Lung surgery

Referrals

Patients are most commonly referred for thoracic surgery at Harefield Hospital by GPs or respiratory physicians at other hospitals. Harefield Hospital provides thoracic surgical services for a large catchment area, which commonly includes the areas listed below, but anyone in the NHS can be referred to our services.

• Milton Keynes
• Watford
• Churchill Hospital Oxford
• Hillingdon
• Luton and Dunstable
• Hemel Hempstead
• Wycombe
• Windsor King Edward VII Hospital

Waiting for surgery

Usually you'll be offered an admission and operation date during your outpatient consultation with the surgeon. You could be admitted for surgery within a week. 

Under normal circumstances, we'll admit you to hospital a day before your operation, but sometimes we may have to admit you several days in advance for final tests or physiotherapy to help prepare you for surgery. On the basis of the tests, a team of doctors, nurses and other healthcare specialists will make a plan about your tests and treatment. 

Please bring your medicines, tablets or inhalers (in their original containers) with you.

Your assessment team

When you are admitted to hospital, you'll be assessed by:

A doctor (or thoracic nurse) 

Either a doctor, or sometimes a thoracic nurse if you are at Harefield Hospital, from your consultant's team will examine you and ask you questions about your past medical history. 

They will explain more about the operation/examination, why it's necessary, any risks involved, and about alternative treatments. If you need an operation or examination under anaesthetic, the doctor will ask you to sign a consent form. This is a legal requirement and is designed to protect your interests. Please make sure you understand everything before you sign and ask them anything you like about your illness and its treatment.

An anaesthetist 

The anaesthetist will visit you on the ward before your operation to find out more about your general health, any medication you're on and if you've ever had an anaesthetic before. They'll also discuss the types of pain control available to you after your operation. If you have any questions about the anaesthetic, please ask them. 

A nurse 

The nurse will take you through a number of practical measures, such as showing you the hospital's facilities and assessing your condition so they can begin planning your care with you. They'll also take your blood pressure, pulse, temperature, height and weight before discussing your discharge plan with you. At this stage, we need to make sure you have the right support ready for you at home when you leave hospital. 

When you leave hospital you'll need to arrange transport. Hospital transport is only available for those who have a medical need for it. If you are having difficulty arranging for family or friends to collect you when you go home, please mention it when you are admitted to hospital. 

Pre-operation tests

Before your operation, we'll arrange for you to have tests done to assess your general state of health and fitness for surgery.

You won't need to be under anaesthetic for the following tests:

• blood tests - to assess your general state of health and fitness for surgery
• chest X-ray - to look at your heart and lungs
• electrocardiogram (ECG) - to look at the electrical activity of your heart beat and muscle function
• spirometry - a simple test which assesses your breathing by blowing into a machine
• lung function tests - a lung capacity test to see how your lungs are working - you'll need to spend up to an hour in the lung function laboratory for this
• computerised tomography (CT) and magnetic resonance (MRI) scans allow us to build up a picture of cross sections of your body and give us a more detailed picture than a normal chest X-ray
• PET scan - this shows how the organs are functioning rather than just how they look. As this scan uses a glucose injection to accurately monitor activity in cells, you cannot eat for six hours before this test. You will be given clear information before this test, especially if you are suffering from diabetes.
• bone scan - to look at bone structure.​​​​​​
• ventilation/perfusion (VQ) scan - this examines the volume of gas and blood flow in the lungs.
• barium swallow - we'll ask you to swallow a solution of radio opaque barium before taking x-rays. This gives us a better picture of the oesophagus and stomach

Tests which don't involve anaesthetic:

One or more of these may be carried out first to see if you need further surgery:

• bronchoscopy - this involves passing a telescopic camera into your windpipe to examine the airways of the lungs. At the same time the doctor may take tissue samples (biopsy and washings). However, it is possible that the doctor who referred you to us may have performed this test already
• mediastinoscopy - a test often carried out at the same time as a bronchoscopy. A small cut (approximately two inches) is made just above the breastbone at the base of the neck so we can pass a telescopic camera down the space between your lungs and the inside of your breastbone. This allows the doctor to take tissue samples
• Oesophagoscopy - a telescopic camera is passed into the oesophagus, or 'food pipe' and stomach. Biopsies of tissue can be taken at this time.
• Video Assisted Thoracoscopy (VATS) - a form of keyhole surgery that involves passing a telescopic camera through small cuts in the chest to examine the lungs or pleura (linings of the lung) under video guidance. If, however, keyhole surgery is found at the time of operation to be inappropriate, the surgeon may perform a larger cut on the side of the chest (thoracotomy). Biopsies of the lung, pleura and/or samples of fluid may be taken during this procedure. At the end of the procedure one or two chest drains may be left in place for one to four days.

Results

Any biopsies taken during tests will help in the diagnosis of your condition and will be examined in the laboratory. Most results are available within two to five working days and can help your consultant decide on the best treatment for you. 

However, if special tests are requested (e.g. tests for tuberculosis cultures), it may be several weeks before we can give you an answer. If you are discharged before the final results are available, we will send a full report to your GP and your local consultant or you may be seen as an out-patient at this hospital.

Cancer diagnosis

At first, many people find it hard to accept that they or their relative or friend has cancer. You may find that you and your family go through stages of disbelief, despair, anger and denial. You will probably get most comfort from relatives and friends, so please do discuss your fears with them. They may well be experiencing similar feelings to your own.

Our staff are always available to listen to you or your relatives. If you feel the need to talk, please do not hesitate to ask. Should you prefer, we can arrange for you to see a social worker or a religious representative.

Our cancer and palliative care nurse specialists will also be available to provide support and information to you and your family. If your tests do reveal cancer, your doctor will discuss the most suitable treatment for you. This may be surgery, radiotherapy or chemotherapy, or a combination of treatments.

Find out more about our lung assessment service. 

Lung surgery may involve part or all of the lung being removed, particularly if it has been damaged (by emphysema, for example), or because of a tumour (because of cancer). There are other conditions which may require lung surgery, but your consultant will discuss this with you in detail. 

If lung surgery is required, we can perform a:

Lung biopsy

We remove a small piece of lung tissue to help us diagnose the illness. It’s commonly done via keyhole surgery, which means that a small cut (incision) is made so the operation can be done

Wedge resection

If a tumour is found close to the outside of the lung, we can try to get rid of it by removing the part of the lung tissue (wedge). 

Metastasectomy

When a cancer spreads to a different part of the body from where it started, causing secondary growths, we call this metastasis. We can remove a growth – or growths - along with a small area of surrounding tissue. Your surgeon will tell you how many have been removed after the operation

Lobes

The right lung is divided into what we call lobes. The right lung has three lobes (an upper, middle and lower lobe) and the left has two. We carry out two operations which involve lobes:

Segmentectomy

For patients with bronchiectasis, it’s quite common to remove part of one of the lobes of the lung if necessary. This is called a segmentectomy.

Lobectomy

Removing one or more of the lungs' five lobes is called a lobectomy. The remaining lobes will gradually expand in order to fill the space left by the removed lobe(s). This procedure is performed to remove a problem within the lobe.

Sleeve resection

This procedure involves removing the upper lobe of the lung and part of the main airway. The rest of the lung is then reattached to the main airway. The procedure is performed to resolve problems in the lung and airways.

Pneumonectomy

The removal of a whole lung is called a pneumonectomy. People who have had a lung removed are able to lead normal lives but may notice that they get tired more quickly than they used to. This operation is performed because the problem involves the whole lung.

Decortication

This involves removing damaged and infected tissue around the lung and the chest cavity. People may need this after a long infection around the lung. This procedure is commonly performed via a thoracotomy.

The pleura is a double-layered membrane that surrounds the lungs and coats the inside of the chest wall. The space between these two layers is called the pleural space. A small amount of natural bodily fluid in this space helps to lubricate the two surfaces as they move as you breath.

Pleura complications

Sometimes, the small amount of fluid in the pleural space increases to an abnormal amount - we call this pleural effusion. It can be dangerous because it can squash the lung and cause it to collapse. To avoid this we can drain the fluid by either inserting a needle into the lung to draw it out, or a chest drain, which helps get rid of the fluid more slowly. 

Repeated pleural effusions are not recommended, so a surgeon may decide to to perform a pleurodesis and stick the two linings together to prevent the fluid returning.

Pneumothorax

A pneumothorax is the presence of air between these two layers, which causes the lung to become squashed and collapse, leading to breathlessness and acute pain. A pneumothorax can occur as a result of injury (e.g. a hard knock to the chest such as would occur in a heavy fall or car crash) or spontaneously.

A spontaneous pneumothorax may be because of a problem in the lung tissue itself e.g. a cyst or blister or for no specific reason. The immediate treatment may involve inserting a chest drain to allow the lung to re-expand, relieving the breathlessness and pain. If repeated collapses have occurred the surgeon may need to perform an operation to prevent it from happening again.

Pleura operations

Pleurodesis

This operation is performed to stick the two pleural layers back together to prevent further build-up of fluid or air in the pleural space. This can be done chemically or mechanically. 

Chemical pleurodesis

Several substances (eg. talc) can be used to cause a reaction in the pleural tissue which leads to the two layers sticking together permanently. This procedure is usually performed under a general anaesthetic via keyhole surgery. However, it can also be performed via a chest drain on the ward and so can be used for patients who are not suitable for a general anaesthetic.

Mechanical pleurodesis

The surgeon irritates the lining of the chest wall by gentle rubbing so that the lung will stick to it. This procedure is carried out if you have suffered a pneumothorax (lung collapse) on more than one occasion. This procedure is called pleural abrasion and is usually carried out through “keyhole” surgery.

Pleurectomy

This is the removal of the outer of the two pleural layers.This procedure enables the lung to stick to the inside of the chest wall and prevents further collapse.

Bullectomy

Bullae are ballooned areas caused by weakness on the surface of the lung. If they burst they can cause a collapse of the lung (pneumothorax). The surgeon will try to prevent further problems by stapling and removing the weak area. The surgeon may perform a pleurodesis or pleural abrasion at the same time.  

Chest wall resection

This procedure involves removing part of your ribs, pleura (the membrane covering the lung) and the skin covering the chest. Depending on how much tissue needs to be removed, the operation will be performed either by your thoracic surgeon alone or with the help of a plastic surgeon.

This is a cancer treatment which uses a probe with a frozen tip to freeze cancerous cells and destroy them. When the tissue defrosts, the cancer should have shrunk in size.

If cryosurgery is applied direct to lung tissue, you’ll need a thoracotomy so the surgeon can get to your lung tissue. 

There are three main ways to carry out lung surgery:

Thoracotomy

An incision is made around the side of the chest to access the lung. Sometimes, it may only be a few centimetres long, but it can run from under the nipple around to the back and under the shoulder blade.

Video-Assisted Thoracoscopy (VATS)

Often referred to as keyhole surgery, this involves passing a telescopic camera through small cuts in the chest to examine the lungs or pleura (linings of the lung) while being guided by a video.The surgeon will make one or two small incisions on the side of the chest so they can insert the camera and surgical tools needed to complete the surgery. Not all surgery can be performed using VATS. If it is not used, your surgeon will usually carry out a thoracotomy instead.

Sternotomy

Surgeons make a cut through the sternum (breastbone) so they can access both of the chest cavities.

Your health

Like any surgical procedure certain risks are attached, some of which will depend on on the state of your health before your operation/procedure. Try to remember that we only recommend surgery if the potential benefits are greater than the potential risks. We want your surgery to give you a better quality of life and minimise any symptoms you may have. 

Common surgery risks

Bleeding: Some blood loss into your chest drains is normal. If you start to lose a lot of blood, you may have to go back to theatre so your surgeon can find out what's causing the bleeding. You may need to have a blood transfusion.

Prolonged air leak: This happens when air leaks from the lung. You may need to go home with a chest drain in place if you have prolonged air leak.

Chest infection: Speak to your physiotherapist about reducing the risk of a chest infection. You can also help yourself by keeping as active as possible after surgery.

Wound infection: Showering before your surgery and changing into a clean theatre gown will help to reduce the chance of wound infection. We also encourage you and your visitors to cleanse hands by using the hand basins and alcohol rubs provided. You should was hands thoroughly especially before touching your wound, and your medical and nursing team will do the same. Despite these measures, there is a small chance that you may develop an infection, which may need antibiotics.

Blood clot (deep vein thrombosis (DVT): Wearing support stockings during your stay in hospital should reduce the risk of blood clots. You may also have a small daily injection to thin your blood. Staying active and walking as much as possible will help reduce the risk of clots forming. If a clot forms, we can treat it with extra medication or a small procedure.

Anaesthetic:Risks from having a general anaesthetic depend largely on your overall health, what kind of operation you're having and how serious the operation is. Risks also vary with each patient, something your anaesthetist should explain more to you to about. There can be complications with bruising, sore throats, nausea, damage to teeth, for example, and sometimes more serious complications. If you're concerned, please don't hesitate to discuss this with your anaesthetist.

Other risks

Because all surgery carries a certain degree of risk, this can also include risk of death. The exact risk will vary from procedure to procedure and patient to patient. As part of your consent form (the form you sign to show you agree to the treatment), your doctor and the anaesthetist will talk to you about specific risks that apply to you, and you will be able to ask questions about those issues which concern you. If you're concerned, you can find out more about:

• the risks and benefits of the procedure
• alternatives
• what could happen if you don't have the operation/procedure

Don't worry about asking questions. We want you to be fully informed about the procedure and to feel happy about signing the consent form.

Your admission

We will call you or send you a letter to know your date of admission. The letter may ask you to respond to some of the information given, so please bear that in mind. 

If you're due to arrive on a Sunday or Monday, you may be asked to contact the surgical bed manager via the hospital switchboard to find out which ward you're on. 

Cancellations

Emergency cases mean that we sometimes have to cancel and reschedule booked admissions on short notice.

What to bring to hospital

• any of your current medication
• comfortable clothes, nightwear, dressing gown and slippers
• toiletries (e.g. shaving items, toothbrush and toothpaste, hairbrush)
• any valuables you need with you
• small change for telephones, a pen, and books or magazines to read

Find out more coming in to hospital 

On the day - your lung surgery

Before your operation 

On the morning of your operation you will not be able to eat or drink for several hours before you go into the operating theatre. Your nurse or doctor will discuss this with you.

We will ask you to have a bath or shower and put on a clean hospital gown. Your legs will be measured and fitted with some anti-thrombus (TED) stockings. These help to prevent blood clots developing in the legs by improving circulation during and after your operation. There is an increased risk of blood clots forming when you are not exercising your legs as much as usual. You will need to carry on wearing these stockings until you are told not to – usually when you are discharged home.

On the morning of your operation the nurse caring for you will check some important details with you such as your name, date of birth, any allergies you have, and will confirm your signature on your consent form.

Pre-medication

If you have been prescribed a pre-medication, the nurse looking after you will give you this one to two hours before the operation, which may make you a little sleepy. After you have had your premedication you should not get out of bed unless a member of staff is present in case you feel a little light-headed.

Leaving the ward

When you go to the operating theatre your belongings will be labelled and locked away for safekeeping until you return to the ward. Please pack your toiletries and other small items which you may require straight after the operation in a separate bag.

If your family want to wait with you before the operation, please liaise with the ward nursing staff. A porter and a nurse will take you on your bed (Royal Brompton Hospital) or on a trolley (Harefield Hospital) to the operating department, where a member of the theatre staff will check your details. You will then be transferred on to a trolley and taken to the anaesthetic room.

What happens in the anaesthetic room?

Before you go to sleep you will have heart and oxygen monitors attached to you and a small soft plastic tube (cannula) will be inserted into a vein in your arm. Sticky pads are used to attach monitoring leads on your chest (they do not hurt). Monitoring equipment is used to measure your heart rate, blood pressure and oxygen levels in your blood.

The anaesthetist will then give you some drugs in your vein to make you go to sleep. Once you are asleep, a tube will be inserted into your windpipe. This will be attached to a breathing machine (ventilator) to support your lungs. Other drips may need to be inserted into a vein in your neck and into your wrist. These are to help the anaesthetist monitor your heart and blood pressure closely during the operation.

If you are having an epidural this will be inserted in the anaesthetic room before the operation starts. The anaesthetist will be looking after you throughout your operation and will give you medication to keep you asleep and to relieve pain. Fluids may also be given through the drip to prevent you from becoming dehydrated.

After the operation

When the operation is over we'll wake you up in the operating theatre, remove the tube in your windpipe and transfer you to the recovery ward. A specially trained nurse will look after you and make sure that your pain relief is okay and that you are breathing well. During this time you will be given oxygen through a facemask.

You may have up to three drains in your chest after the operation to remove any air and fluid, and help the lungs to re-expand. An X-ray may be taken of your chest while you are in the recovery ward.

Sometimes we may need you to stay in the recovery ward overnight (Royal Brompton Hospital), or we may take you back to the high dependency unit and/or the ward for close observation.

Your relatives will be able to see you when you are stable. One of our nurses will be available to talk to them. 

The first 24-hours

in the first 24-hours after surgery, you may be given one, or more, of the following: 

Chest drains: up to three drains may be in place after your operation. These remove fluid from your chest and help your lungs to re-expand. Find out more about chest drains. 

Cardiac monitor: sticky pads on your chest attach the monitor to you and allow the nurses to check your heartbeat.

Drip in your hand(s): you may have one or two intravenous drips going into the back of your hand(s) giving you fluids and/or medicines.

Arterial line: this is like the drip in your hand but goes into an artery, not a vein. This allows the nurses and doctors to monitor your blood pressure and oxygen levels.

Neck line: another intravenous line but this one goes into a main vein in your neck.Bladder catheter: a tube going into your bladder to drain away urine (water).

Oxygen saturation monitor: the monitor may be attached to your finger or ear lobe and reads the amount of oxygen circulating in your blood.

Oxygen mask or nasal prongs: you may need oxygen after your operation. This can be given to you via a mask over your mouth and nose or via two small soft plastic tubes which sit just inside each nostril.

Pain relief after surgery

Throughout your stay your nurse will assess your pain with you using a scale of 0 (no pain) to 10 (serious pain). Our aim is to ensure your pain is at a level acceptable to you. This will mean that you can carry out your deep breathing and coughing exercises. At Harefield, there is a team of experts who deal only with pain and making sure that any discomfort is treated quickly and effectively. It's important for you to tell us about any pain or discomfort so that we can make changes to your pain-relieving medication.

For the first 24-72 hours after your operation, you will be given a pain-relieving medication in one of the following ways:

Epidural: pain-relieving medication is given through a small tube in your back (this is inserted while you are in the anaesthetic room).

Paravertebral Block (PVB): pain-relieving medication is given through a small tube placed in the chest cavity at the time of the operation.

Patient Controlled Analgesia (PCA): pain-relieving medication is given into a drip in your hand or arm. PCA lets you give yourself pain-relieving medication when you feel you need it by pressing a button. There is no risk of addiction or overdosing.

Intravenous infusion: A pump gives you a constant dose of pain relieving medication through a drip. Once you are eating and drinking again, we will also give you pain relief tablets at regular intervals to maintain your comfort. Our staff will discuss with you the best pain relief method for you. 

Recovery - in hospital and at home

Exercise is a very important part of your recovery. As soon as possible after your surgery, the physiotherapist will help you to start with basic exercises. This usually involves short walks around the ward with assistance if needed. As your recovery continues, you should be able to walk further.

If you are unable to move away from your bed due to lines and drains, you can exercise by walking on the spot or using a static exercise bike.

If you have any sputum (phlegm) after your surgery, the physiotherapist will show you how to clear it effectively.

The physiotherapist will also make sure that you can move your arm fully on the operated side. This is because you may unconsciously be keeping it still for fear of pain. If you do not move your arm, it may develop into a stiff shoulder, which would require treatment in the future.

Going home

Before you go home, we'll check your wound and make sure your stitches are in place. The stitches will dissolve over time.

If you had a chest drain removed after your surgery, you will need to have the drain stitch(es) removed within a week after you leave hospital. We will arrange for your GP practice or district nurse to remove your stitches.

If you have any problems with your wound when you are at home, such as redness, soreness, or if the wound feels hot to touch or oozes liquid, please see your GP or call the ward for advice.  

When you leave hospital we will give you:

A supply of medication

Your nurse will discuss the medication with you and how to take it, and the pharmacist will give you enough medication for the first few weeks. After that, you can arrange a repeat prescription from your GP if needed. You should take pain medication for as long as you feel you need it. If you need any advice on your medication, you can call our medicines helpline on 020 7351 8901.

An outpatient appointment

This is usually around three to six weeks after your operation. You will be able to discuss your wound, pain and general recovery at this appointment.

Two letters

You'll receive two letters: one for your records - to keep - and the other which you should give to your GP. 

It's important not to leave the hospital without these letters because they list your medication and describe the surgery you had.

More support

Our aim is to help you regain maximum independence and health. We will help you to plan your discharge to the most appropriate setting - for most patients this is back in their own home. 

However, some people may need extra help or further treatment at another hospital. Once you've finished your treatment here, we may transfer you back to your local hospital or to another specialist centre for further care and rehabilitation. We'll keep you informed if this is a possibility. 

To help support you through your treatment, we also have the Patient Advice and Liaison Service, social workers and welfare officers.