figure 29-2 Resection of the carina with involvement of a longer segment of trachea. A, The gap after the resection, indicated by the dashed lines, is sufficiently long so that excessive anastomotic tension would result if the bronchi were first sutured together, or anastomosis might be impossible. This is because the mobility of the left main bronchus is checked by the aortic arch. The gap between the trachea and left main bronchus should be no greater than 4 cm. B, Anastomosis is first completed between the trachea and left main bronchus. The long proximal endotracheal tube is then advanced into the left main bronchus. The right main bronchus, which has been freed by intraperi-cardial hilar mobilization, is anastomosed to an orifice in the lateral wall of the trachea. On rare occasions, it may be preferable to implant the right main bronchus into the medial wall of the left main bronchus. The decision is based on evaluation of relative tensions intraoperatively. C, Anastomosis of the right main bronchus to the trachea. The oval orifice in the trachea is located entirely within the cartilaginous wall. The lung is retracted anteriorly. The opening is as long as the bronchus is wide, but the width of the aperture is somewhat less than the antero-posterior diameter of the bronchus. Note the location of the orifice about two rings above the prior anastomosis. The initial anastomotic suture is shown. Stay sutures in the trachea on either side of the aperture, which are sometimes omitted, are placed closer to the ends of the aperture, if used. An alternative is to use an anastomotic suture of 3-0 Vicryl at each end of the oval to help in initial approximation and to reduce tension on the other 4-0 anastomotic sutures. See the text for details of technique.
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