Page 190 - BSAVA Manual of Canine and Feline Head, Neck and Thoracic Surgery, 2nd Edition

Chapter 14 · Surgery of the lung

Advanced imaging, such as computed tomography both hemithoraces is possible. In dorsal recumbency, a
(CT) or magnetic resonance imaging (MRI), has increased subxiphoid camera port is usually established along with
VetBooks.ir disease (i.e. lymph node involvement), and may be useful for sides to give access to the periphery of one of the lung
two further instrument ports placed on the right or left
sensitivity for detecting pulmonary changes and metastatic
surgical planning.
lobes. In lateral recumbency it is important to place the
ports in a triangulating pattern around the anticipated lobe
Lavage to be biopsied. A VATS lung biopsy specimen can be
harvested by use of a loop ligature placed around the
Transtracheal wash (TTW), endotracheal wash (EW) and periphery of the lobe or by using an endoscopic stapling
bronchoalveolar lavage (BAL) can be useful diagnostic device (Figure 14.1).
tools in cases of pneumonia, parasitic disease, inflam-
matory disease and lung tumours. TTW is minimally inva-
sive and easily performed on a conscious or lightly
sedated patient; EW and BAL require general anaesthesia.
EW requires intubation with a sterile endotracheal tube, or
use of a laryngeal mask airway and careful insertion of a
bronchoscope. BAL uses bronchoscopy to facilitate
sampling of specific lung lobe bronchi. Samples should be
evaluated for cytology, and both aerobic and anaerobic
cultures performed. Anaerobic cultures were positive in
18/104 cultures in a recent study (Johnson et al., 2013).
Details of these techniques are given in the BSAVA Manual
of Canine and Feline Clinical Pathology.

PRACTICAL TIP (a)
Preoxygenation prior to performing TTW or EW is
helpful to prevent hypoxia during the procedure

Thoracotomy
Exploratory thoracotomy can be a diagnostic and/or thera -
peutic tool. If the underlying disease process can be
localized to one side, a lateral thoracotomy is indicated. If
exploration of the entire thoracic cavity is necessary, then
a median sternotomy should be performed (for surgical
approaches, see Chapter 11). In cases of primary pulmo- (b)
nary neoplasia, thoracotomy with lung lobectomy is both
therapeutic and diagnostic. See Operative Technique 14.1 (a) An endoscopic stapler is seen in place across a section of
lung lobe. (b) After discharge of the staple cartridge the triple
14.1 for details of the technique for lung lobectomy. Lung rows of staples can be seen on either side of the resection site.
biopsy may also be performed via a ‘keyhole’ (mini-thora-
cotomy) approach, and this has proven useful in the
management of interstitial lung diseases (Norris et al.,
2002). The keyhole biopsy technique is best for diffuse
lung disease or peripheral lung lesions because access VATS and VATS-assisted lung lobectomy
to the hilus is difficult through a limited incision. In general, the VATS-assisted technique may be used in
cases where the thoracic mass is modestly sized and
Thoracoscopy or video-assisted located somewhat peripherally within the lobe, and where
thoracoscopic surgery (VATS) it requires larger thoracic wall incisions to exteriorize the
lobe in question safely. It may be more challenging to
An alternative to open thoracotomy, VATS is a minimally resect masses close to the pulmonary hilus with this
invasive technique that offers the advantages of decreased technique. However, the VATS-assisted technique does
postoperative pain and shorter recovery time. Disad- not involve induction of one-lung ventilation (OLV), which
vantages include the need for specialized equipment and a is considered mandatory for VATS lung lobectomy. A
steep learning curve (Garcia et al., 1998). Lung biopsy VATS-only approach allows resection of larger masses
using VATS allows sampling of any lung lobe tip in cases of closer to the hilus, although the easiest cases remain
diffuse disease but requires careful port placement to those that are modestly sized and peripheral (Lansdowne
target a specific lung lesion. VATS lung lobectomy et al., 2005). The VATS technique is generally performed
(Lansdowne et al., 2005; Mayhew et al., 2013) and VATS- for masses 3 4 cm in si e in dogs kg, masses 4 7
assisted lung lobectomies (Laksito et al., 2010; Wormser cm in diameter in dogs 3 kg and masses 8 9 cm in
et al., 2014) have been described in dogs. dogs >30 kg.
For VATS-assisted and VATS lung lobectomy, most
patients will be positioned in the corresponding left or right
VATS lung biopsy lateral recumbency depending on mass location. Recom-
For lung biopsy, dorsal or lateral recumbency can be used. mended portal placement sites for VATS lobectomy are
Using dorsal recumbency, a more complete examination of shown in Figures 14.2 and 14.3.

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