Pneumonectomy
When Removing a Whole Lung Is the Right Operation

A pneumonectomy removes one entire lung. The main bronchus is divided and closed, the pulmonary artery and both pulmonary veins on that side are divided, and the lung is taken out as a single specimen, together with a systematic dissection of the lymph nodes in the centre of the chest. No reconstruction follows: the space where the lung was is simply left, and the body fills it over the following months.

It is a radical operation, and the arithmetic is unforgiving. Removing the right lung takes slightly more than half of the total lung tissue and a corresponding share of the pulmonary vascular bed; removing the left takes slightly less. That loss is permanent and it is the reason the assessment beforehand is as important as the surgery itself.

Where the tumour sits very centrally, the pulmonary vessels may be divided inside the pericardium — the sac around the heart — rather than outside it. Opening the pericardium gives a longer and safer segment of vessel to work with and a better margin of clearance around a central tumour. That is a judgement made at the operation rather than in advance.

A pneumonectomy is not a bigger version of a lobectomy. It is a different operation with a different physiology afterwards, and it is offered on that basis.

Several things can alter how much lung has to be removed. None of them applies to every patient, and the sequence is not fixed. What determines which are relevant is the stage, the nodal status, the molecular profile of the tumour and the anatomy of the disease — decided at a multidisciplinary team meeting rather than by any single clinician.

In Dr Okiror’s own SCTS returns, across the two most recent audited years, six patients underwent sleeve resection for every one who underwent pneumonectomy. That is a description of case selection in those particular patients, not a target ratio and not a claim that a pneumonectomy can usually be avoided.

The principle underneath all four. The goal of surgery is complete resection. An operation that leaves visible tumour behind confers no therapeutic advantage, and the completeness of the resection is the strongest determinant of outcome that is under the surgeon’s control. Where a smaller operation would be incomplete, the larger operation is the right one — and where a smaller operation would be complete, the smaller one is.

Two reasons, and both are anatomical. The right lung has three lobes and contributes slightly more than half of total lung function, so a right pneumonectomy imposes a greater physiological loss than a left. And the right main bronchus, once the lung is removed, lies more exposed within the chest with less surrounding tissue to support the closed stump.

Breakdown of that closure — a bronchopleural fistula — is the complication with the greatest influence on early mortality after pneumonectomy, and it is more common on the right. Across published series it occurs in roughly 1.5 to 12.5 per cent of pneumonectomies. It is the reason the bronchial stump is closed with particular care and, where the tissue warrants it, covered with a flap of local tissue to support healing.

None of this makes a right pneumonectomy the wrong operation where it is the operation the disease requires. It does mean that the assessment beforehand is stricter, that the threshold for reconstructing rather than removing is lower on the right, and that anyone offering a right pneumonectomy should be able to explain why a lung-sparing alternative was not possible.

Not every pneumonectomy is a first operation. Where a patient has already had a lobectomy and cancer later returns on the same side — either as a recurrence or as a new primary cancer in the remaining lobe — removing what is left of that lung is called a completion pneumonectomy.

It is harder than a first-time pneumonectomy, and honestly so. Scarring from the previous operation obliterates the tissue planes that would normally separate the pulmonary artery, the veins and the bronchus from the surrounding structures, so the dissection is slower and the vessels are reached with more difficulty. The hilum may need to be approached from within the pericardium for that reason.

The published outcomes reflect that difficulty without ruling out the operation. A multicentre international study of 165 patients reported operative mortality of 10.3 per cent with complications in 55 per cent, and overall five-year survival of 37.6 per cent, higher in squamous cell carcinoma and metastatic disease than in adenocarcinoma. A single-centre series of 69 patients operated between 1998 and 2020 reported 30-day mortality of 7.2 per cent and overall morbidity of 37.6 per cent, and found that induction treatment beforehand did not worsen those outcomes.

Read together, the message is consistent: a completion pneumonectomy is a high-risk operation reserved for carefully selected patients in experienced hands, and in those patients it offers a further chance of cure that would not otherwise exist. It is not the preferred answer where anything smaller will do. Survival after completion pneumonectomy is worse than after a lesser second operation — one series reported five-year survival of 20 per cent against 57.5 per cent after lobectomy — which is why the assessment always begins by asking whether a lung-sparing resection can clear the disease instead. The alternatives for disease returning on a previously operated side are set out on the lung cancer recurrence and salvage lung surgery pages.

The assessment asks what function will remain after the operation, not what function exists now. Spirometry measures the volume the lungs can move; gas transfer measures how efficiently oxygen crosses from the air into the blood. Both are used to calculate predicted postoperative values for the lung that will be left.

Gas transfer deserves particular attention here. It predicts complications and long-term breathlessness independently of spirometry, and a patient can have entirely normal spirometry with a markedly reduced transfer factor. Both are measured before any major lung resection for exactly that reason. The detail is on the lung function and thoracic surgery page.

Where the predicted values are borderline, cardiopulmonary exercise testing becomes the arbiter, because it measures the heart and lungs working together under load rather than either in isolation. A peak oxygen uptake above roughly 20 mL/kg/min, or above 75 per cent of predicted, indicates that resection up to a pneumonectomy should be tolerated. Values below about 10 mL/kg/min, or below 35 per cent of predicted, indicate high risk and prompt a discussion about lesser resections or non-surgical treatment instead.

Quantitative perfusion imaging is used where it will change the calculation. A lung largely obstructed by a central tumour may already be receiving very little of the blood flow, in which case removing it costs less function than the raw numbers suggest. Cardiac assessment is performed where the history warrants it, and any significant coronary disease is addressed before lung resection rather than after.

Where the assessment returns a borderline answer, that is a starting point for a conversation rather than an automatic refusal — the approach to patients in that position is set out on the borderline lung function page.

This is the question patients actually want answered, and it is often the one given least time in clinic. Most people who have had a pneumonectomy return to independent daily life. They work, drive, travel, shop, garden and walk. What changes is reserve: the margin available when demand rises. Breathlessness appears on hills, on stairs taken quickly, and on sustained exertion, rather than sitting in a chair.

How much is lost depends on how much the removed lung was contributing beforehand. A lung largely blocked by a central tumour may have been doing very little work, and some patients notice a smaller change than they feared. This is measured rather than estimated, which is why the perfusion scan is sometimes worth doing.

What happens to the empty space. It fills. Over weeks and months, fluid gradually accumulates in the space where the lung was, the remaining lung expands across the midline to some extent, the diaphragm on the operated side rises, and the heart and mediastinum shift towards that side. All of this is expected. It is also why chest imaging afterwards looks dramatically abnormal to anyone who does not know the history — worth mentioning to any clinician reporting your scans.

Practical matters. Commercial flying is generally possible once recovery is established and the remaining lung is working well, though it is worth discussing before booking. Swimming and cycling are usually resumed. Chest infections in the remaining lung are treated promptly rather than watched, because there is no spare capacity to absorb them, and annual influenza and pneumococcal vaccination is worth having. Smoking cessation, if relevant, matters more now than it ever did.

Pulmonary rehabilitation, where available, is worth pursuing. The remaining lung adapts over three to six months and conditioning makes a measurable difference to what that adaptation delivers.

Patients who have had a lung removed often assume that surgery is now closed to them for good. It is not necessarily so. Dr Okiror is senior author on a published case report describing the resection of a contralateral scapular oligometastasis in non-small cell lung cancer following a previous salvage pneumonectomy (Cureus, 2023).

A single case report is not evidence for a general pathway, and it should not be read as one. What it demonstrates is narrower and still useful: complex resection and reconstruction of the chest wall remains technically feasible in a patient with one lung, where the disease is limited, where the assessment of respiratory reserve supports it, and where the case has been through a multidisciplinary discussion.

The principles of en bloc resection and reconstruction of the chest wall, and how those decisions are made, are set out on the chest wall invasion page.

The hospital stay is longer than after a lobectomy and the first days are managed with particular attention to fluid balance, because a single remaining lung tolerates fluid overload poorly. Breathing exercises and getting out of bed begin immediately; both matter more here than after a smaller resection.

Pain control after an open operation is planned before surgery rather than improvised afterwards; the approaches used are described on the pain relief after thoracic surgery page. General guidance on the weeks after chest surgery is on the recovery after lung surgery page.

Return to full activity is measured in months. Most patients notice steady improvement over three to six months as the remaining lung adapts. Follow-up is clinical and by CT, and the appearance of the operated side on imaging changes over that period in the expected way.

Adjuvant treatment, where the pathology indicates it, is decided at the multidisciplinary team meeting once the specimen has been reported. Systemic treatment is harder to tolerate with one lung than with two, which is an argument for lung-sparing surgery where it achieves the same clearance — and not an argument against pneumonectomy where it does not.

Risk, stated plainly

Pneumonectomy carries a higher risk than lobectomy and it is right to know the size of that difference. Published series report 30-day mortality of around 4 to 7 per cent and 90-day mortality of around 7 to 12 per cent after pneumonectomy for lung cancer; a single-centre cohort of 514 patients reported 4.3 per cent and 9.1 per cent respectively, and a propensity-matched comparison against lobectomy found 90-day mortality of 6.9 per cent against 1.9 per cent. Mortality after major lung resection roughly doubles between 30 and 90 days, which is why the 90-day figure is the more honest one to quote.

Context matters alongside those numbers. At Guy’s and St Thomas’, pneumonectomy has fallen to 1.5% of lung resections from 3.7% seven years earlier, while departmental operative survival across all resections reached 99.59% in 2024–25. A unit that performs the operation rarely, and reserves it for the patients who need it, is a different setting from one that performs it routinely.

In Dr Okiror’s own practice, across six audited years of SCTS returns, 10 patients underwent pneumonectomy and there were no operative deaths in that series. Ten is a small number and no general conclusion should be drawn from it; it is offered with its denominator attached as a description of the practice rather than as a benchmark.