Do Japanese thoracic surgeons think that dissection of the pulmonary ligament is necessary after an upper lobectomy?

Abstract

It is uncertain whether the dissection of the pulmonary ligament is necessary in patients who undergo an upper lobectomy. A questionnaire was sent to the directors of Thoracic Surgery in 102 hospitals, asking whether dissection of the pulmonary ligament is performed in such patients, and the complications associated with dissecting or preserving the ligament. Seventy-eight directors (76%) returned the questionnaire. The preservation of the ligament is the current practice in 54 hospitals (69%), while 13 hospitals (17%) occasionally dissect, 9 hospitals (11%) regularly dissect, and 2 hospitals (3%) half dissect the ligament. Thirty directors experienced complications which were thought to be associated with dissecting the ligament: bronchial stenosis (21 directors), atelectasis (8), and bronchial obstruction (4). Twenty-six directors described complications thought to be associated with preserving the ligament: the pooling of pleural effusion (19 directors), insufficient expansion of lung (18), atelectasis (8), and empyema (7). Preservation of the ligament may therefore be useful in preventing bronchial stenosis and obstruction, while its dissection may be useful to prevent the pooling of pleural effusion.

Does Division of the Pulmonary Ligaments Affect the Outcomes after Thoracoscopic Lobectomy: A Retrospective Study of 72 Cases

“…Currently, many thoracic surgeon dissect IPLs during superior lobectomy, which can reduce the residual cavity of the chest and prevent atelectasis, but which also induces risks of bronchial distortion, stenosis, obstruction, and even ventilation dysfunction (9,12). A study from Japan has shown that 69% of hospitals preserve IPLs during superior lobectomy, and that the doctors in these hospitals think that preservation of IPLs can reduce the incidence rate of bronchial distortion and stenosis, but will increase the risks of pleural effusion and infection (13). In the present study, there was no significant difference in terms of complication rate, chest drainage, drainage time, and delayed air leak.…”

“…No mortality or conversion to open surgery was observed in the present study, while previous series in which the IPLs were dissected observed a mortality rate of 0.5-3.7% and a conversion rate of 1.8-17.6% (21,22). In these previous series, the most common complication was air leak, which was observed in two patients from group D. When preserving the IPLs, the most common complications are pleural effusion, insufficient lung expansion, atelectasis, empyema, pneumonia, pooling of sputum and fistula (13). In the present study, one case of arrhythmia, two with pneumonia, and one with atelectasis were observed.…”

The choice of dissection or preservation of the inferior pulmonary ligament after an upper lobectomy: a systematic review and meta-analysis

“…Nevertheless, the whole drainage time was not obviously prolonged, which might be also affected by other factors, such as different numbers, diameters of chest tubes, and different volume thresholds for chest tube removal used among studies. A questionnaire survey conducted by Usuda et al [4] in Japan has revealed that nearly 28% directors in the Department of Thoracic Surgery tend to attribute the pooling of pleural effusion to the preservation of IPL. However, a recent study performed by Kim et al [11] has stated that no significant difference is found between the preservation and dissection groups in terms of delayed pleural effusion.…”

“…During upper lobectomy, whether the inferior pulmonary ligament (IPL) should be dissected remains a controversial issue. A traditional view has suggested that the dissection of IPL can improve the reexpansion of the inferior lobe, obliterate the free place in thoracic cavity, and then reduce the accumulation of pleural effusion [4, 5]. However, several other studies have also stated that the dissection of IPL can lead to the excessive bronchial displacement, which may be associated with the chronic dry cough or even other fatal outcomes postoperatively [6, 7].…”

Ventilation failure after lateral jackknife positioning for robot-assisted lung cancer surgery in a patient after lingula-sparing left upper lobectomy

“…In patients undergoing second lung cancer surgery, special caution is required regarding bronchial displacement after previous surgery [1]. Particularly, patients after a left upper lobectomy commonly have U-or V-shaped angulation of the left main bronchus [2][3][4][5]. Although a standard left-sided double-lumen tube (DLT) is most commonly used to achieve one-lung ventilation (OLV), patients after a left upper lobectomy may encounter ventilation failure with this tube due to bronchial angulation [5].…”