figure 28-4 Buttressing a tracheobronchial anastomosis with pedicled pericardial fat pad. A, The line of dissection (dotted line) preferably starts below the large middle pericardial branch of the internal thoracic artery, follows the anterior fold of mediastinal pleura into the costophrenic sinus, and then back and up on the pericardium along the border of the subpleural fat pad. The pad is raised from the pericardial surface, dividing small branches of musculo-phrenic and pericardiacophrenic arteries in this course. B, The elevated pedicle ofpericardial fat is passed beneath the anastomosis. The fragile tissue must be handled with delicacy and without tension on the pedicle. It is sutured with fine (4-0) sutures to the airway proximal and distal to the anastomotic line and to itself. The fat pad is thus packed against the suture line. It must be viable tissue.

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