Pulmonary Lobectomy
What the Examiner Expects
Surgical removal of an anatomic lobe of the lung, the standard of care for stage I–II non-small cell lung cancer. The examiner expects you to stage the patient (CT chest, PET scan, mediastinoscopy or EBUS for mediastinal lymph node staging), assess pulmonary reserve (PFTs — predicted postop FEV1 and DLCO must both be > 40%), and describe the procedure: individual ligation and division of the lobar artery branches, lobar vein, and lobar bronchus, with en bloc removal of the lobe and systematic mediastinal lymph node dissection. VATS lobectomy is preferred when technically feasible, with equivalent oncologic outcomes and reduced morbidity.
Key Examiner Focus Points
- Standard oncologic resection for early-stage non-small cell lung cancer (NSCLC)
- Requires adequate pulmonary reserve: predicted postop FEV1 > 40% and DLCO > 40%
- VATS (video-assisted) or robotic approach preferred over open thoracotomy when feasible
- Systematic mediastinal lymph node dissection or sampling for staging
- Bronchial stump tested underwater for air leak
Common Curveballs
PET scan shows an ipsilateral mediastinal lymph node with increased uptake
This is N2 disease (stage IIIA) if confirmed. Tissue confirmation is required — perform EBUS-guided FNA or mediastinoscopy. If positive for metastatic disease, the patient is not a primary surgical candidate. Neoadjuvant chemoradiation or definitive chemoradiation is recommended, with surgery considered after restaging.
Postop persistent air leak on day 7
Prolonged air leak (> 5 days) is the most common complication. Management: Heimlich valve for outpatient management if clinically stable, chemical pleurodesis (doxycycline or talc), or blood patch pleurodesis. Most resolve within 2 weeks. Reoperation is rarely needed.
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