Lung cancer surgery is an option for some patients depending on the type, location and stage of their lung cancer and other medical conditions. Attempts to cure lung cancer with the surgery will remove the tumour along with some surrounding lung tissue. Removing the tumour with lung cancer surgery is considered the best option when the tumour is localised and unlikely to have spread. This includes early-stage non-small cell lung cancers and carcinoid tumours.
Surgery may be the first step in lung cancer treatment, or it may follow other procedures. People with early non-small cell lung cancer (stage I or II) will generally be offered surgery to remove the tumour. How much of the lung is removed depends on the location of cancer, its size, your general wellbeing and fitness, as well as your lung function.
Lung cancer is usually diagnosed at a later stage once it has caused symptoms, so most people with lung cancer will not have surgery. You will have general anesthesia before surgery. You will be asleep and unable to feel pain. Two common ways to do surgery on your lungs are thoracotomy and video-assisted thoracoscopic surgery (VATS). Robotic surgery may also be used.
Lung surgery using a thoracotomy is called open surgery. In this surgery:
- You will lie on your side on an operating table. Your arm will be placed above your head.
- Your surgeon will make a surgical cut between two ribs. The reduction will go from the front of your chest wall to your back, passing just underneath the armpit. These ribs will be separated, or a bone may be removed.
- Your lung on this side will be deflated so that air will not move in and out of it during surgery. This makes it easier for the surgeon to operate on the lung.
- Your surgeon may not know how much of your lung needs to be removed until your chest is open, and the lung can be seen.
- Your surgeon may also remove lymph nodes in this area.
- After surgery, one or more drainage tubes will be placed into your chest area to drain out fluids that build up. These tubes are called chest tubes.
- After the surgery on your lung, your surgeon will close the ribs, muscles, and skin with sutures.
- Open lung surgery may take from 2 to 6 hours.
The epidemiology of lung cancer has changed dramatically within the last 40 years. The incidence has increased, especially among women, and there are more adenocarcinomas. The number of surgical candidates in stage I and II disease have increased both for patients below and above 70 years. There is an ongoing debate regarding centralisation of lung cancer surgery. Generally, hospitals with low volumes of lung cancer surgery have lower five years of survival and more complications than teaching hospitals and hospitals with high volumes . Predictors of higher survival rate or lower complication rate have been female gender , lower age , early preoperative stage , lobectomy , adenocarcinoma , no previous coronary heart disease , and normal pulmonary function tests . Some of these predictors have been analysed only in univariate tests. There are as far as we know no previous reports from county hospitals where lung cancer surgery is performed with staff from larger teaching hospitals.
Aalesund Hospital in Norway is a county hospital with a catchment area of approximately 100 000 inhabitants. This study aimed to evaluate lung cancer surgery performed in a county hospital in terms of 30 days mortality, complications and long time survival, and to evaluate predictors of long time survival.
There are three types of lung cancer surgery:
- lobectomy – where one or more substantial parts of the lung (called lobes) are removed. Your doctors will suggest this operation if the cancer is just in 1 section of 1 lung.
- Pneumonectomy – where the entire lung is removed. This is used when the tumour is located in the middle of the lung or has spread throughout the lung.
- Wedge resection or segmentectomy – where a small piece of the lung is removed. This procedure is only suitable for a small number of patients. It is only used if your doctors think your cancer is low and limited to one area of the lung. This is usually very early-stage non-small-cell lung cancer.
People may be concerned about being able to breathe if some or all of a lung is removed, but it’s possible to breathe normally with one lung. However, if you have breathing problems before the operation, it’s likely these symptoms will continue after surgery.
Tests before surgery
Before surgery, you’ll need to have some tests to check your general state of health and your lung function. These may include:
- an electrocardiogram (ECG) – electrodes are used to monitor the electrical activity of your heart
- a lung function test called spirometry – you’ll breathe into a machine which measures how much air your lungs can breathe in and out
- an exercise test
Before the Procedure
You will have several visits with your healthcare provider and undergo medical tests before your surgery. Your provider will:
- Do a complete physical exam
- Make sure other medical conditions you may have, such as diabetes, high blood pressure, or heart or lung problems are under control
- Perform tests to make sure that you will be able to tolerate the removal of your lung tissue, if necessary
- If you are a smoker, you should stop smoking several weeks before your surgery. Ask your provider for help.
- Always tell your provider:
- Which drugs, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription
- If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day
- During the week before your surgery:
- You may be asked to stop taking drugs that make it hard for your blood to clot. Some of these are aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), clopidogrel (Plavix), or ticlopidine (Ticlid).
- Ask your provider which drugs you should still take on the day of your surgery.
- Prepare your home for your return from the hospital.
- On the day of your surgery:
- Do not eat or drink anything after midnight the night before your surgery.
- Take the medicines your doctor prescribed with small sips of water.
- Your provider will tell you when to arrive at the hospital.
How it’s performed
Surgery is usually done by making a cut (incision) in your chest or side and removing a section or all of the affected lung. Nearby lymph nodes may also be removed if it’s thought that cancer may have spread to them.
In some cases, an alternative to this approach, called video-assisted thoracoscopic surgery (VATS), may be suitable. VATS is a type of keyhole surgery, where small incisions are made in the chest. A small camera is inserted into one of the incisions, so the surgeon can see the inside of your chest on a monitor as they remove the section of the affected lung.
There are two commonly used approaches to removing portions of the lung. The choice depends on the location, size and stage of the lung tumour and the expertise of the surgeon.
This is an incision on the back and side of the chest and follows the curve of your ribs. It typically involves dividing some of the muscles of the chest wall and uses an instrument to gently spread between two bones to provide the surgeon access to the lung. The muscles are repaired when the incision is closed. If a cut is made between the bones in the side of the chest, the operation is called a thoracotomy. You will need to stay in the hospital for 3–7 days.
Minimally invasive surgery
This approach typically involves 1 to 4 small incisions to access the inside of the chest. The surgeon uses a camera to visualise the lung and specialised instruments to perform the surgery. This is known as thoracoscopy or video-assisted thoracoscopic surgery (VATS) and can also be done with the assistance of a surgical robot. It’s becoming more common for lung surgery to be done with a keyhole approach. This is known as video-assisted thoracoscopic surgery (VATS). The surgeon makes a few small cuts in the chest wall, inserts a tiny video camera and operating instruments, and performs the operation from outside the chest. A keyhole approach usually means a shorter hospital stay, faster recovery and fewer side effects.
You will have a few tubes in place when you wake up from the operation, such as a drip and a chest drain. You usually go home after 5 to 10 days.
Most people stay in the hospital for 5 to 7 days after open thoracotomy. Hospital stay for a video-assisted thoracoscopic surgery is most often shorter. You may spend time in the intensive care unit (ICU) after either surgery.
During your hospital stay, you will:
- Be asked to sit on the side of the bed and walk as soon as possible after surgery.
- Have tube(s) coming out of the side of your chest to drain fluids and air.
- Wear special stockings on your feet and legs to prevent blood clots.
- Receive shots to prevent blood clots.
- Receive pain medicine through an IV (a tube that goes into your veins) or by mouth with pills. You may receive your pain medicine through a particular machine that gives you a dose of pain medicine when you push a button. This allows you to control how much pain medicine you get. You may also have an epidural placed. This is a catheter in the back that delivers pain medicine to numb the nerves to the surgical area.
- Be asked to do a lot of deep breathing to help prevent pneumonia and infection. Deep breathing exercises also help inflate the lung that was operated on. Your chest tube(s) will remain in place until your lung has fully inflated.
When you wake up after your operation
After a big operation, you wake up in the intensive care unit or a high dependency recovery unit. You usually move back to the ward within a day or so.
In intensive care, you have one to one nursing care. In the high dependency unit, you have very close nursing care. Your surgeon and anaesthetist also keep an eye on your progress.
These units are busy and often noisy places that some people find strange and disorientating. You’ll feel drowsy because of the anaesthetic and painkillers.
Lung resection is surgery to remove part or all of your lung. It is used to treat a damaged or diseased lung.
It is common to feel tired for 6 to 8 weeks after surgery. Your chest may hurt and be swollen for up to 6 weeks. It may ache or contact stiff for up to 3 months. For up to 3 months, you may also feel tightness, itching, numbness, or tingling around the cut (incision) the doctor made. Your doctor will give you medicines to help with the pain.
You may have stitches or staples in the incision. Your doctor will take these out 1 to 2 weeks after your surgery. You may have one or more tubes coming out of your chest to drain fluids. Your doctor will probably take these out about one week after surgery.
After surgery, you will probably feel short of breath. Your doctor, nurse, or respiratory therapist will teach you deep-breathing and coughing exercises to help your body get as much oxygen as possible. At first, you also may need to get extra oxygen through a mask or a plastic tube in your nostrils (nasal cannula).
This care sheet gives you a general idea about how long it will take for you to recover. But each person recovers at a different pace. Follow the steps below to get better as quickly as possible.
You have dressings over your wounds. After a couple of days, your nurse changes the bandages and cleans the wounds.
The size and number of your surgical wounds depend on whether you had open surgery or keyhole surgery. You might have about three smaller scars if you had keyhole surgery. You have at least one wound, a longer incision, with open surgery.
The wounds have stitches or clips that stay in for about ten days. You can go home with the stitches in if your injury is still healing and you’re otherwise well. A nurse then takes the stitches out. This could be at home, or you might need to go back to the hospital.
Before you go home, your nurse gives you information about how to care for the wound.
Tubes and drains
When you wake up, you’ll have several tubes or drains. This can be frightening, so it helps to know what they’re for.
These might include:
- drips to give you blood transfusions and fluids, usually into a vein in your neck
- a chest drain – this is a tube attached to a bottle that helps to drain air and fluid from around your wound and to improve your lung expand again
- a container into your bladder (catheter) to measure how much urine you pass
- a small machine into a vein to check your blood pressure
You might also have an oxygen mask over your nose and mouth.
Electronic pumps may control any medicines you have through your drip.
It’s normal to have some soreness or pain for the first week or so. You will be given painkillers. Tell your doctor or nurse as soon as you feel any pain. They need your help to find the right type and dose of painkiller for you. Painkillers work best when you take them regularly.
Immediately after surgery, you might have one or more of the following to control your pain:
- continuous painkillers through a drip into your bloodstream – you control this by pressing a button when you have anxiety (patient-controlled analgesia or PCA)
- painkillers given directly into the area around the lung through a small tube called a paravertebral catheter
- an injection of anaesthetic into the nerves close to the lung (a nerve block)
- You get painkillers to take home. Follow the instructions your nurse gives you about how often and when to take them. Contact your doctor if you still have pain or if it gets worse.
Some people find they have pain for a long time after surgery for lung cancer. Let your doctor or specialist nurse know if your pain continues for more than a few weeks.
Eating and drinking
Once you are fully awake and feel able to, you can have something to eat and drink. You might not feel like eating much at first. You gradually build up what you drink and eat.
Your nurses and physiotherapists help you to move around as soon as possible. They check you’re doing your breathing and leg exercises. This enables you to recover.
You might be sitting in a chair within 12 hours of your operation. The day after, you’ll be walking around your bed. And within a few days, you’ll be able to walk along the hospital corridor.
During the first few days after your operation, you’ll start to feel better. The drips and drains come out, you start eating, and you can move about a bit more. You’ll begin to feel that you’re making progress. How long you stay in the hospital will depend on your progress. It could be anything from 3 to 7 days.
You’ll need help when you first go home.
You’re likely to feel very tired for several weeks and sometimes months after your surgery. It helps to do a bit more every day.
- sitting for less time each day
- walking around the house a bit more each day
- building up to walking outside
What you can do depends on how fit you were before your surgery and any problems you have afterwards. Talk to the physiotherapist or your doctor if you’re unsure about what you should be doing.
Contact your doctor or specialist nurse if you have any problems or symptoms you are unsure about.
After surgery to your chest, you shouldn’t drive until the effects of the anaesthetic and painkillers have worn off. Your wounds must have healed well. At first, the seat belt may press on your injury and make it sore.
Your doctor will tell you when you can start driving again, but it is usually about 4 to 6 weeks after surgery. It might be sooner than this after keyhole surgery. Some insurance companies also specify that you shouldn’t drive for a certain amount of time after chest surgery. So it is essential to check with your car insurance company.
You have a follow-up appointment about 2 to 6 weeks after your surgery.
At the follow-up appointment, your surgeon:
- gives you the results of the surgery
- examines you
- asks you how you are and if you have had any problems
The appointment is also your chance to ask the doctor questions. Write down any questions you have before your date to help you remember what you want to ask. Taking someone with you can help you to remember what the doctor says.
How often you have checkups after that depends on the results of your surgery. Ask your doctor or specialist nurse how often you need to have checkups and what they will involve.
If you are worried about anything or notice any new symptoms between appointments, let your doctor or nurse know as soon as possible. You don’t have to wait until the next meeting.