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From Hippocrates to Modern Times: How did lung surgery evolve into the sophisticated technology it is today?
Lung surgery is a type of chest surgery that involves the repair or removal of lung tissue and is used to treat a variety of conditions, from lung cancer to pulmonary hypertension. Common surgeries include anatomical and nonanatomical resection, pleurodesis, and lung transplantation. Although records of lung surgery date back to classical times, new technologies such as video-assisted surgery (VATS) continue to evolve today.
History Review
The earliest written record of lung surgery comes from Hippocrates, who described a method of draining a chest abscess. Thoracic surgery became more feasible with the introduction of positive pressure ventilation in 1909, which allowed surgeons to avoid hypoxia during open-chest operations, significantly reducing patient mortality. This technique is currently combined with a double-lumen endotracheal tube to isolate ventilation of the affected lung.
The 20th century saw further innovations in a variety of new surgical procedures, such as the radical lung resection first performed by Evarts Graham in 1933.
In minimally invasive lung surgery, the breakthrough was thoracoscopy, developed by Hans Christian Jacobinus in 1910. Thoracoscopy was later used by surgeons to perform thoracic surgery without the need for thoracotomy; however, thoracotomy remains a common method for accessing the pleural cavity.
Outdated surgical methodBefore the advent of chemotherapy for tuberculosis in the 1940s, the disease was treated with "collapse therapy." This approach is designed to create an artificial pneumothorax, giving the infected lung a rest to limit the spread of infection and speed healing. However, the traumatic nature of collapse therapy and the discovery of anti-tuberculosis drugs have led to its gradual elimination.
Types of Lung Disease
Lung cancer
Lung cancer can be divided into two major types: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Non-small cell lung cancer is the most common type and includes squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. For stage I to III NSCLC, surgical resection is the mainstay of treatment, while stage IV is primarily treated with palliative care.
Pneumothorax
Pneumothorax, or collapsed lung, is the accumulation of air in the pleural space outside the lung. Depending on the cause, pneumothorax can be divided into spontaneous, traumatic and iatrogenic. Spontaneous pneumothorax is further divided into primary and secondary, the former occurring in people without clinical lung disease and the latter occurring as a complication of preexisting lung disease.
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a group of conditions that block airflow, thus causing breathing problems. COPD includes emphysema and chronic bronchitis.
Cystic fibrosisCystic fibrosis is a disease caused by a gene mutation that leads to defects in the movement of salt and water in and out of cells, which can cause thick mucus to form in tubes in the body, such as the lungs.
Pulmonary hypertension
Pulmonary hypertension is usually caused by excessive pressure in the blood vessels that carry blood from the heart to the lungs. A hallmark of pulmonary hypertension is thickening of the muscular walls of the lungs' arteries. Treatment includes oxygen therapy and medications to reduce swelling, but in some extreme cases a lung transplant may be needed.
Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis causes fibrosis in the lungs, which can make it difficult to breathe. The exact cause of the disease is still not fully understood, but preventive measures include quitting smoking and getting adequate exercise. Commonly used drugs such as pirfenidone and nintedanib are mainly used to reduce the rate of lung fibrosis. Lung transplantation is effective in some cases, but healthy donor lungs must be available.
Anatomical resectionAnatomical resection refers to the partial removal of lung tissue based on the anatomy of the lung lobe or segment, and is commonly used in the treatment of non-small cell lung cancer. Preoperative evaluation includes cancer staging via chest CT scan and PET scan, followed by assessment of lung capacity and heart function to determine the amount of lung tissue that can be safely removed. After resection, the end of the bronchus is pressure tested to check for air leaks.
Radical lung resection
A pneumonectomy is the removal of the entire lung. Due to the potential high morbidity and mortality of this operation, the indications remain controversial; however, pneumonectomy is still used for large and centrally located tumors.
Lobectomy
Lobectomy, which involves removing one of the five lobes of the lung, is the standard surgery for most people with non-small cell lung cancer. The surgical technique varies depending on which lobe of the lung is removed, but the general process is similar.
Segment resection
Segmentectomy refers to the removal of a bronchopulmonary segment and usually involves the resection of two adjacent segments. This procedure has been associated with a higher survival rate compared with lobectomy in patients with stage I A disease and tumors ≤ 2 cm in diameter.
Non-anatomical resection
Non-anatomical resection refers to the removal of lung tissue without sticking to the anatomy of the lung lobe or segment, and is commonly used to treat various lung diseases.
Wedge resection
A wedge resection is the non-anatomical removal of a small triangle of tissue from the lung. The effectiveness of this procedure in non-small cell lung cancer is controversial.
Future Directions
Although lung surgery is considered an invasive procedure with potential side effects, new technologies such as video-assisted surgery (VATS) offer a minimally invasive solution. However, advances in robotic surgery have enabled surgeons to achieve greater precision and three-dimensional vision, further improving the outcomes of lung surgery. As technology advances, the possibilities for lung surgery in the future are endless. Does this mean that every patient can receive a tailor-made treatment plan?
