CPT® Code 32445

1. Indications

The extrapleural pneumonectomy (CPT® Code 32445) is indicated for specific conditions that necessitate the removal of the lung along with surrounding structures. The following are the primary indications for this procedure:

• Malignant Lung Tumors Patients with lung cancer that has invaded surrounding tissues, including the pleura, pericardium, or diaphragm, may require this extensive surgical intervention to achieve complete resection of the tumor.
• Severe Lung Disease Conditions such as advanced pulmonary infections or other severe lung diseases that compromise lung function and may not be amenable to less invasive treatments.
• Trauma Significant thoracic trauma that results in extensive lung damage or necessitates the removal of the lung and adjacent structures for repair or reconstruction.

2. Procedure

The extrapleural pneumonectomy involves several critical procedural steps, which are outlined as follows:

• Step 1: Incision A posterolateral thoracic incision is made in the intercostal space, beginning just below the shoulder blade and extending around to the front of the chest. This incision provides the necessary access to the thoracic cavity for the surgical procedure.
• Step 2: Rib Removal (if necessary) If additional access is required, a rib may be removed to facilitate the surgical approach and ensure adequate visibility and maneuverability during the operation.
• Step 3: Lung Deflation and Vascular Control The lung is deflated to minimize its size and facilitate removal. Major blood vessels supplying the lung are carefully ligated and divided to prevent excessive bleeding during the procedure.
• Step 4: Bronchus Clamping and Incision The main bronchus is clamped and incised, allowing for the disconnection of the lung from the airway, which is essential for its removal.
• Step 5: Tissue Dissection The tissue surrounding the lung is meticulously dissected, taking care to avoid entering the pleural cavity. This step is crucial to ensure that the procedure is performed extrapleurally, as intended.
• Step 6: Lung and Pleura Removal The lung is removed along with the parietal pleura, which is the outer layer of the pleura that lines the thoracic cavity.
• Step 7: Pericardium and Diaphragm Management Any involved portion of the pericardium is excised and typically replaced with a synthetic patch to maintain structural integrity. Additionally, a portion of the diaphragm may also be removed and replaced with a synthetic patch.
• Step 8: Closure of the Bronchus The remaining segment of the bronchus is then stapled or sutured closed to ensure that the airway is properly sealed after the lung removal.

3. Post-Procedure

After the extrapleural pneumonectomy, patients typically require close monitoring in a postoperative setting. Post-procedure care may include the management of pain, monitoring for any signs of complications such as bleeding or infection, and ensuring proper respiratory function. A chest tube is usually placed to facilitate drainage of any fluid or air that may accumulate in the thoracic cavity. The expected recovery period can vary based on the patient's overall health and the extent of the surgery, but patients may need to engage in pulmonary rehabilitation to aid in recovery and improve lung function. Follow-up appointments are essential to monitor healing and address any ongoing health concerns.