This procedure is very similar to the procedure for right lower and middle lobe bronchoplasty (Figure 30-3F). The lower lobe resection is carried out in standard fashion until the bronchus is reached. The bronchus to the left upper lobe is divided at its origin, and the left main bronchus just proximal to the takeoff of the left upper lobe bronchus. Traction sutures are placed to ensure proper alignment. The remainder of the anastomosis is carried out as described previously.
I have occasionally had difficulty with left-sided bronchoplastic procedures using standard techniques. The problem has usually been related to airway alignment causing kinking or twisting of the anastomosis. It is difficult to know if this is related to the presence of the aorta or pulmonary artery or both. Sometimes, the problem can be anticipated beforehand because the airway does not appear to line up properly. At other times, it is only determined by bronchoscopy, after completion of the anastomosis. I have dealt with this sit-
figure 30-3 Diagrams of specific bronchoplasties. A, Right upper lobe. B, Right upper lobe and middle lobe. C, Right upper and middle lobe with resection of the bronchus intermedius. D, Right lower and middle lobe. E, Left upper lobe. F, Left lower lobe. G, Main bronchial resection. H, Segmental bronchoplasty.
uation by modifying the standard technique as follows. Traction sutures still help with alignment, reduction of anastomotic tension, and bringing the ends of the airway together. The modification consists of placing and tying individual sutures serially. The traction sutures are held together to reduce tension on the first two sutures, and ultimately are tied at the completion of the anastomosis. As each subsequent anastomotic suture is carefully placed and tied, the surgical assistant helps to "roll" the distal bronchus into perfect alignment. Alternatively, beveling the bronchial ends can assist in alignment for anastomosis.
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