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by pulling together the paired traction sutures of the trachea and left main bronchus on both sides. In general, anastomosis of the trachea to the left main bronchus may be safely accomplished in the adult without dangerous tension, if the initial gap is no greater than 4 cm. This varies with individual patients. If tension seems too great, the technique described in the next section should be employed instead.

The end-to-end anastomosis between the trachea and left main bronchus is accomplished in the usual manner, even though there is discrepancy between the diameter of the trachea and that of the left main bronchus. Ordinarily, I do not make any effort to bevel the main bronchus or to reduce the circumference of the trachea. The anastomotic sutures are placed proportionally between the trachea and bronchus (see Figure 30-1 in Chapter 30, "Main and Lobar Bronchoplasty"). When the ends are drawn together, there may be a small degree of intussusception. Although one might expect that the resulting irregularity inside the lumen would produce granulation tissue at the point of healing, this is almost never the case, probably because epithelization proceeds rapidly. The lateral traction sutures are tied first, followed by the anastomotic sutures. Placement of sutures and their temporary alignment on the drapes is done in a manner analogous to that described for transthoracic tracheal reconstruction (see Chapter 28, "Reconstruction of the Lower Trachea [Transthoracic] and Procedures for Extended Resection").

The special long ET is now passed from above, through the anastomosis between the trachea and left main bronchus into the left main bronchus (see Figure 18-2b in Chapter 18, "Anesthesia for Tracheal Surgery"). Care is taken not to advance it so far that the left upper lobe orifice becomes obstructed. Inhalation anesthesia is continued using the left lung only. The right lung remains collapsed. An ovoid opening is made in the right lateral wall of the lower trachea, approximately 1 cm proximal to the anastomosis just performed between the trachea and left main bronchus (Figure 29-2C). This is done in order to maintain blood supply in this isthmus of cartilage between the two anastomoses and to separate them by a bridge of healthy tissue. The aperture lies entirely within the cartilaginous lateral wall of the trachea to help assure patency (see Figure 29-2C). It does not extend into the membranous wall. The right main bronchus should be easily elevated to this level, facilitated by prior inferior intrapericardial release (see Figures 28-5A,B in Chapter 28, "Reconstruction of the Lower Trachea [Transthoracic] and Procedures for Extended Resection"). If there appears to be tension when the right main bronchus is advanced to the new aperture in the lower trachea, it may be necessary to complete the intrapericardial release circumferentially. Cervical flexion is maintained during completion of the anastomosis. Anastomoses are tested for air tightness under saline after retracting the ET proximally to a point above the anastomoses.

Anastomosis between the trachea and right main bronchus, which in some cases is essentially at the bifurcation into the upper lobe bronchus and bronchus intermedius, must be made with great care. 4-0 Vicryl sutures from the anterior wall of the right main bronchus to the anterior margin of the ovoid opening are placed carefully so that the knots will lie on the outside of the lumen (see Figure 29-2C). Lateral traction sutures may be helpful. These are placed in the usual orientation in the right main bronchus or sometimes in the lateral walls of the right upper lobe bronchus and bronchus intermedius if much of the right main bronchus has been resected. Traction sutures at the superior and inferior margins of the oval opening in the trachea, if used, must be placed with unusual care, not too close or too far from the new stoma, and possibly transversely or obliquely. 3-0 Vicryl is preferred for traction sutures in these locations to avoid injury to the thinner cartilage of the bronchus.

One or two anastomotic sutures may be placed just anterior to the midlateral traction suture in the inferior margin of the right main bronchus. The balance of sutures, beginning just beyond this point, is serially placed anteriorly, ranging to the superior margin of the right main bronchus. When the bronchus is approximated to the tracheal aperture, fingertip access for tying the sutures is better from cephalad to caudad, except for the first few sutures placed, which are accessible inferior to the bronchus. The posterior wall sutures are placed after the anterior ones, retracting the lung anteriorly.

It often is not necessary to place traction sutures in the trachea for approximation to the traction sutures in the main bronchus, since the approximation is usually made without tension by simply sliding the collapsed lobe and its bronchus very carefully toward the point of anastomosis. The traction sutures on the bronchial side are helpful in thus positioning the bronchus for anastomosis. An alternative is to use two slightly heavier anastomotic sutures (3-0) at either end of the ovoid anastomosis. The anterior and superior cartilage-to-cartilage sutures are tied, beginning superiorly and progressing in a caudad direction. The few caudad sutures are tied with a little more difficulty because of the presence of the apical segmental branch of the upper division of the right pulmonary artery. The artery is retracted gently. The posterior anastomotic sutures are then tied. Special care must be taken not to pull sharply on these sutures in the membranous wall, since they can easily cut through the thinner membranous wall of the bronchus, causing troublesome leaks.

An alternative method, less often used, is to anastomose the right main bronchus to the trachea and implant the left main bronchus into the left side of the trachea. There is no special reason to recommend this scheme.

A second layer wrap is interposed between the anastomoses and pulmonary artery. The pericardial fat pad is preferred (see Figure 28-4 in Chapter 28, "Reconstruction of the Lower Trachea [Transthoracic] and Procedures for Extended Resection"), but is somewhat more difficult to use than a broad-based pleural flap because of the bulkiness of the fat and the small space between the anastomosis of the right main bronchus to the trachea and the pulmonary artery ramus. A fat pad flap is employed by splitting it into two tails in its distal portion so that one may be carried around the anastomosis of trachea to the left main bronchus and the other circumferentially around the right main bronchial anastomosis to the trachea. To simplify passing these flaps in these tight spaces, they may first be carefully drawn into a Penrose drain (using three hemostats to spread the drain lumen). The sheathed and moistened flap is then pulled gently into place around the anastomosis, and the drain slipped off.

Before suturing the second layer flaps, the ET is drawn up into the trachea (with cuff deflated) to a point above the proximal anastomosis and the cuff is reinflated. The anastomoses are checked for leaks under saline. The ET is guided back into the left main bronchus in order to collapse the right lung again. After suturing the pericardial fat pad over the anastomoses and to itself, the ET is repositioned in the proximal trachea and the right lung fully expanded before closing the chest.

Extended Resection of Carina and Trachea. Where even a greater length of trachea must be removed, the technique just described will not suffice (Figure 29-3A). The length of tracheal resection will not permit safe approximation of the trachea to the left main bronchus, even with maximum mobilization. The left main bronchus remains tethered by the aortic arch. Access is not regularly available to perform intraperi-cardial mobilization of the left hilum, and even this would often not provide sufficient mobility. In contrast, full intrapericardial mobilization of the right hilum permits the right main bronchus to be elevated high in the chest for end-to-end anastomosis to the remaining trachea (Figure 29-3B). Ventilation is maintained with a tube across the operative field in the left main bronchus during this phase (see Figure 18-2C in Chapter 18, "Anesthesia for Tracheal Surgery").

After anastomosis of the trachea to the right main bronchus, an ovoid opening is made in the medial wall of the bronchus intermedius, and the left main bronchus is anastomosed to this opening (see Figure 29-3B). This technique was first described in patients by Barclay and colleagues,5 who reported 2 cases in 1957, and then by Eschapasse and colleagues7 and Grillo.1 The bronchotomy is made with care not to remove excessive cartilage and so narrow the bronchus intermedius. On the other hand, a simple slit will not remain sufficiently patent. A slim oval of bronchial wall is excised, leaving a margin of cartilage all around the aperture. The anteroposterior diameter of the left main bronchus is somewhat greater than the

figure 29-3 Resection of the carina and a significant length of the trachea. A, The length of trachea resected (dotted lines) exceeds 4 cm. The trachea and left main bronchus will not approximate safely. B, The elevated right main bronchus is anastomosed to the trachea after intrapericardial hilar mobilization. The left main bronchus is then anastomosed to the medial figure 29-3 Resection of the carina and a significant length of the trachea. A, The length of trachea resected (dotted lines) exceeds 4 cm. The trachea and left main bronchus will not approximate safely. B, The elevated right main bronchus is anastomosed to the trachea after intrapericardial hilar mobilization. The left main bronchus is then anastomosed to the medial wall of the bronchus intermedius, in similar fashion to Figure 29-2C.

width of the ovoid opening. When the anastomosis is completed, the neo-orifice is held more widely open and the circumference of intermediate bronchus is slightly increased at this point.

Exposure is more difficult in this repair than in the two previously described. Sutures from the anterior cartilaginous wall of the left main bronchus to the anterior margin of the stoma in the bronchus inter-medius are placed with half of the sutures ranged cephalad and half caudad. Posterior sutures are then placed from the membranous wall of the left main bronchus to the posterior margin of the ovoid opening in the bronchus intermedius. All sutures are placed before any are tied. The same considerations apply here to use of traction sutures as in the anastomosis earlier described between the end of the right main bronchus and the side of the trachea (see Figure 29-2C).

It is difficult to perform the second anastomosis using cross-field anesthesia. The flexible armored tube must be removed intermittently for placement of the sutures. The right lung should remain collapsed for access. Following placement of all the sutures, a small flexible tube may sometimes be passed from above, through the new opening into the left main bronchus, while the sutures are tied. This may be cumbersome or not be feasible. I, therefore, prefer to do this part of the anastomosis using high-frequency jet ventilation of the left lung, usually with a catheter passed from above, through the ET that lies in the trachea or across the operative field, and which is removed as the last sutures are tied (see Figure 18-2C in Chapter 18, "Anesthesia for Tracheal Surgery"). In using high-frequency ventilation in this situation, both the surgeon and anesthetist must be continuously alert to the hazard of inadvertent occlusion of the route of egress of the gases that are being insufflated. Although, mechanically, one would expect that there would be free flow, this is not always the case. Development of sudden high pressure could rupture the left lung. If oxygenation is unsatisfactory, supplementary high-frequency ventilation may be added with a catheter in the right main bronchus or a bifid catheter in the right upper lobe bronchus and in the bronchus inter-medius. Since the right lung does not fully expand, gentle retraction allows satisfactory surgical exposure.

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