Lobektomi: A. Definition

LOBEKTOMI
A. Definition
Lobectomy is a surgical procedure performed to remove or remove one lobe
from an organ. If the lobe removed is the pulmonary lobe, it is called pulmonary
lobectomy. A lobectomy most often refers to lung lobectomy. In some cases, this term
may refer to lobectomy of other organs, such as the brain, thyroid, pancreas or liver.
This procedure is carried out when abnormalities are found in certain parts of
the lungs. If the disorder affects only one lobe, lobectomy can be performed while
other lung tissue that is still healthy is still functioning normally. Lobectomy is
usually performed in conjunction with thoracotomy surgery (surgery on the chest
cavity) 1. A lobectomy is a major operation with serious risks and potential
complications. Before lobectomy, there are several less invasive treatment options.
Consider other treatment options before lobectomy2.
B. Anatomy of the Respiratory System

The respiratory system functions to exchange oxygen gas and carbon dioxide,
which consists of:
1. Nose
2. Pharynx
3. Larynx
1
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/lobectomy_92,P07749/ accessed at
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2
http://www.healthgrades.com/procedures/lobectomy accessed at 3.16 WIB 13 Oct 2014
4. Trachea
5. Bronchi
6. Lungs
The upper respiratory system includes:
1. Nose
2. Nasal Cavity
3. Ethmoidal air cells
4. Frontal sinuses
5. Maxillary sinus
6. Larynx
7. Trachea
The lower respiratory system includes the lungs, bronchi, and alveoli.
C. Lobectomy type
1. Bilobectomy, removes two lobes of the lung
2. Left upper lobectomy, lift the left upper lobe of the lung
3. Left lower lobectomy, lifting the left lower lobe of the lung
4. Right upper lobectomy, lifting the right lobe over the lungs
5. Right middle lobectomy, removes the right middle lobe of the lung
6. Right lower lobectomy, lifting the right lower lobe of the lung
7. Sleeve lobectomy, remove lobes and bronchi
D. Indication
1. Bronchiectasis, which is scarring and dilation of the airways in the lungs
2. That cancer starts in the lungs and is limited in one or two lobes
3. Malformationcongenital, cystic adenomatoid (CCAM), a non-cancerous mass of
abnormal lung tissue obtained at birth. The doctor will recommend lobectomy
during childhood for this condition
4. Fungal infections who are already resistant to treatment
5. Emphysematosa bleb or bullae or blebs lung, large blisters in the lungs that can
cause it to collapse
6. Bronchogenic carcinoma located in one lobe
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7. Lung abscess, lung abscess can cause pus, if the abscess cannot be treated with
antibiotics then lobectomy is done so that it does not infect other parts of the
body.
8. Benign tumor,
9. Tuberculosis, a chronic bacterial infection that usually infects the lungs, TB is an
air-borne disease2,3.
E. Complications
In every surgery complications can occur. Complications can occur but do not
always occur, including:
1. Infection and septicema, spread from local infections into the blood, including
pneumonia.
2. Tension pneumothorax occurs when air is trapped in the pleural space (air
between the lungs and chest wall, which can cause collapse
3. Bleeding
4. Bronchopleural fistula is a tube-like opening between the bronchi and pleural
cavity that causes air or fluid leakage to the surgical area.
5. Empyema, accumulation of pus in the chest cavity1.
Other potential complications:
1. Abnormal heart rhythm
2. Fluid buildup in the space where the lobe is removed
3. Collapsed lung
4. Moveits organs and body tissues into the space where the lobe is removed
5. Breath failure and death
Reducing the risk of complications can be done by following treatment and:
1. Be active, adjust your diet and lifestyle, and comply with per-operation and
recovery procedures
2. Notify the doctor immediately if the patient is pregnant
3. Immediately notify the doctor if there are signs of bleeding, fever, increased pain,
redness and swelling in the surgical wound
4. Take medicine regularly
5. Notify health workers if you have allergies.
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3
Asih, Niluh Gede Yamin and Christantie Effendy. 2004. Surgical Medical Nursing: Clients with Respiratory
System Disorders. Jakarta: EGC
F. Pre-operation
 The doctor will explain the procedure to you and offer you the opportunity to ask
any questions that you might have about the procedure.
 Patient will be asked to sign a consent form that gives permission to do the
procedure. Read the form carefully and ask questions if something is not clear.
 In addition to a complete medical history, the doctor may perform a physical
examination to ensure you are in good health before you undergo the procedure.
Patients may also go under blood tests and other diagnostic tests.
 Patients will be asked to fast for eight hours before the procedure, generally after
midnight.
 If the patient is pregnant or suspect that you are pregnant, the patient should
notify the doctor.
 Notify doctor if you are sensitive to or are allergic to any medications, latex,
iodine, tape, and anesthetic agents (local or general).
 Notify doctor of all medications (prescribed and over-the-counter) and herbal
supplements that you are taking.
 Notify doctor if the patient has a history of bleeding disorders or if you are taking
any anticoagulant (blood-thinning) medications, aspirin, or other medications that
affect blood clotting. It may be necessary for patients to stop these medications
prior to the procedure.
 If the patient smoke, the patient should stop smoking as soon as possible prior to
the procedure, in order to improve the patient's chances for a successful recovery
from surgery and to improve your overall health status.
 Patients may receive a sedative prior to the procedure to help you relax.
 Based on patient's medical condition, doctor may request other specific
preparations1.
G. Operation
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A lobectomy requires a hospital stay of several days. Procedures may vary
depending on patient conditions and doctor's practices. Generally, a lobectomy
follows this process:
 Patients will be asked to remove any jewelry or other objects that may interfere
with the procedure.
 Patient will be asked to remove clothing and will be given a gown to wear.
 An intravenous (IV) line will be inserted in your arm or hand.
 If there is excessive hair at the surgical site, it may be clipped off.
 A urinary catheter may be inserted into your bladder to drain urine during the
procedure.
 Patient will be positioned on the operating table in a manner that provides the best
access to the side of the chest being operated on, usually lying on the side
opposite the surgical site.
 After the patient is sedated, the anesthesiologist
will insert a tube into the lungs so that breathing
can be controlled by a ventilator. The
anesthesiologist will continuously monitor the
patient's heart rate, blood pressure, breathing, and
blood oxygen levels during the surgery.
 The skin over the surgical site will be cleansed
with an antiseptic solution.
 An incision will be made along the front aspect of the chest at the level of the
lobe being removed. The incision will extend under your arm to your back.
 When the ribs are visualized, a special instrument will be used to spread the ribs
apart, leaving the lung area exposed.
 The blood vessels and air tubes that supply the lobe being removed will be tied
off with nonabsorbable sutures.
 The lobe will be removed. In order to facilitate the removal of the lung tissue, a
rib or a portion of a rib may be removed.
 One or more chest tubes may be inserted into the chest cavity to aid
postoperatively in the removal of air or fluid.
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 The skin incision will be closed with sutures or surgical staples.
 A sterile bandage or dressing will be applied.
 An epidural catheter to infuse pain medication into the patient's back may be
inserted before the patient leaves the operating room or in the recovery room1.
Other procedures may occur, including:
 Video-assisted thoracoscopic surgery (VATS)is a minimally invasive surgery.
Your surgeon will insert special instruments and a thoracoscope through three
small incisions in your chest. The thoracoscope is a thin, lighted instrument with a
small camera that transmits pictures of the inside of your body to a video screen.
Your surgeon sees the inside of your chest on the video screen while performing
surgery. Minimally invasive surgery generally involves a faster recovery and less
pain than open surgery. This is because it causes less trauma to tissues. Your
surgeon will make small incisions instead of a larger one used in open surgery.
Surgical tools are threaded around muscles and tissues instead of cutting through
or displacing them as in open surgery. Some surgeons use a surgical robot to assist
in minimally invasive surgery2.
 Open surgery (thoracotomy)involves making a large incision in the chest
between the ribs. Open surgery allows your surgeon to directly view and access
the surgical area. Open surgery generally involves a longer recovery and more
pain than minimally invasive surgery. Open surgery requires a larger incision and
more cutting and displacement of muscles and other tissues than minimally
invasive surgery. Despite this, open surgery may be a safer or more effective
method for certain patients.
Types of anesthesia that may be used:
Your doctor will perform a lobectomy using general anesthesia. General
anesthesia is a combination of intravenous (IV) medications and gases that put you in
a deep sleep. You are unaware of the procedure and will not feel any pain. An
epidural catheter (regional anesthesia) may also be placed to help with pain during
and after the procedure.
H. Post-Operation
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1. In the hospital
After the procedure, the patient will be taken to the recovery room for
observation. Patient's recovery process will vary depending on the type of
procedure performed and the type of anesthesia that is given. Once the patient's
blood pressure, pulse, and breathing are stable and the patient is alert, the patient
will be taken to the hospital room.
Patients may receive pain medication as needed, either by a nurse, through
an epidural catheter, or by administering it yourself through a device connected to
an intravenous line.
Patients may have one or more chest tubes inserted near the surgical
incision to drain water and / or fluid from the chest. The chest tubes may be
painful when moving, coughing, or breathing deeply. The chest tubes will be
removed before discharged from the hospital.
Patients may need to receive oxygen for a period of time after surgery.
Generally, the oxygen will be discontinued before you go home. However, some
patients may need to go home with oxygen, depending on their medical condition.
Patient will be taught deep breathing exercises and coughing techniques to
help facilitate lung re-expansion and prevent postoperative pneumonia.
Patient will be able to move around as tolerated while you are in bed and
get out of bed and walk around as your strength improves.
Depending on the patient's situation, the patient may be given liquids to
drink a few hours after surgery. Diet may be gradually advanced to more solid
foods as tolerated.
Before being discharged from the hospital, arrangements will be made for
a follow-up visit with the doctor. The length of time may vary depending on the
reason for patient's lobectomy1.
2. At home
Once patient is home, it is important to keep the clean and dry incision.
Doctor will give specific bathing instructions. The stitches or surgical staples will
be removed during a follow-up office visit.
The incision, and chest and shoulder muscles, may ache, especially with
deep breathing, coughing, and exertion. Take a pain reliever for soreness as
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recommended by doctors. Aspirin or certain other pain medications may increase
the chance of bleeding. Be sure to take only recommended medications.
Patient should continue the breathing exercises used in the hospital.
Patients will be advised to avoid exposure to upper respiratory infections
(colds and flu) and irritants, such as tobacco smoke, fumes, and environmental
pollution.
Patient should gradually increase your physical activity as tolerated. It
may take several weeks to return to your previous levels of stamina.
Patients may be instructed to avoid lifting heavy items for several months
in order to prevent strains on chest muscles and surgical incision.
Notify doctor to report any of the following:
 Fever and / or chills
 Redness, swelling, or bleeding or other drainage from the incision site
 Increased pain around the incision site
 Difficulty breathing, chest pain, irritation cough, anxiety, or change in mental
status
 Green, yellow, or blood-tinged sputum (phlegm) 1.
I. Nursing care
Assessment
a. Pre Operation
1 Activity / training
Insomnia, increased sensitivity, weak muscles, impaired coordination, severe fatigue,
muscle atrophy, increased respiratory frequency, tachypnea, dyspnea
2 Elimination
Large amounts of urine, diarrhea.
3 Koping / self defense
Experiencing anxiety and severe stress, both emotional and physical,
emotionally unstable, depressed.
4 Nutrition and metabolic
Nausea and vomiting, the temperature rises above 37.4ºC. Enlargement of the
thyroid, non-pitting edema especially in the pretibial area, diarrhea or
constipation.
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5 Cognitive and sensory
His speech is rapid and hoarse, confused, restless, coma, tremors in the hands,
deep tendon hyperactivity (RTD), orbital pain, photophobia, palpitations, chest
pain (angina).
6 Reproduction / sexual
Decreased libido, hypomenorrhea, menorea and impotence.
b. Post operation
1 Basic assessment data
a. KDB considerations show evenly treated: 3 days
b. Pattern of activity / rest: insomnia, severe weakness, impaired coordination
c. Neurosensory patterns: disorders of mental status and behavior, such as: confusion,
disorientation, anxiety, excitement, hyperactive deep tendon reflex
2 Nursing priorities
a. Returns hyperthyroid status through preoperative
b. Prevents complications
c. Relieve pain
d. Provide information about procedures
3 The purpose of repatriation

a. Complications can be prevented or reduced
b. Pain disappeared
c. Surgical procedures / prognosis and treatment can be understood
d. May need help with treatment techniques in part or in full,
e. Daily activities, maintaining house chores
Nursing diagnoses
a. Pre operative
1 Anxiety is a change in health status.
Aim :
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After taking action for ... x 24 hours is expected to reduce stressors that burden
individual sources.
Results Criteria:
b. Anxiety is reduced, proven by showing control of aggression, control of anxiety,
coping.
c. Plan coping strategies for stressful situations
d. Manifestations due to anxiety do not exist
Intervention
a. Behavioral observations that indicate the level of anxiety
Rational: measure the level of anxiety
b. Monitor physical response, palpitations, repetitive movements, hyperventilation,
insomnia.
Rational: Effects of excess thyroid hormone cause clinical manifestations of
catecholamine excess events when epinephrine levels are normal.
c. Give anti-anxiety drugs, for example: transquilizers, sedatives and monitor their
effects.
Rational: help reduce client anxiety in dealing with operations.
2 Nutritional imbalances less than the body's needs are related to the client's
inability to enter or swallow food.
Aim :
After taking action for ... x24 hours expected level of nutrients available are able to
meet metabolic needs.
Results Criteria:
a. Fulfilled food intake, fluids, and nutrients
b. Tolerance to the recommended diet
c. Maintain body mass and weight within normal limits
d. Report the energy level adequacy
Intervention
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a. Auscultation of bowel sounds
Rational: hyperactive bowel noise reflects an increase in gastric motality that
decreases or changes the absorption function.
b. Monitor food input every day. And weigh every day and report a decrease.
Rational: continuous weight loss in a state of sufficient calorie intake is an indication
of failure of antithyroid therapy.
c. Avoid giving food that can increase intestinal peristaltic.
Rational: increased gastrointestinal totality can cause diarrhea and impaired
absorption of nutrients needed.
d. Collaborate with a doctor on drugs or vitamins that are needed to meet the client's
nutritional needs.
Post operative
1 Airway clearance is ineffective in airway obstruction (airway spasm).
Aim :
Maintaining the patency of the airway after nursing actions performed for ... x 24
hours.
Results Criteria:
a. Demonstrating effective airway cleansing evidenced by gas exchange and harmless
ventilation.
b. Easy to breathe.
c. Anxiety, cyanosis, and dyspnea are absent.
d. O2 saturation is within normal limits.
Intervention:
a. Monitor breathing frequency, depth and respiratory work.
Rational: normal breathing is sometimes fast, but the development of respiratory
distress is an indication of tracheal compression due to edema or bleeding.
b. Auscultate the sound of breathing, note the sound of crackles.
Rational: crackling is an indication of laryngeal obstruction / spasm which requires
rapid evaluation and intervention.
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c. Check neck dressing every hour in the initial postoperative period, then every 4
hours.
Rational: Surgery in the neck area can cause airway obstruction due to
postoperative edema.
2 Acute pain is associated with postoperative edema

Aim :
After taking action for ... x 24 hours is expected to control pain and can be reduced.
Result criteria:
a. No moans
b. relaxed facial expression
c. reported pain can be reduced or disappear., from a scale of 7 reduced to 2.
Intervention:
a. Assess for signs of pain both verbally and nonverbally, note location, intensity
(scale 0-10), and duration.
Rational: useful in evaluating pain, determine the choice of intervention determine
the effectiveness of therapy.
b. Give the patient in the semi-Fowler position and prop the head / neck with a small
pillow.
Rational: prevent neck hyperextension and protect the integrity of the suture line
c. Encourage patients to use relaxation techniques, such as imagination, soft music,
progressive relaxation.
Rational: help to refocus attention and help patients to deal with pain / discomfort
more effectively.
d. Provide prescribed narcotic analgesics & evaluate their effectiveness.
Rational: Narcotic analgesics need great pain to block pain.
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B. Anatomy of the Respiratory System

3 The purpose of repatriation

2 Acute pain is associated with postoperative edema

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