Surgery to Treat Lung Cancer

Lung cancer is a serious disease, but the good news is that it can be curable with early detection and proper treatment. Surgery offers the best chance for cure for those diagnosed with early-stage lung cancer that can be safely removed.

Before any lung cancer surgery, you will undergo thorough testing to assess your heart and lung health. This is crucial to ensure you are fit enough to undergo the surgery and anesthesia required for the procedure. Your doctor will evaluate your cardiovascular function as well as your pulmonary (lung) function through various tests and scans.

For stages 2 to 3 non-small cell lung cancer, surgery is often combined with other treatments. You may receive neoadjuvant (before surgery) therapy like chemotherapy or immunotherapy to shrink the tumor first. Or you may have adjuvant (after surgery) therapy like chemotherapy, immunotherapy, or radiation to eliminate any remaining cancer cells.

In limited-stage small cell lung cancer without nodal or distant spread, the standard approach is usually a lobectomy followed by chemotherapy and possibly radiotherapy to continue treating the disease.

We have two lungs, with the right lung divided into three lobes and the left lung into two lobes. Air comes in through the nostrils, travels down the trachea (windpipe), and then branches out through the main bronchi (airways) to reach the lungs.

The right lung is slightly larger than the left, so the distribution of lung function is around 55% for the right and 45% for the left. Removing a lobe reduces overall lung capacity.

There are several types of lung resection (removal) procedures used for lung cancer, depending on the tumor location and size, as well as your lung function:

Pneumonectomy involves the removal of an entire lung. This extensive surgery is reserved for centrally located cancers or cases where the function of the removed lung is greatly diminished.

Lobectomy involves the removal of an entire lobe, while the remaining healthy lobe(s) of the lung is (are) preserved. This is the most common procedure for lung cancer. In some cases, 2 lobes are removed (bilobectomy).

Segmentectomy involves the removal of only a “segment” of the lung, which is smaller than a lobe (each lung has 9-10 segments). This procedure is preferred for small (usually < 2 cm) tumors without nodal spread. In some cases, 2 or 3 segments are removed.

Wedge resection involves the removal of the tumor only plus a small margin of surrounding lung tissue. This procedure is used for small, outer-located tumors and/or when preserving lung function is important.

Sleeve resection involves the removal of a lobe along with a portion of the bronchial airway it arose from. The bronchus is then reconnected. This procedure is used when the tumor is close to the main airway to avoid performing a pneumonectomy.

During all these procedures, the surgeon usually also removes nearby lymph nodes to identify any signs of cancer involvement.

All these surgeries require general anesthesia (deep sleep) and can be done via traditional open chest surgery or newer minimally invasive techniques, using small incisions and a camera (refer to surgical approaches below).

Your doctor will carefully evaluate your specific case and overall health status to determine which type of procedure gives you the best chance at removing the cancer while preserving as much healthy lung as possible. Be sure to discuss all options and risks with your care team.

For early-stage lung cancer, minimally invasive techniques are now the preferred surgical approach over traditional open surgery. These techniques allow for smaller incisions, less pain, and faster recovery.

Video-assisted thoracoscopic surgery (VATS) is one minimally invasive option. In VATS, your surgeon makes one or more small keyhole incisions in your chest wall. Long, thin instruments and a small camera are inserted through these ports to access and remove the lung tumor.

An even more advanced approach is robotic-assisted thoracoscopic surgery (RATS). This uses the same concept of small ports but with robotic arms controlled remotely by the surgeon for extremely precise movements.

Early research shows RATS to be just as effective as VATS and open surgery for lung cancer. However, it requires special equipment (a robotic system), which is not available at every hospital, as well as specialised surgeon training.

The classic open thoracotomy surgery involves making a larger incision and spreading the ribs to directly access the lung. While more invasive, it may still be recommended for some patients if the tumor location or size makes minimally invasive approaches too difficult.

In some cases, if unexpected bleeding occurs during VATS or RATS that impairs visibility, the surgeon may need to convert to open thoracotomy as a safety measure.

No matter which specific approach is used, the key is that your surgical team carefully evaluates your case to determine the safest and most effective option, personalized for your lung cancer situation and overall health status.

After your lung surgery, you will wake up with one (or sometimes two) tubes inserted into your chest. These are attached to containers that help drain excess fluid and air from around your lung as it re-expands. The tubes will remain in place until the air drainage stops, which is usually within a few days.

Most patients can expect to stay in the hospital for around 4-5 days after lung surgery before being discharged home. Your actual hospital stay may be slightly shorter or longer depending on your specific procedure and recovery.

Removing a lobe results in some loss of lung capacity and function. However, the remaining lung can compensate well. Therefore, you should not notice major breathing issues with normal daily activities, unless you plan vigorous exercise like running long distances. In general, home oxygen is not required long-term after lung surgery.

As with any major operation, there are some risks and complications that can occur after lung surgery:

• Infection – Pneumonia is one of the most common complications. Taking deep breaths and coughing helps clear secretions from your lungs and reduces the risk of pneumonia.
• Pain – Chest wall pain at the incision and tube sites is to be expected and can last for weeks. Numbness at the surgical area may persist longer. Oral painkillers are usually prescribed when discharged home.
• Persistent air leakage from the lung – Sometimes air can leak from the lung after the operation. Most air leakage resolves on its own as the tissues heal. Persistent air leakage may require a bedside procedure performed through the chest tube called pleurodesis. Alternatively, you may go home with the chest tube connected to an ambulatory bag and come back for tube removal after a few days.
• Bleeding – If bleeding occurs, you may need additional surgery to repair the area and stop it, although this is not common.
• Reduced appetite and nausea – Anti-nausea medication can help relieve any stomach discomfort after surgery. Avoid heavy, greasy foods initially.

Other less common but potentially serious complications, such as blood clots and heart issues, are also possibilities that your care team will monitor closely.

The road to recovery can be challenging, but staying motivated and following your care team's instructions will give you the best chance at successful healing and outcome after lung cancer surgery.

If cancer is found to have returned after initial surgery, your doctor may recommend an additional resection surgery if it is limited and you are fit enough. Otherwise, radiation therapy may be used to treat areas that cannot be surgically removed or if you are not a surgical candidate.

Related: First-Line Treatments for Lung Cancer