this paragraph, which totaltwenty-three deaths (20 per cent.) out of one hundred and fifteen patients,are the most favorable ones known to me for the one-stage operation.

The success of the modern lobectomy operation in two or more stagesis based upon the production of firm pleural adhesions over the lobe thatis not to be resected. The largest series is that of Sauerbruch and Nissen;there were six deaths (I2.7 per cent.) among forty-seven patients. Ninepatients among the forty-seven had a "piece-by-piece" lobectomy; two died.Only four (10.5 per cent.) of the thirty-eight who had other types of multiple-stage operations died. My associates, Cameron Haight, John C. Jones,Duane Carr, and I have used a two or more stage total lobectomy for twenty-five patients, five of whom died (20 per cent.). Two of these five deathsoccurred in patients with extensive bilateral bronchiectasis; one patient diedfrom atelectasis of the right lower lobe two weeks after removal of the rightmiddle lobe, the left lower and left "middle" lobes having been removed sev-eral months previously; the other patient died from progressive cavitationin both lungs about two months after removal of the right lower and middlelobes; the eventual removal of the left lower and left "middle" lobes had beencontemplated. By excluding these two fatal cases of extensive bilateralbronchiectasis, we have used the type of two-stage operation that I am con-vinced offers the greatest protection against the dangers that are inherent inlobectomy in our last twelve patients, of whom only one died (8.3 per cent.).Churchill has performed ten two-stage lobectomies for bronchiectasis; onepatient died (io per cent.). There were twelve deaths (I4.6 per cent.) outof the eighty-two patients included in these three series of two-stage op-erations.

The deaths reported in the various one-stage and two-stage series herequoted were not all immediately directly due to the operation; occasionallydeath was due to some such complication as pneumonia, cerebral abscess oractivation of a latent tuberculous pulmonary lesion.

ONE-STAGE LOBECTOMY

Briefly, the type of one-stage lobectomy operation that is now in useconsists of a long intercostal incision, lineal division of the posterior endsof two or three ribs, temporary occlusion of the hilum of the diseased lobeby a special tourniquet, resection of the lobe, oversewing of the hilar stump,removal of the tourniquet, suture of the stump against the interlobar surfaceof the remaining lobe, introduction of an air-tight intercostal drainage tubeinto the pleural cavity and complete closure of the intercostal incision. Thetechnical details are given in articles by Brunn, Shenstone and Janes, Janes,and by Roberts and Nelson. Probably a majority of the patients operatedupon by the modern one-stage technic do not develop a bronchopleural fistulaor, if one develops, it closes spontaneously within one or two weeks. Theair-tight drainage tube causes the remaining lobe to expand rapidly; thepleural space left by removal of the pulmonary lobe becomes rapidly reducedin size by virtue of expansion of the remaining lobe, elevation of the para-

394

TOTAL PULMONARY LOBECTOMY AND PNEUMONECTOMY

lyzed diaphragm and traction displacement of the mediastinum. Only aminority of the patients who have had a basal lobectomy require an opendrainage operation for the residual empyema.

In spite of the highly satisfactory operative and post-operative course ofthose patients whose one-stage lobectomies have been accomplished withoutoperative accident or post-operative complication, fatal or grave complicationsare not rare. The most dangerous complications are severe infection of theentire pleural cavity before the undiseased lobe has become adherent to theparietal pleura, operative or post-operative haemorrhage from the hilar stumpof the resected lobe, sudden tension pneumothorax due to opening of a hilarbronchus in the presence of an accidentally occluded drainage tube, and pneu-monia or an exacerbation of infective pulmonary lesions that may have beenpresent in the contralateral lung before operation. Although post-operativepneumonic complications are not restricted to patients who have had one-stageoperations, I believe that the relatively prolonged time required for a one-stage operation in the presence of a wide-open pleural cavity exposes thepatient to a greater danger of pneumonia than if each operation were quicklycompleted, as it ordinarily is in the two-stage procedure.

Generalized infection of the pleural cavity does not often occur after theone-stage operation in spite of the fact that the pleura becomes at least slightlysoiled when the surgeon divides the pus-containing bronchi in the hilum.Generalized pleural infection is usually avoided because the remaining loberapidly becomes adherent to the parietal pleura when the lobe is caused toexpand by the negative intrapleural pressure that is created by the air-tight,water-seal drainage system. When, however, the remaining lobe fails toexpand satisfactorily, infection of the generalized pleural cavity may be severeand has occasionally proven fatal. When the upper lobe has been resected,the lower lobe usually fails to expand sufficiently to fill the upper portion ofthe pleural cavity. Even when the upper lobe has not been removed, air thatis admitted into the pleural cavity at the time of operation may become trappedin the dome of the thorax and fail to be evacuated by the drainage tube thatis customarily anchored at the bottom of the pleural cavity. If the dome ofthe pleural cavity does not soon become filled with lung, an apical empyemaand bronchopleural fistula are liable to develop and persist in spite of pro-longed adequate drainage; the empyema must then be obliterated by an extra-pleural, or an extrapleural and Schede thoracoplasty.

Haemorrhage from the hilar stump both during and after operation is amajor danger of the one-stage technic. Occlusion of the great pulmonaryvessels until they have been closed by suture depends upon the tourniquetinstrument and its cord not slipping or breaking. I know of two cases inwhich the hilar stump slipped from the grasp of the tourniquet; the hilumwas grasped, the haemorrhage was checked and the patients recovered. Inanother patient of whom I have heard, death from haemorrhage occurred onthe operating table after the hilum had been sutured and the tourniquetreleased.

Delayed haemorrhage from the hilar stump is a relatively frequent com-395

JOHN ALEXANDER

plication in the series of cases with which I am familiar. Roberts and Nelsonreport the following three cases of post-operative haemorrhage among tenpatients: (i) One pint of blood passed through the drainage tube within fourhours after operation; the chest was reopened and a small spurting artery inthe divided pulmonary ligament, which had not bled at the time of operation,was secured; a bronchopneumonia and wound infection developed but thepatient made a complete recovery. (2) Six hours after operation a definitetrickle of blood was seen passing through the drainage tube; the tube wasclamped for twelve hours, "Coagulin" was injected into the pleural cavityand no further bleeding was observed; the patient completely recovered. (3)Fourteen days after operation a sudden, severe haemorrhage of at least threepints occurred; a basal empyema cavity was opened but the bleeding hadalready ceased and did not recur; a wound infection and a subphrenic abscessdeveloped; the patient completely recovered.

One of Brunn's eight one-stage lobectomy patients died from a post-opera-tive haemorrhage which was not discovered in time for effective treatmentbecause the drainage tube had accidentally become kinked. Shenstone andJanes have occasionally observed post-operative haemorrhage, which presuma-bly came from the hilar stump, but no patient died from it.

Edwards has not as yet reported what haemorrhage complications, if any,he has experienced in his forty-eight one-stage lobectomy series. I have per-formed the Brunn-Shenstone-Janes one-stage lobectomy operation in onlythree patients. No haemorrhage occurred in the first patient in whom theupper lobe was removed for a tremendous and almost fatal hemoptysis froma non-syphilitic aneurism of a pulmonary vein. In the second patient signsof bleeding appeared twelve hours after a basal lobectomy for bronchiectasis;twenty-two hours after operation the chest was reopened and a slow but steadyoozing of blood was seen coming from the edge of the hilum at the superiorlimit of the pulmonary ligament. In the third patient the upper and middlelobes were removed for malignant disease which did not involve the hilarbronchi; one hour after operation the patient's condition was satisfactory; hethen suddenly developed the signs of haemorrhage; several minutes later therewas a gush of blood from the air-tight drainage tube and death quickly fol-lowed. At autopsy the forcing of water into the pulmonary vein showed threesmall openings in the hilar stump that had been sutured with approximately adozen interrupted interlocking mattress sutures.

It is impossible to see and separately to ligate all of the pulmonary vesselsin the hilum after it has been divided' and while it is being squeezed by atourniquet. The cut surface of the hilum has a rather homogeneous appear-ance except for the stiff-walled bronchi. An attempt is made to seal theentire cut surface with one or more layers of continuous or mattress sutures,many of which probably pierce large pulmonary vessels. It is apparent thatsuch sutures may fail to seal the entire surface of the divided hilum, which isfrom four to five centimetres long. When the tourniquet is released, bleedingalmost invariably occurs from one or more vessels that had not been securedby the first sutures; such bleeding vessels may be easily closed with additional

396

TOTAL PULMONARY LOBECTOMY AND PNEUMONECTOMY

sutures. In my cases and, presumably, in those of the other surgeons whohave used the Brunn-Shenstone-Janes one-stage lobectomy technic, the dividedhilar surface has been perfectly dry at the time the incision in the thoracicwall was closed. It is likely that those vessels that bleed only after the con-clusion of the operation were crushed by the temporary application of thepowerful tourniquet and were forced open only when the blood-pressure roseafter operation. Since all of the vessels cannot be seen on the cut surface ofthe hilar stump and since those that may escape closure by the hilar suturesdo not necessarily bleed immediately after removal of the tourniquet, theconclusion must be accepted that an attempt to seal the entire hilar surfacewith "blind" sutures does not necessarily exclude the possibility of a post-operative reactionary haemorrhage.

The hilum is usually sealed by two layers of continuous sutures that arepassed into and out of the divided surface of the hilum and do not includethe pleural edge of the hilum. Interrupted interlocking mattress sutures areperhaps more secure than a continuous suture. After removal of the tourniqueta second line of defense against haemorrhage is provided by the next row ofsutures that includes the periphery of the hilum and folds it over the firstrow, or rows, of sutures. The incision that effected amputation of the lobeshould have been made so that the visceral pleura was divided approximatelyfour centimetres distal to the tourniquet cord; the central point of the incisionshould be not less than one centimetre distal to the tourniquet cord. Theresulting cone-shaped excavation of the hilum permits an infolding of theperiphery of the hilum and apposition of visceral pleura to visceral pleura.Care should be taken that the incision in the hilum should not pass nearerthan one centimetre to the tourniquet cord; if it did, the hilum might collapseand the tourniquet loosen with resulting terrific haemorrhage. A third line ofdefense against haemorrhage, as well as against the formation of a broncho-pleural fistula, is obtained by tacking the end of the sutured hilum against theadjacent interlobar surface of the remaining pulmonary lobe.

Tension pneumothorax is another danger, though a remote one, of theone-stage lobectomy technic. Since the incision in the thoracic wall remainscompletely closed after operation, the air-tight drainage tube serves as theonly exit for air that might pass into the pleural cavity through a one-wayvalvular type of bronchopleural fistula that might form unexpectedly at anytime during the first one or two post-operative weeks. If the drainage tubeshould have become occluded by a clot of fibrin or by kinking, if expansion ofthe remaining lobe and its adhesion to the parietal pleura should cover thetube's openings, or if the tube should already have been removed from thechest, air escaping from a valvular type of bronchopleural fistula would findno egress but would accumulate in the pleural cavity and might cause fatalpressure upon the mediastinum. In one of my three one-stage lobectomypatients, the air-tight drainage tube had functioned perfectly during the firstfourteen post-operative days and there was no evidence of a bronchopleuralfistula; the tube then accidentally became kinked; a bronchopleural fistuladeveloped; the patient was discovered in a state of cardiorespiratory collapse;

397

JOHN ALEXANDER

the first person who saw the patient did not recognize that the drainage tubehad become kinked but fortunately the second person did and the patientrecovered from the immediate consequences of the accident but died twoweeks later from a brain abscess or meningitis.A tension pneumothorax occurring within the first two weeks after opera-

tion would probably rupture the adhesions that had formed between ther-emaining lobe and the thoracic wall; the bronchopleural fistula would proba-bly then infect the entire pleural cavity. An empyema involving the dome ofthe pleural cavity in the presence of a bronchopleural fistula only occasionallybecomes obliterated when treated by drainage; an extrapleural, or an extra-pleural and Schede thoracoplasty, is usually eventually necessary in order toobliterate such an empyema.

TWO-STAGE LOBECTOMY

The two-stage lobectomy technic with which this article is concerned con-sists, at the first stage, of separation of the pleural adhesions over the diseasedlobe, and gentle stroking with gauze of the visceral and parietal pleura of theentire hemithorax in order to produce a reactionary inflammatory barrieragainst the pleural infection that will occur after the second stage of theoperation, and in order to create firm pleural adhesions over the lobe that isnot to be removed. At the second stage the adhesions that have formed overthe diseased lobe are separated and the hilum of the lobe is tightly ligatedwith a special automatic ligating instrument. The lobe is then resectedapproximately three or four centimetres distal to the ligature and the incisionin the thoracic wall closed; the residual pleural space is drained by an air-tight tube. This brief description of the operation includes several importanttechnical improvements which have been made during the two years that havepassed since I described the operation in 1933. These improvements will beconsidered in the paragraphs to follow.

An incision in the seventh intercostal space, and resection of two or threecentimetres of the extreme posterior ends of the one, two or three ribs adjacentto the intercostal incision is probably preferable to removal of the sixth, sev-enth and eighth ribs between the vertebral transverse processes and theposterior axillary line, which I recommended in 1933. My colleague, Cam-eron Haight, has suggested that retention of these portions of the sixth, sev-enth and eighth ribs probably assists the patient in expectorating the bronchialsecretions during the ten or twelve days between the stages of the operation.

It is more difficult, but not impossible, to divide extensive pleural adhe-sions through an intercostal incision than through one in which the entireposterior portions of three ribs have been resected. Since even a long inter-costal incision does not always afford a sufficiently broad access to the pleuralcavity, the extreme posterior ends of the one, two or three ribs adjacent tothe intercostal incision may be sectioned in order to permit a wider spreadingof the intercostal incision. Linear division of these ribs, which is customarilyrecommended, may result in severe pain during coughing because of rubbing

398

TOTAL PULMONARY LOBECTOMY AND PNEUMONECTOMY

together of the costal ends; so as to avoid this complication the extremeposterior two or three centimetres of these ribs should be resected.

During my early experience with the two-stage lobectomy operation Ioccasionally found at the second stage that a part of the undiseased upperlobe was not adherent to the parietal pleura, being separated from it by awalled-off collection of pleural fluid that had been produced by the trauma ofthe first stage and that had not been drained by the aspirating needle that Ithen used at suitable intervals between stages. Adhesion of the upper lobe tothe parietal pleura has been satisfactory since I have introduced, at the firststage, two air-tight drainage tubes, split spirally in their intrathoracic por-tions, into the pleural cavity from the bottom of the costophrenic sinus; one ofthese tubes should be passed upward from the posterior axillary line forapproximately twelve or fourteen centimetres in the costovertebral gutter, andthe other from the anterior axillary line for sixteen or eighteen centimetresin front of the upper lobe. A week after the first stage the anterior tubemay be withdrawn for several centimetres and completely removed at the timeof the second stage. The posterior tube should be retained until the residualpleural hole that remains after removal of the lobe at the second stage hasbecome completely obliterated, but most of the spirally-split interpleural por-tion of this tube should be removed during the second operation.

The most important improvement that has been made in the operativetechnic that I described in I933 is concerned with ligation of the lobar hilumduring the second stage. In a number of my patients the tightest possibleligation of the hilum failed to cause complete occlusion of the pulmonaryartery in the indurated hilar tissues. In several instances, the additionalapplication of a tight ligature of a live rubber tube failed to close the artery,which was finally closed only after one, two or three ligatures of heavy silkor rubber had been added at intervals of twelve or twenty-four hours. Unlessthe artery as well as the vein is completely closed, wet rather than dry gangreneof the lobe occurs and a considerable amount of blood is lost into the lobeand thence onto its surface. My colleague, Duane Carr, has devised a smallflat metal box* containing two dogs that prevent a loop of cord, passed aroundthe hilum of the diseased lobe, from loosening after it has been tightened bya mechanically powerful handle. After the loop has been tightly applied thehandle of the instrument is unscrewed from the box through which the cordpasses; the box is left in position until it falls off when the gangrenous por-tion of the hilum spontaneously separates from the living portion where theyare demarcated by the cord ligature. If at any time after the automatic liga-ture is applied, swelling of the lobe should indicate that the artery is notcompletely closed, the handle may be reattached to the head of the instrument,the ends of the cord reattached to the handle, and the loop around the hilumfurther tightened. My associates and I have used this instrument in our lastfive patients, in all of whom the artery was completely closed by the firstapplication of the automatic ligature.

* Manufactured by the Geo. P. Pilling Son and Co., 23rd and Arch Sts., Philadel-phia, Pa.

399

JOHN ALEXANDER

Until Carr's automatic ligature instrument became available, ligation of thehilum by hand did not offer sufficient certainty of complete permanent occlu-sion of the pulmonary vessels to justify immediate resection of the lobe andclosure of the thoracic-wall incision. During the period in which I usedligation by hand and in the first two patients in which Carr's instrument wasused the lobe was left in place for several days. When the lobe was seen tobe in a dry-gangrenous condition it was cut away with scissors approximatelyfour centimetres distal to the hilar ligatures, and the pleural hole, from whichthe lobe was removed, packed open. In the last three patients, in whom theautomatic ligature was used, I felt reasonably certain that the pulmonaryvessels were securely closed and that immediate amputation of the lobe threeor four centimetres distal to the ligature was safe. Therefore, the lobe wasamputated, no ribs were resected, the intercostal incision was firmly closedand the posterior air-tight drainage tube was retained, its inner end beingtacked to the dome of the diaphragm as in the Brunn-Shenstone-Janes tech-nic; an air-tight tube was introduced into the lower pleural cavity forantiseptic irrigations. The drainage tube provided for discharge of the dis-integrated gangrenous hilar stump and for secretions from the infected lowerpleural cavity that remains after resection of the diseased lobe. The longends of the hilar ligature were passed together through an intercostal spaceand through the skin at the level of the dome of the diaphragm; the ligatureand the attached little metal box should be removed through a small incisionin the intercostal space not less than sixteen days after the second stage ofthe operation.

The procedure that was described in the preceding paragraph has the greatadvantage of permitting completion of the entire two-stage lobectomy throughan intercostal incision and of not requiring open packing of the pleural spacethat had been occupied by the resected lobe. The closed drainage tube assiststhe remaining lobe to expand and the diaphragm and mediastinum to shift andclose the residual pleural space. If a residual empyema cavity should persistit would probably be a small one and should heal after open drainage. If alarge bronchopleural fistula should persist it could be closed by applications of40 per cent. silver nitrate solution or by a muscle plastic operation. Closureof the incision in the thoracic wall has the disadvantage of exposing thepatient to the same danger of tension pneumothorax that exists after a one-stage lobectomy, should a valvular bronchopleural fistula develop, and shouldthe drainage tube become kinked or otherwise occluded. The chance of thiscombination of circumstances is, however, small.

Several surgeons who have adopted the two-stage operation use the firststage as I have described it, but at the second stage resect the diseased lobe,suture the hilar stump and close the thoracic wall, except for an air-tightdrain, as in the Brunn-Shenstone-Janes one-stage technic. This method ofremoving the lobe has all of the advantages offered by the method that I havejust described and the additional advantage that an automatic ligature boxand gangrenous hilar stump are not even temporarily retained in the body.Temporary retention of the box and stump, however, constitutes a minor

400

TOTAL PULMONARY LOBECTOMY AND PNEUMONECTOMY

disadvantage. The danger of reactionary or secondary haemorrhage from thesutured hilar stump is so great (see the section on one-stage lobectomy, inwhich the experience of various surgeons with haemorrhage has been cited)that I feel that suture should not be relied upon to secure the pulmonaryvessels but that they should be entrusted to the far more certain action of thepowerful circumferential automatic ligature.

MISCELLANEOUS CONSIDERATIONS

A number of other suggestions as to lobectomy have been made by varioussurgeons. Archibald has emphasized that the more severe the pulmonaryinfection, the greater the risk. Patients should not be operated upon during,or for several weeks after, an exacerbation or extension of the pulmonaryinfection.

In cases of bronchiectasis all five lobes of the lungs should be studied bymeans of iodized oil bronchograms so that the exact extent of the disease maybe definitely known. If only the basal lobes are studied, because only one orboth of them are suspected of being diseased, a single lobectomy may befollowed by disappointment in the discovery of some other diseased lobe. Itis usually best to introduce the iodized oil in two or three stages. The lobeson the right side may be injected at one sitting and those on the left sideseveral days later. If the supraglottic method of injecting the iodized oilshould be unsatisfactory, as it is in some adults and many children, the oilshould be introduced through an intrabronchial catheter. Each injection ofthe oil should be preceded and followed by a thorough postural drainage.

Several surgeons have successfully resected the right lower and middlelobes, or the left lower and that part of the left upper lobe which correspondsto the right middle lobe. Both lobes should be removed at the same opera-tion. Eloesser has successfully removed both lower lobes for bronchiectasis.We have undertaken to perform bilateral two-stage lobectomy of two or morelobes in four patients; in three of these the operations on the first side weresuccessfully concluded; one patient died from massive collapse of the rightlower lobe two weeks after her right middle lobe had been removed andseveral months after the removal of the left "middle" and lower lobes; thefourth patient died from progressive cavitation in both lungs about twomonths after removal of the right lower and middle lobes.

I agree with Churchill that a temporary phrenic nerve paralysis is prefera-ble to a permanent one before a unilateral lobectomy is performed. Paralysisof the hemidiaphragm hastens closure of the pleural space that remains afterremoval of the lobe; return of diaphragmatic function is desirable from thepoint of view of respiratory function. In patients in whom bilateral lobectomyis contemplated, and in whom operation upon the second side may be desirablebefore the temporarily paralyzed diaphragm on the side of the first lobectomyhas resumed function, it may be best not to paralyze the diaphragm on theside that is first to be operated upon. The phrenic nerve, however, might beadvantageously lightly pinched just above the diaphragm so as to produce a

401

JOHN ALEXANDER

brief diaphragtnatic paralysis to facilitate the operation and immediatelydecrease the size of the space left by removal of the lobe.

Induced pneumothorax has been occasionally advocated as a desirablemeasure preliminary to lobectomy. Sometimes it greatly reduces the amountof sputum and, in such cases, probably decreases the risk of post-operativeaspiration or stasis pneumonia. I feel, however, that this advantage is of lessimportance than the risk that is run of producing an empyema, or a pleuraleffusion and stiffening of the visceral pleura that would tend to delay orprevent eventual expansion and adhesion of the undiseased lobe.

Bethune has proposed the production of a pneumothorax, the introductionof a thoracoscope into the pneumothorax space and inflation of a powderthrough the thoracoscope so as to coat the pleural surface and cause adhesion-formation after abandonment of the pneumothorax. I have not used thissomewhat complicated procedure. It may prove to be of value if experienceshows that the powder consistently produces sufficiently firm pleural adhesionsover the undiseased lobe to prevent collapse of this lobe at the time of thelobectomy operation and yet does not produce such firm adhesions over thediseased lobe as to make their division at the time of operation too difficultor dangerous.

Intratracheal anasthesia with intermittent aspiration of tracheal or bron-chial secretions is used by some surgeons. I have not yet employed thisprocedure but I believe that further experience with it may conclusivelydemonstrate its value. When intrabronchial secretions are not aspiratedduring operation it sometimes becomes necessary to remove them immediatelyafter operation by means of a bronchoscope; the resulting relief of dyspnceaand anoxaemia is dramatic.

Churchill prefers to extend the interval between the first and second stagesto two or three months. He has found that during this time his patients gainweight, raise less sputum and are in better general condition for the secondstage than if only ten or twelve days have elapsed between stages. Onlyexceptionally has Churchill had difficulty in dividing the pleural adhesionsover the diseased lobe at the second stage. In this connection it is interestingto recall that even the pleural adhesions that have formed as the result of anempyema may sometimes be divided without great difficulty several monthsafter the empyema has become closed.

PNEUMONECTOMY

Until three years ago no patient had ever recovered after a certainly com-plete removal of one lung. As a consequence, carcinoma involving the mainstem bronchus, and bronchiectasis involving the entire lung were consideredvirtually hopeless diseases except for such relief as could be obtained bypalliative measures. In I93I, Nissen successfully removed the entire left lungin two stages for bronchiectasis; Windsberg, Haight, Alexander, Mason, VanAllen and Overholt (for abscess) have since had similar successes. Evarts Gra-ham and Singer, in I933, were the first successfully to remove an entire lungfor carcinoma. Since then, technical operative success has been obtained in re-

402

TOTAL PULMONARY LOBECTOMY AND PNEUMONECTOMY

moving the lung for carcinoma or sarcoma by Archibald, Rienhoff (two cases),Overholt (two cases), Churchill (three cases), Flick, Haight. Perhapsother surgeons, of whose cases I do not yet know, have attained technicalsuccess with the operation of total pneumonectomy. My only patient whohad pneumonectomy for carcinoma died thirty-two days after operation; hewas out of bed two weeks after operation; his previously diseased heartfibrillated and, in spite of intermittent improvement, was responsible for hisdeath; at autopsy there was no gross or microscopical evidence of any remain-ing malignant tissue. Excellent articles on pneumonectomy, which should beconsulted by the reader, have been recently contributed by Archibald, Gra-ham and Singer, Haight, Heuer, and Rienhoff.

Haight has made the interesting observation that all of the successful totalpneumonectomies for bronchiectasis have been performed in two or morestages and all of the successful pneumonectomies for malignant disease havebeen, so far as he knows, one-stage operations. The protection afforded tothe parietal pleura and mediastinum by a two or more stage operation mightbe expected to reduce the infectious risk in a bronchiectatic patient. In mostpatients who have bronchial carcinoma in an operable condition, complicatingsuppurative phenomena in the lung are not prominent and the danger ofgrave pleural and mediastinal infection after a one-stage pneumonectomy is,therefore, less than it would be in bronchiectatic patients. In carcinomapatients a pre-operative pneumothorax should be induced to aid the r6nt-genologist in diagnosing possible extrapulmonary metastases and to causethe patients' cardiorespiratory system to adapt itself to the physiologicalchange that will obtain after pneumonectomy.

It is fortunate for patients with carcinoma of the stem bronchus that aone-stage pneumonectomy is relatively safe. Complete removal of the growthin the bronchus frequently requires that the pulmonary vessels be separatelyligated and the stem bronchus dissected free from the mediastinal structuresand divided close to the bifurcation of the trachea; also, occasionally, resectionof glands from the mediastinum is indicated. Isolation and ligation of thepulmonary vessels in the hilum and dissection of the bronchus and lymph-glands in the mediastinum would be both difficult and dangerous at the secondstage of a two-stage pneumonectomy because of the traumatic inflammatoryinfiltration in the hilum and mediastinum, and the friability of the structuresthat would follow the first stage of the operation.

In cases of bronchiectasis, prolonged infection in the lung usually causesthe hilar structures to become matted together by inflammatory tissue thatwould make isolation and ligation of each of the thin-walled pulmonary vesselshighly dangerous. Since it is unnecessary for the surgeon to remove thehilum or the intramediastinal portion of the bronchus when performing apneumonectomy for bronchiectasis, the hila of the lobes or the hilum of theentire lung may be circumferentially ligated. Haight has had the experienceof being obliged to ligate the hilum of the entire lung, rather than the hila ofthe lobes separately, because the interlobar fissure was firmly fused by adhe-sions. Though the hilum, stiffened by fibrous induration, was ligated as

403

JOHN ALEXANDER

tightly as possible by hand with heavy silk and a rubber tube, the pulmonaryartery was only partly occluded and wet rather than dry gangrene of the lungresulted. During the following few days two additional but unsuccessfulattempts were made completely to close the artery; finally a Bethune tourni-quet, which was left in place, closed the pulmonary artery; a series of increas-ingly severe haemorrhages from the pulmonary artery ensued, ending in thepatient's death. At autopsy an ulcer was seen in the friable wall of the incom-pletely thrombosed pulmonary artery where the ligatures had been applied closeto the pericardium; it was also seen that ligation of the pulmonary artery with-in the pericardium, which had been considered as an emergency measure,would have failed to check the haemorrhages because the intrapericardial por-tion of the right pulmonary artery is very short and, in this patient, was in-fected and friable. Haight concludes that a similar accident should be antici-pated in any patient whose hilum is much indurated as a~result of chronicinfection. He feels that the hilum of each lobe should, whenever tough inter-lobar adhesions do not prevent separation of the lobes, be separately ligatedbecause the lobar hilum is more easily compressed than the hilum of the entirelung and because a greater length of the pulmonary vessels would remain be-tween ligatures and the heart to become thrombosed. Should it be neces-sary to ligate the hilum of the entire lung, Carr's automatic ligature should beapplied to the hilum as far as possible from the pericardium; this instrumentis so powerful that it is probably capable of completely and immediatelyoccluding the pulmonary artery; if it should fail at the first application, 'asecond tightening of the ligature, when the hilar tissues had become somewhatsoftened from the previous pressure, would almost certainly shut off theartery. This same instrument should be used if the lobar hila are to be ligated.

A two-stage pneumonectomy operation with circumferential ligation of thehila of the lobes or the hilum of the lung should be performed through aposterolateral incision because this affords the surgeon access to the entirepleural cavity, and especially good access to the dome of the pleura and thecostovertebral gutter where strong adhesions are likely to be met in cases ofbronchiectasis. Archibald has indicated that an anterior incision in the tho-racic wall is usually best when a one-stage pneumonectomy is intended forbronchial carcinoma; such an incision gives immediate access to the pulmonaryvessels in the anterior portion of the hilum and usually gives sufficient accessto what few pleural adhesions are likely to be present in cases of operablebronchial carcinoma; a posterolateral incision gives poor access to the anteriorsurface of the hilum if the lung is bulky and stiff as a result of neoplastic andcomplicating inflammatory infiltration.

The clinical experience of several surgeons has shown that the entire spacethat was occupied by the lung may become obliterated by displacement of themediastinum, diaphragm and costal thoracic wall. If a residual pleural spaceshould become infected and if prolonged drainage and paralysis of the hemi-diaphragm should fail to obliterate it, a thoracoplasty should be performed.

The fact that eleven patients have survived the period of surgical con-valescence after resection of an entire lung for malignant disease, has done

404

TOTAL PULMONARY LOBECTOMY AND PNEUMONECTOMY

miuch to stimulate interest in the diagnosis of bronchial carcinoma in theoperable stage. However, numerous patients are still being referred to thesurgeon and bronchoscopist in the inoperable rather thani the operable stagebecause too few physicians at present realize that carcinioma of the lung is arelatively commonplace disease in middle age, as well as in old age, and thatmild pulmonary symptonms which are not diagnostic of other disease may bethe expression of an early phase of bronchial carcinoma demanding ar6ntgenogram and bronchoscopy.

Total pneumonectoniy will probably always be a relatively dangerousoperation. Even an exploratory thoracotomy, undertaken to determine theoperability of a carcinoma, may prove to be an operation of gravity in an oldperson whose carcinoma has probably been growing for months and in whomanaemia, loss of weight and other signs of advancing malignant disease areindications of impaired general resistance, if not of metastases. The recentdemonstration of the feasibility of pneumonectomy in man will probablygreatly stimulate interest in the early diagnosis and surgical treatment ofpulmonary carcinoma. As a direct result of this growing interest it is almostcertain that a steadily increasing number of technically successful pneumonec-tomies, followed by prolonged freedom from recurrence of carcinoma, willbe reported.

REFERENCES*Alexander, John: Total Pulmonary Lobectomy; a Simple and Effective Two-Stage

Technique. Surg., Gynec., and Obstet., vol. 56, p. 658, 1933.Archibald, E. W.: The Technique of Total Unilateral Pneumonectomy, with the Report

of Two Cases. To be published in Trans. Amer. Surg. Assn., I934.Ballon, Harry, Singer, J. J., and Graham, E. A.: Bronchiectasis. Jour. Thor. Surg.,

vol. I, p. 502, I932.Bethune, Norman: "Pleural Poudrage," the Production of Pleural Adhesions as a Pre

liminary to Lobectomy. To be published in Jour. Thor. Surg., I934-I935.Biondi, D.: Contributo alla Chirurgia Polmonare. Clin. chir., vol. 3, p. 425, I895.Brunn, Harold: Surgical Principles Underlying One-Stage Lobectomy. Arch. Surg.,

vol. I8, p. 490, I929.Brunn, Harold: The Technique of Lobectomy in One Stage. Surg., Gynec., and Obstet.,

vol. 55, p. 6i6, I932.Carlson, H. A., and Ballon, H. C.: The Operability of Carcinoma of the Lung. Jour.

Thor. Surg., vol. 2, p. 323, I933.Carr, Duane: Automatic Lobectomy Ligature. To be published in Jour. Thor. Surg.,

I935.

Churchill, E. D.: The Surgical Treatment of Carcinoma of the Lung. Jour. Thor.Surg., vol. 2, p. 254, 1933.

Edwards, A. Tudor: Some Reflections on Intrathoracic Malignant Disease. To be pub-lished in Jour. Thor. Surg., I934-I935.

Eloesser, Leo: Bilateral Lobectomy. Surg., Gynec., and Obstet., vol. 57, p. 247, I933.Garre, C., and Quincke, H.: Lungenchirurgie, 2d ed., pp. 63-68, Gustav Fischer, Jena,

19I2.

* The clinical results and opinions of several surgeons have been referred to inthe text of the article without representation in the bibliography. These data have notyet been published; they were sent to Dr. Cameron Haight and the author in the formof personal communications.

405

JOHN ALEXANDER

Graham, E. A., and Singer, J. J.: Successful Removal of an Entire Lung for Carcinomaof the Bronchus. Jour. Amer. Med. Assn., vol. IOI, p. i37i, 1933.

Haight, Cameron: Total Removal of Left Lung for Bronchiectasis. Surg., Gynec., andObstet., vol. 58, p. 768, 1934.

Heuer, G. J.: The Development of Lobectomy and Pneumectomy in Man. Jour. Thor.Surg., vol. 3, p. 56o, I934.

Heuer, G. J., and Dunn, G. R.: Experimental Pnieumectomy. Bull. Johns HopkinisHosp., vol. 3I, P. 3I, I920.

Janes, R. M.: The Surgical Treatment of Bronchiectasis. Brit. Jour. Surg., vol. 21,p. 257, I933.

Kuemmell, H.: Verhandl. d. Deutsch. Gesellsch. f. Chir., vol. 40, p. 147, 1911.Lilienthal, Howard: Thoracic Surgery, vol. 2, PP. I34-2I8, W. B. Saunders Co., Phila-

delphia and London, I925.Lilienthal, Howard: Pneumonectomy for Sarcoma of the Lung in a Tuberculous Patient.

Jour. Thor. Surg., vol. 2, p. 6oo, 1933.Meyer, W.: Pneumectomy with the Aid of Differential Air Pressure, an Experimental

Study. Jour. Amer. Med. Assn., vol. 53, p. 1978, I909.Nissen, R.: Exstirpation eines ganzen Lungenfluegels. Zentralbl. f. Chir., vol. 58,

P. 3003, 1931.Rienhoff, W. F., Jr., and Broyles, E. N.: The Surgical Treatment of Carcinoma of

the Bronchi and Lungs. Jour. Amer. Med. Assn., vol. IO3, p. II21, I934.Roberts, J. E. H., and Nelson, H. P.: Pulmonary Lobectomy; Technique and Report

of Ten Cases. Brit. Jour. Surg., vol. 21, P. 277, I933.Robinson, S.: The Surgery of Bronchiectasis Including a Report of Five Complete

Restorations. Surg., Gynec., and Obstet., vol. 24, P. 194, 1917.Robinson, S., and Sauerbruch, F.: Untersuchungen ueber die Lungenexstirpation unter

vergleichender Anwendung beider Formen des Druchdifferenzverfahrens. DeutscheZtschr. f. Chir., vol. 102, P. 542, 1909.

Sauerbruch, F.: Die Nekrose einer Lungenhaelfte nach Exstirpation eines Ganglion-neuroms des Brustsympathikus und ihre allgemein pathologische Bedeutung.Muenchen. med. Wchnschr., vol. 70, P. IOII, I923.

Sauerbruch, F.: Die Chirurgie der Brustorgane, vol. i, pp. 869-905, I928, and vol. i,pt. 2, Pp. II37-II54, Julius Springer, Berlin, 1930.

Schlueter, S. A., and Weidlein, I. F.: Surgery of the Lung: Experimental Lobectomyand Pneumectomy. Arch. Surg., vol. 13, P. 459, I926.

Shenstone, N. S., and Janes, R. M.: Experiences in Pulmonary Lobectomy. Canad.Med. Assn. Jour., vol. 27, p. I38, I932.

Whittemore, Wyman: The Treatment of Such Cases of Chronic Suppurative Bronchiec-tasis as Are Limited to One Lobe of the Lung. ANNALS OF SURGERY, vol. 86,P. 2I9, I927.

Zaaijer, J. H.: Beitraege und Auffassungen ueber Thoraxchirurgie. Arch. f. klin. Chir.,vol. I57, p. 540, 1931.

406