laryngeal nerve where it lies beneath and on the aortic arch.Anastomosis is performed as described earlier and a second layer closure is always applied. As always, approximation is facilitated by cervical flexion.

Carinal Resection and Left Pneumonectomy. Carcinoma of the left lung only rarely extends to the carina, given the length of the left main bronchus. Infrequently, other primary tumors such as adenoid cystic carcinoma are encountered, which involve the left main bronchus and the carina. The entire left main bronchus may be resected separately (see Chapter 30, "Main and Lobar Bronchoplasty") and the lobar bronchial bifurcation of the left lung reattached to the base of the carina13; however, if the carina also must be resected with a large part of the left main bronchus, there is currently no feasible technique to salvage the left lung. Under these circumstances, a left pneumonectomy and carinal resection may be performed through a left thoracotomy (Figure 29-6A).1 This approach is safely feasible only where a limited amount of trachea is involved; that is to say, where no more than 1 cm of trachea and of right main bronchus will have to be resected above and below the margins of the left main bronchus.1,14,15

Access to the carina from the left is constricted, but adequate for such limited resection (Figure 29-6B). The right main bronchus is selectively intubated with a Wilson tube. After determination of resectability, dissection is carried up beneath the aortic arch, taking great care to identify and preserve the recurrent laryngeal nerve. The left vagus nerve will be divided well below the point of origin of the recurrent nerve. The ligamentum arteriosum is divided to improve exposure. The aortic arch is dissected cir-cumferentially and tapes placed around it for retraction. With the aid of these tapes and retractors, and with cervical flexion to devolve the trachea, dissection is carried around the lowermost end of the trachea and a Penrose drain placed around the trachea. The pretracheal plane is dissected bluntly into the neck. The carina is identified, the right main bronchus is dissected, and a Penrose drain placed around it. Once it is absolutely certain that resection and reconstruction will be possible, the pulmonary vessels are divided.

The neck is held in flexion, the aorta retracted, and traction placed on the peritracheal and peribronchial tapes, pulling the carina into the field. Then, 2-0 Vicryl traction sutures are placed in the left lateral wall of the trachea, proximal to the projected point of transection, and in the medial wall of the right main bronchus, distal to the point of bronchial division. The endotracheal tube is withdrawn into the proximal trachea. The right main bronchus is transected and a cross-field flexible ET is passed into the most proximal portion of the right main bronchus. The trachea is transected and the specimen extracted. With traction on the initial stay sutures, additional 2-0 Vicryl traction sutures are now placed in the right side of the lower trachea and in the right side of the right main bronchus. Blunt dissection should not be carried very far down the right main bronchus, because of the proximity of the pulmonary artery and the short length of the bronchus.

Using the tapes around the aorta for intermittent retraction of the aortic arch, anastomotic sutures are placed in the usual manner, commencing just anterior to the right lateral traction sutures of trachea and main bronchus and arranging these sutures forward on the anterior cartilaginous wall until the left-sided traction sutures are reached. A similar group of sutures is placed posteriorly, including the membranous wall and the two segments of cartilaginous wall posterior to the traction sutures on either side. When all of these sutures have been placed, the cross-field ET is removed, the tube from above is once again passed just into the right main bronchus, and, with cervical flexion, both sets of lateral traction sutures are tied. The ET must not be pushed into the right main bronchus or it will hinder approximation or obstruct the upper lobe orifice.

The anastomotic sutures in the cartilaginous parts of the tracheobronchial walls, posterior to the traction sutures, are tied first on both sides. With this added security, the membranous wall sutures are tied gently to avoid cutting through the soft wall. Excess suture is cut after each is tied. The sutures in the cartilaginous walls, anterior to the stay sutures, are then tied, completing the anastomosis (Figure 29-6C).

The anastomosis is tested for air tightness under saline and, following this, a second layer pedicled flap is passed around the anastomosis and sutured to the airway and to itself. The long ends of the tied

Trachea Forma

Trachea figure 29-6 Left carinal pneumonectomy. A, The procedure is feasible via a left thoracotomy with subaortic approach, but only when a short length of carina and trachea is involved. B, Exposure is facilitated by retraction of the aortic arch using tapes. The left pulmonary artery is also gently retracted, with care not to injure the first branch. The ligamentum arteriosum is usually divided. The recurrent laryngeal nerve must be meticulously identified and preserved. The vagus nerve is usually well divided, distal to the recurrent nerve, in order to improve exposure. After pretracheal blunt dissection and with cervical flexion, traction is placed on the trachea just above the carina and on the right main bronchus at its origin, using tapes. Traction sutures are placed in the trachea and right main bronchus before the airway is divided. C, Completed anastomosis. It is wrapped with a second layer. RMB = right main bronchus.

traction sutures are left in place until the second layer flap is passed beneath the anastomosis in order to facilitate this maneuver. The excess length is cut off, but the knotted traction sutures remain to minimize tension on the anastomotic sutures during early healing.

Carinal Resection for Recurrent Tumor or Stenosis after Pneumonectomy. I have treated a number of patients with tumor either residually present following a left pneumonectomy, as in a case with adenoid cystic carcinoma where concurrent carinal resection should have been done initially, or where later recurrence of tumor such as adenoid cystic carcinoma or carcinoid had followed a left pneumonectomy (Figures 29-7A,B). These patients and others with stenosis of an anastomosis between the trachea and the right main bronchus following prior left carinal pneumonectomy have been approached through the right chest with gentle retraction of a ventilated right lung. This can be done conventionally using hand ventilation or with high-frequency ventilation.

The area of the lesion is carefully dissected out, first encircling the trachea above the stump of the left main bronchus and then the right main bronchus just below the carina. With traction on both of these loops, the specimen is gradually dissected out, with meticulous care being taken to avoid any possible injury to the stump of the left pulmonary artery. The pretracheal plane is bluntly dissected. Once the specimen is resected (Figure 29-7C), end-to-end anastomosis is done in the manner already described and a second layer closure applied (Figure 29-7D). Intrapericardial hilar mobilization is very likely to be necessary and is best done before resection. On a rare occasion, anastomotic stenosis between the trachea and left main bronchus after a right pneumonectomy has been managed by repeat right thoracotomy and excision of the stenotic area deeply in the mediastinum.

In one patient who underwent extensive tracheal resection for adenoid cystic carcinoma that also required removal of the carina and left lung, anastomotic stenosis occurred after postoperative irradiation. The anastomotic stenosis was successfully resected through a cervical incision, for it rose that high in the mediastinum upon cervical extension. The long-term result was excellent.

Carinal Resection for Lesions Involving Major Portions of the Trachea and Left Main Bronchus. Special difficulties are presented by a lesion that involves a considerable length of trachea, carina, and enough of the left main bronchus so that the left lung cannot be salvaged (Figure 29-8A). When it seemed feasible that the right main bronchus could be elevated sufficiently to meet the length of trachea that would remain after resection of the lesion, several approaches for resection were employed. Perelman initially advocated approach through the right chest, stapling the left main bronchus distal to the lesion, leaving the left lung in situ.8 However, this resulted in postoperative physiological difficulties, due to a large shunt through the nonventilated residual lung, which later required left pneumonectomy.1 He, therefore, later advocated lig-ating the left pulmonary artery via the right chest through an opening in the pericardium. Another option was to perform concomitant or delayed left thoracotomy for left pneumonectomy, after the lesion had been removed and the right-sided anastomosis completed.

The approach that I favor for this rare and difficult problem is single-stage resection and reconstruction via transverse bilateral thoracotomy through the fourth interspace across the sternum (see Figure 23-8 in Chapter 23, "Surgical Approaches"). The thoracotomy extends to the posterior axillary line on both sides and provides generous access for carinal resection, left pneumonectomy, and anastomosis of the trachea to the right main bronchus. The postoperative physiological burden of the incision must be considered, but epidural analgesia for chest wall pain has made this approach safely applicable. Prolonged postoperative ventilatory support is no longer routinely expected. Alternate exposure via median sternotomy and left anterior thoracotomy is less satisfactory and presents technical difficulties for dissection of an extensive tumor, bilateral hilar dissection, and reconstruction.

figure 29-7 Carinal resection for recurrent or residual tumor or for stenosis following prior left pneumonectomy. A, Recurrent tumor of some bulk, after left pneumonectomy, is shown. Resection is done via a right thoracotomy, with right hilar intrapericardial mobilization. The right lung is ventilated gently throughout the procedure. High-frequency ventilation may be preferred. A smaller recurrent tumor or residual tumor at the carina, following left pneumonectomy, is resected from the left (see Figure 29-6). Residual tumor on the right after right pneumonectomy is, of course, approached from the right. B, Tomogram showing recurrent carcinoid at the location of the left main bronchial stump in a 28-year-old woman who had undergone left pneumonectomy 14 years previously. C, The tumor seen in Figure 29-7B was resected through a right thoracotomy. There was no recurrence in 29 years of follow-up. D, The completed anastomosis.

figure 29-8 A, Carinal resection for tumor that involves a long segment of trachea and extends so far into the left main bronchus that salvage of the left lung is impossible by present anastomotic techniques. See text for details. Reconstruction is done by end-to-end anastomosis of the right main bronchus to residual trachea, high in the thorax. Approach is via bilateral thoracotomy (see Figure 23-8). B, Ventilation is maintained initially in the left lung through an endotracheal tube (ET), which was bronchoscopically guided past the tumor into the left main bronchus. Dissection is commenced. Right hilar intrapericardial mobilization is completed. The trachea is next divided above the tumor, and left lung ventilation is continued via an ET placed across the operative field, into the trachea, and thence into the left main bronchus. The right lung remains collapsed. The right main bronchus is then divided below the tumor and dissection completed, as fully as possible from the right. Anastomosis between the trachea and the elevated right main bronchus is performed anterior to the ET and the fully-mobilized specimen.

The right side of the incision including transverse sternotomy is completed initially for exploration. If the lesion can be removed and is not so extensive that reconstruction will be unsafe, the left side of the incision is completed. After mobilizing the tumor, the trachea is divided above the tumor and a flexible ET is threaded distally through the divided end of the trachea, past the tumor into the left main bronchus, and is sutured into position to ventilate the left lung (Figure 29-8B). The left main bronchus, in many such cases, cannot be conveniently transected, since there is insufficient bronchus distal to the tumor to accept the seating of an ET. If need be, some tumor may be cored out at initial rigid bronchoscopy to provide a channel for an ET. The right main bronchus is transected next and the specimen dissected as completely as is possible from the right. The dissected but attached specimen, with its inlying ET, is dropped posteriorly

figure 29-8 (continued) C, Anastomosis in progress. All sutures have been placed between the trachea (white arrow) and a short stump of right main bronchus (black arrow). The left-sided tracheal stay suture is clearly visible, lying on the ventilated left lung. The cross-field endotracheal tube enters the distal transected trachea near proximal tumor and lies on the collapsed right lung parenchyma, which is behind the anastomosis. After completion of the anastomosis, the right lung is ventilated, the left lung is collapsed, the hilar structures on the left are divided, and the left lung is extracted with the attached tracheal and cari-nal specimen. The final anastomosis is as shown in Figure 29-7D.

(see Figure 29-8B). Intrapericardial hilar mobilization of the right lung is accomplished, and anastomosis performed between the trachea and the right main bronchus (Figure 29-8C). The right lung is expanded and ventilation commenced on that side. The ET into the left lung is extracted, and the dissection and left pneumonectomy completed from the left side.

Individualized Reconstruction after Carinal Resection. Unique problems present that demand individualized solutions. In devising bronchoplastic procedures, the surgeon must be careful not to revert inadvertently to an earlier procedure that might be likely to fail. Complex tracheo- or bronchoplasties may seem attractive, but can fail easily due to 1) deficits in healing of complex suture lines, with leak, mediastinitis, and death, or tracheal or bronchial stenosis; or 2) early recurrence of inadequately excised neoplasm. Wedge resections at the carina usually have little to recommend them, since they are more likely to effect incomplete resection, can easily produce extra tension on a suture line, or cause lumenal buckling.

A solution used for a patient with adenoid cystic carcinoma, involving a long length of trachea, the right main bronchus, and the right upper lobe bronchus, is illustrated (Figure 29-9A) as an example. Circumferential resection of that length of trachea, carina, and right main bronchus would have made reconstruction impossible, since neither the left main bronchus nor the bronchus intermedius could have reached the proximal trachea. Fortunately, the tumor was limited to the right tracheal wall. The diagrammed procedure was done after careful appraisal of the extent of circumferential tracheal involvement (Figures 29-9B,C). The patient healed per primam, received routine postoperative irradiation, and remained tumor free for 32 years.

figure 29-9 Individualized solutions to unique problems. A, This 34-year-old woman had recurrent and persistent middle lobe pneumonitis, but a normal chest x-ray. Her adenoid cystic carcinoma involved a considerable length of the right lateral wall of the trachea, the carina on the right side, the right main bronchus, and the right upper lobe bronchus. The necessary length of circumferential tracheal resection would have obviated tracheal anastomosis to the left main bronchus. The bronchus intermedius would not have reached the shortened trachea. A compromise approach was designed as diagrammed, resecting half the circumference of the trachea. B, The lateral defect was reduced markedly by resection of lateral wedges of trachea, as diagrammed. The transected bronchus intermedius was trimmed obliquely (dotted line in A) to enlarge its circumference to fit the sizable defect that still remained after tailoring the trachea. C, The completed anastomosis. The woman enjoyed a good result and remains disease free after 32 years.

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