**1. Introduction**

[131] Detterbeck, F. C. Efficacy of methods of intercostal nerve blockade for pain relief af‐ ter thoracotomy. Ann Thorac Surg. [Research Support, Non-U.S. Gov't Review].

[132] Wurnig, P. N, Lackner, H, Teiner, C, Hollaus, P. H, Pospisil, M, Fohsl-grande, B, et al. Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia? Eur J Cardiothorac Surg. [Clinical Trial Comparative Study‐

[133] Meierhenrich, R, Hock, D, Kuhn, S, Baltes, E, Muehling, B, Muche, R, et al. Analgesia and pulmonary function after lung surgery: is a single intercostal nerve block plus patient-controlled intravenous morphine as effective as patient-controlled epidural anaesthesia? A randomized non-inferiority clinical trial. Br J Anaesth. [Comparative

[134] Dahl, J. B, Moiniche, S, & Kehlet, H. Wound infiltration with local anaesthetics for postoperative pain relief. Acta Anaesthesiol Scand. [Research Support, Non-U.S.

[135] Kehlet, H, & Dahl, J. B. Anaesthesia, surgery, and challenges in postoperative recov‐

[136] Wheatley, G. H. rd, Rosenbaum DH, Paul MC, Dine AP, Wait MA, Meyer DM, et al. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg. [Comparative Study Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Research Support, U.S. Gov't,

[137] Baig, M. K, Zmora, O, Derdemezi, J, Weiss, E. G, Nogueras, J. J, & Wexner, S. D. Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study. J Am Coll Surg. [Randomized Controlled Trial Research Support, Non-U.S. Gov't]. (2006). Feb;,

[138] Horlocker, T. T, Wedel, D. J, Rowlingson, J. C, Enneking, F. K, Kopp, S. L, Benzon, H. T, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. [Practice Guideline]. (2010).

Randomized Controlled Trial]. (2002). Jun;, 21(6), 1115-9.

ery. Lancet. [Review]. (2003). Dec 6;, 362(9399), 1921-8.

Gov't Review]. (1994). Jan;, 38(1), 7-14.

P.H.S.]. (2005). Aug;, 130(2), 464-8.

202(2), 297-305.

Jan-Feb;, 35(1), 64-101.

Study Randomized Controlled Trial]. (2011). Apr;, 106(4), 580-9.

(2005). Oct;, 80(4), 1550-9.

46 Principles and Practice of Cardiothoracic Surgery

Early surgical interventions were highly morbid, painful and deadly. Understanding of antisepsis, after Lister's first report in 1867 and development of anesthetic techniques, in particular chloroform and ether made way for early successful surgical intervention. Thoracic surgery and lung resection, however, proved more difficult to advance than other surgical specialties due to the problem of pneumothorax. The principles of intra-thoracic and intrapleural surgery developed during the early 20th century with significant progress in a short time.

Lung surgery prior to the late 1800's was largely rare reports of draining deep abscesses, resecting prolapsing gangrenous tissue after trauma and resecting portions of the chest wall with small segments of accompanying lung. Tuffier performed the first partial lung resection that consisted of placing a ligature on the lung, excising and suturing the lung to the perios‐ teum.[1], [2] Initial works demonstrating the feasibility of lung resection came from extensive animal experimentation. Block of Danzig described many lung resections in rabbits and dogs. The animals survived surgery and returned to health. The problem of pneumothorax however plagued the operative and the post-operative period. Positive pressure ventilation was not immediately seen as a solution to advance intra-thoracic surgery and those who did use it were divided between the use of face-masks, intra-pharyngeal and endotracheal insufflation. Sauerbruch, in Germany, with the support of the internationally acclaimed Von Mikulicz, persisted for many years operating in expensive negative pressure chambers. He pioneered the first tank ventilator in 1907, allowing surgeons to operate on an open thorax with the patient's head and anesthesiologist literally in another room. Surgery in the US, less hindered by the negative pressure camp, was quicker to adopt endotracheal intubation, the use of bellows and ultimately endobronchial lung isolation ventilation. Negative pressure was used extensively however and persisted through the polio epidemic until the late 1930's.[2], [3]

© 2013 Williams and Vigneswaran; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Lung surgery developed and progressed because of chronic infections of the lung and pleura particularly tuberculosis and bronchiectasis. Lilienthal described the plight of his patients in 1922[4]:

Brunn published a landmark paper in 1929 on one stage lobectomy. He described the concept of early lung expansion using closed suction drainage. Local anesthesia was used, phrenicot‐ omy, cautery for lung and air testing. He emphasized an airtight closure to allow lung expansion but used a clamp on the pedicle, which caused necrosis and ultimately a broncho‐ pleural fistula with empyema. The argument at the time was that the expanded lung restricted the space into which the empyema would fill allowing it and the subsequent fistula to more

Evolution of Surgical Approaches for Lung Resection

http://dx.doi.org/10.5772/56641

49

Nissen performed his first pneumonectomy in 1931 using a staged technique. In 1932 Shen‐ stone & Janes published an article delineating their experience with 14 operations, five fistula and three deaths. They emphasized not crushing the hilum to preserve the bronchial blood supply, catgut (not silk which could harbor infection) to close the bronchus and suturing the stump to the undersurface of the remaining lobe. The phrenic nerve was crushed and an underwater drain used. Tourniquets and snares were subsequently developed and became common operating equipment.[1], [2], [6] Evarts Graham performed the first single stage pneumonectomy for lung cancer in 1933. He used cautery liberally during his operations

By the end of the 1930's dissection technique was established. Kent and Blades and Belsey and Churchill delineated the anatomy for lobar and segmental resection. A landmark article in 1940 by Kent and Blades is said to have set the stage for the future of thoracic surgery and the segment, rather than the lobe, was proposed to be the new unit of the lung.[3], [7] Overholt described the intersegmental vein for a plane of dissection and he emphasized the utility of suction over simply underwater drainage.[3] Tumors involving or approaching major airways precluded lesser resections. The lower lobe would be sacrificed for large upper lobe tumors or bronchial tumors. Price-Thomas performed the first sleeve lobectomy in 1947. Since that time all matter of bronchial and arterial reconstructions evolved to preserve lung tissue.[8] Regard‐ ing completeness of cancer treatment, now we know sleeve lobectomy has 5-year survival rates better than pneumonectomy with improved quality adjusted life years as determined by

The use of the surgical stapler became common in the 1950's and 60's. Initially, a Russian stapler with a single row of staples oriented parallel to the bronchus was replaced with two rows of staggered staples oriented perpendicularly to the bronchus. Though not eliminating bronchial fistula, stapling was found to be superior to suture techniques in closure of bronchus. It also

The classic postero-lateral thoracotomy, as practiced until recently, provides excellent access to the thoracic cavity but involves transecting the latissimus and serratus muscles and subperiosteal rib resection. With increasing application of thoracic surgery, younger more active patients and improved peri-operative pain control, reduced morbidity became increas‐ ingly important.[11] With improved survival, improving quality of life and early return to full

permitted less sacrifice of lung parenchyma and decreased blood loss.[10]

easily be controlled and permit an easier recovery.[3],[5]

reporting somewhat lower mortality in the 20% range.

decision analysis.[9]

**2. Current practice**

Occasionally an individual coughs his way through life - never a long one - and manages to exist as a semi-invalid, with copious foul expectoration no medicine can control, being a handicap difficult to bear. Patients have even threatened suicide if refused the chance for cure by operation, though they knew the danger was great.

The stethoscope existed from the early 1800's making some diagnosis possible. Higher level of precision and certainty regarding surgical intervention became possible with the advent X-Ray by Röentgen's in 1895. This was quickly taken up by the medical field and the first chest X-ray was performed in 1896.

Gluck from Germany is credited with the first lobectomy in 1907. Morriston Davies reported a landmark lobectomy in 1912 describing individual vessel and bronchial ligation much like we do today but his technique was not followed for some twenty years. It was believed at that time that bronchial stump healing was dependent on the amount of peribronchial tissue remaining after resection and mass ligation was the preferred method.[1] The lung resection was performed in stages as illustrated. The first operation consisted of rib resection without entering the pleura, as done by Robinson at the Massachusetts General Hospital in 1917. Abrading the pleura during the first operation was common to help adhesions form and prevent a pneumothorax during the second operation. A week later the pleura is entered and the lobe resected if the patient tolerated. The bronchus and vasculature were clamped en-mass, transfixed with a suture or left with a clamp in place to be removed a week later. Peri-operative mortality was about 50%. Getting out of the operating room was often an urgency given cyanosis from large amounts of purulent sputum. The diseased lung could be left in place and allowed to slough. The diseased bronchial stump would likely open regardless. Infection was expected post-operatively, packs were left in the chest and wounds granulated in over months.

Samuel Robinson's presidential address to the American Association of Thoracic surgery in 1923 was very telling:

The danger of pneumothorax in wide operation on the human thorax has been dispelled...since the development of the differential pressure apparatus...(regarding bronchiectasis) The patient is placed on the operating table...There may be cyanosis...evacuation of large amounts of pungent, purulent sputum...the pleura is no sooner opened... the need for general anesthesia is obvious...The lower lobe obstinately resists being delivered, the pleural adhesions are strong and widespread... ropelike and tenacious... work with a knife and scissors is blind... the patient's condition may become distressing...then the difficulties multiply. The complete liberating at one setting may have to be abandoned. Tight closure of the chest without drainage seems inadvisable under such conditions, and yet necessary to avoid the ills of post-operative pneumothorax. Suddenly it seems time to return the patient to his bed. Not much has been accomplished... The intra-thoracic pressure has been so altered; the lung expansion is further minimized. Then come the dangers of pleural infection, later in convalescence. There is more operating to do... Nevertheless, we have obtained cures.[1]

Brunn published a landmark paper in 1929 on one stage lobectomy. He described the concept of early lung expansion using closed suction drainage. Local anesthesia was used, phrenicot‐ omy, cautery for lung and air testing. He emphasized an airtight closure to allow lung expansion but used a clamp on the pedicle, which caused necrosis and ultimately a broncho‐ pleural fistula with empyema. The argument at the time was that the expanded lung restricted the space into which the empyema would fill allowing it and the subsequent fistula to more easily be controlled and permit an easier recovery.[3],[5]

Nissen performed his first pneumonectomy in 1931 using a staged technique. In 1932 Shen‐ stone & Janes published an article delineating their experience with 14 operations, five fistula and three deaths. They emphasized not crushing the hilum to preserve the bronchial blood supply, catgut (not silk which could harbor infection) to close the bronchus and suturing the stump to the undersurface of the remaining lobe. The phrenic nerve was crushed and an underwater drain used. Tourniquets and snares were subsequently developed and became common operating equipment.[1], [2], [6] Evarts Graham performed the first single stage pneumonectomy for lung cancer in 1933. He used cautery liberally during his operations reporting somewhat lower mortality in the 20% range.

By the end of the 1930's dissection technique was established. Kent and Blades and Belsey and Churchill delineated the anatomy for lobar and segmental resection. A landmark article in 1940 by Kent and Blades is said to have set the stage for the future of thoracic surgery and the segment, rather than the lobe, was proposed to be the new unit of the lung.[3], [7] Overholt described the intersegmental vein for a plane of dissection and he emphasized the utility of suction over simply underwater drainage.[3] Tumors involving or approaching major airways precluded lesser resections. The lower lobe would be sacrificed for large upper lobe tumors or bronchial tumors. Price-Thomas performed the first sleeve lobectomy in 1947. Since that time all matter of bronchial and arterial reconstructions evolved to preserve lung tissue.[8] Regard‐ ing completeness of cancer treatment, now we know sleeve lobectomy has 5-year survival rates better than pneumonectomy with improved quality adjusted life years as determined by decision analysis.[9]

The use of the surgical stapler became common in the 1950's and 60's. Initially, a Russian stapler with a single row of staples oriented parallel to the bronchus was replaced with two rows of staggered staples oriented perpendicularly to the bronchus. Though not eliminating bronchial fistula, stapling was found to be superior to suture techniques in closure of bronchus. It also permitted less sacrifice of lung parenchyma and decreased blood loss.[10]
