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figure 29-1 (continued) C, After the neocarina is completed, sutures for anastomosis between the trachea and the bronchial circumference are placed. The joined main bronchi are treated as a single unit. Sutures will be closer together on the tracheal side since the bronchial circumference is longer. Sutures are placed proportionally; the tracheal and bronchial edges are not tailored. The anterior cartilaginous wall sutures are placed first. The anterior mattress suture at the confluence of the trachea and both bronchi is shown. The balance of the anterior anastomotic sutures is serially placed on both sides, from the midpoint to the lateral traction sutures, arrayed on each side in the order of placement. These will be tied in reverse order of placement. Membranous wall sutures are placed next. A mattress suture is also used at the posterior confluence. Midlateral stay sutures in the trachea are not shown. If this anastomosis is performed through a median sternotomy (with partial pericardiotomy), the membranous wall sutures are placed first, with half ranged to either side. The anterior sutures are then placed. Traction sutures are tied before the anastomotic sutures. D, After all anastomotic sutures are placed, the paired lateral traction sutures are tied on each side simultaneously. Cervical flexion is maintained during this maneuver. Anastomotic sutures are tied, beginning with the most accessible ones in the cartilaginous wall posterior to the traction sutures. This will further reduce any residual tension as the next sutures are tied, since the membranous wall tears more easily. As each suture is tied, excess suture is removed. Membranous wall sutures are tied next, followed by anterior sutures. Note the mattress suture in the anterior midpoint.

the usual manner, with care taken to place the sutures proportionally in view of the discrepancy in shape and size of proximal and distal "ends." I use a mattress suture both anteriorly and posteriorly at the point of junction of the tracheal anastomosis with the bronchial anastomosis (see Figure 29-1C). This pulls the bronchial suture lines together at the corners (see Figure 29-1D), obtaining an airtight seal. A second layer flap is routinely used (see Figure 28-4 in Chapter 28, Reconstruction of the Lower Trachea [Transthoracic] and Procedures for Extended Resection).

Carinal Lesion with Involvement of the Trachea. If a carinal tumor or stenosis involves more than a minimal amount of trachea, the remaining length of trachea becomes insufficient to approximate it without tension to a neocarina formed by suturing right and left main bronchi together (Figure 29-2A).1 In this case, the trachea is most often sutured end-to-end to the left main bronchus, and the right main bronchus is implanted into the side of the trachea (Figure 29-2B), usually after right hilar intrapericardial release. Ease of approximation of the trachea to the left main bronchus is tested, with the neck in tentative flexion,

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