In the past, when tuberculosis was a more common disease, as many as 50% of nodules discovered on chest x-rays were benign nodules called "granulomas" caused by healing of a TB infection.
In some areas of the country like Arizona and the Central Valley of California a fungal disease call coccidioidomycosis or "Valley Fever" is a frequent cause of pulmonary nodules.
The problem facing the physician when a pulmonary nodule was found in a patient who is a cigarette smoker, was whether to put the patient through a thoracotomy when there was a 50% chance that the nodule would be benign.
This problem is considerably simplified in many cases because of the availability of new technology that allows the thoracic surgeon to resect peripheral pulmonary nodules without thoracotomy. If the lesion is close to the surface of the lung, is not too large and there are no complicating factors such as adhesions (scar tissue) most such nodules can be removed through three small incisions (2-4 cm.) in the intercostal spaces (between the ribs). If the lesion is very small or is in a location where the surgeon is not sure that he will be able to see or feel the nodule, the lesion can be localized by preoperative placement of a hooked needle in the lung, immediately adjacent, so that it can be found at the time of operation. In other cases, in which the lesion is of a size and or location where it can easily be seen or palpated by a finger passed through one of the incisions and preoperative localization is unnecessary.
I prefer to do the operation under general anesthesia using Univent tube. A preliminary bronchoscopy and placement of the blocker balloon of the Univent tube allows the lung to be collapsed during surgery.
The patient is then turned into a lateral decubitus position (on his side). After preparation and draping of the chest, a small incision is made and the pleural cavity is entered by careful dissection. A trochar is placed, through which a telescope attached to a television monitor is introduced. By manipulation of this telescopic camera, the entire pleural cavity is examined. In this illustrative case, a needle had been placed by the radiologist immediately before surgery adjacent to a small nodule in the upper lobe of the lung.
After two more short incisions are made, a long stapling instrument (Ethicon 45mm GIA "thick") is passed into the chest and the tissue beneath the area localized by the needle is stapled. This process can often be simplified by first clamping below the nodule with a long curved or right angle clamp and then stapling below the clamp.
After the staple has been fired and the stapler opened, it can be seen that there are triple rows of staples on each side of the "wedge" of lung to be removed.
Further applications of the stapler are usually required to complete the resection.
The lung specimen is placed in a "Endobag" before removing it through one of the intercostal incisions to avoid possible seeding of the incision with tumor cells.
The specimen is seen here cut open to show the resected nodule.
If the lesion is benign, a thoractomy has been avoided and the patient can usually be discharged from the hospital in a few days. If the lesion is malignant, a thoracotomy and lobectomy should be performed unless there is a strong contraindication such as severe heart disease or emphysema that would put the patient at high risk for thoractomy.
The proceedure is completed by carefully checking the staple line for bleeding.
The pleural cavity is then lavaged with sterile saline solution, a chest tube is place under direct vision through one of the incisions, and the other two incisions are closed in layers. The chest tube is checked for air leak before the patient is allowed to emerge from anesthesia.