Lung Cancer Surgery

Lung cancer surgery is a treatment method planned according to the stage of the disease and the location of the tumor, aiming to surgically remove the cancerous tissue. It can be performed with different techniques such as lobectomy, pneumonectomy, and segmentectomy. The aim is the complete removal of the cancer.

The eligibility criteria for surgery and the preparation process are determined by evaluating the patient’s respiratory capacity, heart health, extent of tumor spread, and overall performance score. During this process, advanced examinations such as PET-CT, bronchoscopy, and pulmonary function tests are performed.

The postoperative recovery process and follow-up vary depending on individual factors. Patients usually stay in the hospital for a few days, and the recovery process is supported with breathing exercises and physical activity. The risk of recurrence is monitored with regular check-ups, and additional treatments are planned if necessary.

Complications and long-term outcomes are shaped according to the surgical technique, the patient’s age, and accompanying diseases. Complications such as infection, bleeding, and air leak may occur after surgery. Survival rates increase significantly in surgeries performed at an early stage.

What Is Lung Cancer Surgery?

Lung Cancer Surgery is the surgical removal of the malignant tumor detected in the lung and, when necessary, the surrounding tissues. It is the main treatment method in early-stage patients and has a curative purpose. Different surgical techniques such as lobectomy, segmentectomy, or pneumonectomy may be performed. Preoperative staging is of great importance. It can increase survival in suitable patients and may be planned together with other treatment methods.

How Is the Decision for Lung Cancer Surgery Made and By Whom?

Recommending surgery to a patient is never a decision made in five minutes at the outpatient clinic door. Lung cancer is a biologically complex disease that can behave differently in each individual. Therefore, the treatment roadmap is drawn not by the initiative of a single doctor but by a “Multidisciplinary Oncology Council” where different specialties come together. This council is a safety circle established to leave no room for error and to find the most ideal path for the patient.

In this council, the surgeon, medical oncologist, radiation oncologist, pulmonologist, radiologist, nuclear medicine specialist, and pathologist gather around the same table. The patient’s imaging, biopsy results, respiratory tests, and general condition are discussed in detail. Each specialist evaluates the risks and advantages from their own perspective.

The main factors evaluated by this council are:

• The exact location of the tumor
• The size of the tumor
• The status of spread to the lymph nodes
• The patient’s respiratory capacity
• Heart health
• General performance status

If the council concludes that the disease can be completely removed by surgery and that the patient can tolerate this process, a surgical decision is made. Sometimes the disease may be at an advanced stage or the tumor may be very large. In such cases, the council may determine a strategy of first shrinking the tumor with drug therapy (chemotherapy or smart drugs) and then operating. This is called “neoadjuvant treatment.” In other words, the decision for surgery is shaped individually by team intelligence according to the patient’s current condition and imaging.

How Does the Stage of the Disease Affect Surgical Options?

The most important parameter determining the extent and type of procedure to be performed in lung cancer is “staging.” In the medical world, we use a universal language called the TNM system. This system tells us how much the tumor (T) has grown, whether it has spread to the lymph nodes (N), and whether it has metastasized to other organs (M). Before entering the operating room, the surgeon clarifies this map in their mind.

In the group we call early stage, the tumor is still small and has not shown significant spread to the lymph nodes. This group is the ideal candidate for surgical treatment and the group with the highest chance of success. Here, the aim is to remove the tumor while preserving the lung tissue as much as possible. However, if the disease has reached the stage we call “locally advanced,” meaning the tumor has grown and come into contact with the chest wall, ribs, or windpipe, the surgical plan changes completely. In this case, it is not enough to remove only part of the lung; the adjacent tissues to which the tumor is attached must also be cleared and, if necessary, those regions must be reconstructed.

Some of the examinations used during the staging process are:

• Computed Tomography
• PET/CT
• Brain MRI
• Bronchoscopy
• EBUS

These examinations guide us. If the cancer has spread to distant organs (such as the brain or bones), meaning it has become Stage 4, the priority is generally systemic drug therapies. However, if the tumor is only within the chest cavity and is technically resectable, surgery is always the strongest option on the table.

Which Tests Should Be Done Before Surgery?

In a patient diagnosed with cancer, the technical feasibility of surgery may not mean that the patient can tolerate the surgery. Since lung surgeries directly intervene with the body’s oxygenation mechanism, the patient’s physiological reserves, that is, endurance, must be measured very well. For us surgeons, the success of surgery is not only removing the tumor but also ensuring that the patient maintains a quality life without shortness of breath with the remaining lung.

For this purpose, one of the most critical tests performed is Pulmonary Function Tests and especially the DLCO test. DLCO is a sensitive parameter that measures how efficiently the lungs can transfer oxygen taken from the air into the blood. A patient may appear to breathe comfortably normally, but if the DLCO value is low, the risk of postoperative complications is high.

The examinations routinely requested before surgery are:

• Pulmonary function test
• DLCO diffusion test
• Cardiological echocardiography
• Complete blood count
• Kidney and liver tests
• Blood group analysis

If the patient’s lung capacity turns out to be borderline, we do not immediately give up on surgery. In this case, we perform more advanced exertion tests (stair climbing test or cardiopulmonary exercise test). We also mathematically predict whether the remaining tissue will be sufficient for the patient by calculating how much of the lung will be removed. These calculations enable us to choose the most appropriate surgical method without putting the patient at risk.

How Much of the Lung Will Be Removed: Lobectomy or Segmentectomy?

One of the issues our patients worry about most is the extent of organ loss. Our lungs are not a single solid organ; they consist of independent chambers called “lobes,” three on the right and two on the left. These lobes are also divided into smaller units called “segments.” The extent of the surgery is determined according to the size of the tumor and the patient’s breathing capacity.

• Lobectomy

The standard procedure accepted in lung cancer surgery in the world and in our country is lobectomy. In this procedure, the entire lobe containing the tumor is removed together with the vessels and airways going to that lobe. For example, if the tumor is in the right upper lobe, that lobe is completely removed. The reason for this is to eliminate the possibility of invisible spread of the cancer within the lymphatic pathways inside the lobe. Lobectomy is a safe and curative method.

• Segmentectomy

In recent years, with the advancement of technology and the ability to detect cancer at very early stages, “Segmentectomy” has gained popularity. In this method, instead of removing an entire lobe, only the segment (small unit) containing the tumor is removed. This is called “parenchyma-sparing surgery.” In other words, the patient’s healthy lung tissue is preserved. Especially in tumors smaller than 2 cm or in patients whose lung capacity cannot tolerate lobectomy, segmentectomy is a life-saving alternative.

• Pneumonectomy

It is the removal of the entire lung on one side. Today, as surgeons, this is the scenario we avoid the most. Because living with one lung reduces the patient’s exertional capacity. However, if the tumor has involved the main airway or the main vessels entering the heart, this procedure may become mandatory to save the patient’s life.

The criteria taken into consideration when determining these types of surgery are:

• The diameter of the tumor
• The tumor’s distance from the center
• The patient’s respiratory reserve
• Lymph node involvement

Why Are Robotic Surgery and Closed Methods Preferred?

In the past, when lung surgery was mentioned, painful and difficult processes came to mind in which the chest cavity was opened from top to bottom and the ribs were separated with metal retractors. Fortunately, this picture has now largely become history. Today, “Minimally Invasive Surgery,” that is, closed methods, has become the standard in lung cancer treatment. These methods are basically divided into two: Video-Assisted Thoracoscopic Surgery (VATS) and Robotic Surgery (RATS).

• Video-Assisted Thoracoscopic Surgery (VATS)

In this method, 1 to 3 small holes are made in the chest cavity. A camera and long surgical instruments are inserted through these holes. The surgeon performs the operation by viewing the inside on a screen in front of them. Since the spaces between the ribs are not spread and the muscles are not cut, the patient feels much less pain.

• Robotic Surgery (RATS)

In robotic surgery, the latest point reached by technology, the surgeon sits at a console at the patient’s side and controls the arms. The robot called “Da Vinci” transmits the surgeon’s hand movements to the internal arms with millimetric precision. The robot’s arms have much greater rotation capability (540 degrees) than the human wrist. In addition, the surgeon sees the tissues enlarged 10-12 times and in three dimensions (3D).

The main advantages of robotic surgery are:

• Less blood loss
• Minimal surgical scar
• Much less pain
• Early discharge
• Reduced risk of infection
• Rapid return to daily life

Robotic surgery provides the surgeon with a great technical advantage especially in procedures such as segmentectomy, where lymph node dissection and delicate vascular separations are required. The system, which filters the surgeon’s tremor, allows safe work even in the riskiest areas.

Why Is the Removal of Lymph Nodes Important?

The success of lung cancer surgery is not measured only by the removal of the main tumor. The systematic removal (dissection) of the lymph nodes located in the chest cavity, around the windpipe, and around the vessels is an indispensable part of this work. Lymph nodes are the body’s defense outposts; however, when cancer cells want to spread through the body, they use these lymphatic pathways like a highway.

The removal of these stations during surgery serves two main purposes. The first is to determine the true stage of the disease. Sometimes a lymph node that appears clean on imaging may hide cancer cells at the microscopic level. Detection of these cells by the pathologist determines whether the patient will receive additional protective treatment (chemotherapy or radiotherapy) after surgery. The second purpose is to prevent “local recurrence.” Removing these foci that may be cancerous from the body minimizes the risk of the disease recurring in the same region.

The areas cleaned during this procedure are:

• Hilar stations
• Subcarinal stations
• Paratracheal stations
• Aortopulmonary window
• Paraesophageal areas

Robotic surgery and closed methods provide a much clearer view and comfort than open surgery in reaching these deep and narrow areas and cleaning the lymph nodes while preserving the vascular and nerve structures.

Is Surgery Possible in Advanced-Stage Tumors?

In some cases, the tumor may exceed the boundaries of the lung and invade adjacent structures. For example, the group we call “Pancoast tumors” may settle at the very top of the lung and adhere to the nerves in the shoulder region or to the ribs. Or the tumor may have progressed to the main vessels emerging from the heart or to the main branching point of the windpipe (carina). These pictures (T3 and T4 tumors) are cases where the surgeon’s experience and technical skill are tested at the highest level.

Many of these cases, which were once called “inoperable,” can now be successfully operated on with advanced techniques. However, these operations require much more than a standard lobectomy. Repair techniques that we call “reconstructive surgery” come into play. If the tumor is attached to a vessel, that part of the vessel is removed and repaired with an artificial vessel. If it has entered the windpipe, that section is cut and the airway is sutured end-to-end.

In chest wall involvement, a part of the ribs is also removed together with the tumor. In this case, the cavity formed in the chest is closed with special titanium plates and artificial patches (mesh) so that the patient’s breathing is not impaired. In this way, the integrity and strength of the chest wall are restored.

The methods used in such complex surgeries are:

• Bronchoplasty
• Angioplasty
• Chest wall resection
• Artificial vascular grafts
• Muscle flaps

Success in these cases is possible with a multidisciplinary approach. By working in cooperation with branches such as plastic surgery and cardiovascular surgery, both the tumor is completely removed and body integrity is preserved.

What Is the Postoperative Recovery Process Like?

The period after surgery is at least as important as the surgery itself. After the patient wakes up, they are generally kept for one night in the intensive care unit or a close monitoring room as a precaution. The aim here is to monitor blood pressure, pulse, and respiratory values instantly. If everything is fine the next morning, the patient is taken to their room in the ward.

In modern surgery, our biggest enemy is immobility. Therefore, we get our patients up and walking the day after surgery, and sometimes even on the evening of the same day. Early movement accelerates circulation, reduces the risk of clots, and allows the lung to reopen at full capacity. In addition, patients are given a breathing exercise device with balls inside, which we call “triflo,” and are asked to use it frequently.

A tube called a “chest tube” or “drain” is attached to remove the fluid and air accumulated in the surgical area. Patients are usually afraid of this tube, but it is one of the greatest helpers of recovery. When the air leak in the lung stops and the amount of fluid decreases, this drain is removed. In patients operated on with closed methods (VATS/RATS), the drain is usually removed within 2-3 days and the patient is discharged.

The things to be considered after discharge are:

• Taking regular walks
• Continuing breathing exercises
• Eating a balanced diet
• Staying away from smoking environments
• Avoiding heavy lifting

There is also no need to worry about pain control. Thanks to nerve blocks, epidural catheters, and next-generation painkillers given intravenously during and after surgery, the process is quite comfortable.

Frequently Asked Questions