Lower Tracheal and Carinal Lesions

Tumors of the lower trachea and carina are best approached through a high right posterolateral thoraco-tomy (Figure 23-7). This is particularly true for tumors of the carina and for more extensive tumors of the lower trachea. I prefer this approach for tumors of the lower trachea of any complexity, although benign stenoses and simple tumors at this level are approached anteriorly. Pearson and colleagues prefer a median sternotomy,5 whereas Perelman,6 who initially favored the transsternal approach to mainstem bronchial fis-tulae, prefers right thoracotomy for lower tracheal and carinal tumors. Perelman has also largely abandoned the transsternal approach for fistulae. For special cases, one must keep in mind both the J-shaped trap door incision (see Figure 23-3B), a "T" extension from median sternotomy (see Figure 23-3C), and bilateral thoracotomy (Figure 23-8).

figure 23-6 Transmediastinal approach to the entire trachea. The sternum is fully divided, as shown in Figure 23-3C. A, The anterior pericardium is opened vertically between the superior vena cava and the aorta. The posterior pericardium is similarly opened (dashed linej. B, Retraction of the vena cava and aorta exposes a quadrilateral space in which the lower trachea and carina are seen. A tape around the brachiocephalic artery and vein helps exposure. The right pulmonary artery lies just below the carina.

figure 23-6 Transmediastinal approach to the entire trachea. The sternum is fully divided, as shown in Figure 23-3C. A, The anterior pericardium is opened vertically between the superior vena cava and the aorta. The posterior pericardium is similarly opened (dashed linej. B, Retraction of the vena cava and aorta exposes a quadrilateral space in which the lower trachea and carina are seen. A tape around the brachiocephalic artery and vein helps exposure. The right pulmonary artery lies just below the carina.

Formerly, when a right thoracotomy was elected for resection of a tumor of greater length in the lower trachea, the patient's right arm was draped into the field and the neck also prepared. This permits access, with some difficulty, for laryngeal release, by swinging the arm to the side and laterally tilting the operating table to a more horizontal position. Laryngeal release is now used only where the lesion reaches up to midtrachea, since it has not been found to provide increased mobility for reconstruction of the lower trachea or carina (see Chapter 29, "Carinal Reconstruction").

Left posterolateral thoracotomy may be used for treating a tumor that involves the carina as well as the left main bronchus to such extent that the left lung cannot be salvaged. It is quite possible to perform left pneumonectomy, excise the carina (see Chapter 29,"Carinal Reconstruction"), and perform end-to-end anastomosis between the trachea and the right main bronchus beneath the aortic arch from the left side. Tracheal excision must be very limited when this approach is used. Swinging the arch of the aorta forward from the left after dividing four upper intercostal arteries, as described by Bjork,7 does not provide good access for tracheal procedures.8

If tumor at the carina involves any significant length of trachea, and also enough of the left main bronchus, to force consideration of a left pneumonectomy as well as tracheal and carinal resection, then the

Carina Reconstruction

figure 23-7 Transthoracic approach provides excellent access to the lower trachea and carina, including the left main bronchus. The posterior cutaneous incision lies midway between the vertebral spine and posterior scapular border. The incision curves beneath the scapular tip, is directed transversely forward, and then curves inferiorly in its anterior portion, in order to overlie the anterior portion of the fourth and fifth ribs; hence, the "Lazy S" configuration of the incision. Individuals vary, but resection of the fourth rib is usually optimal (anterior arrow). For airway dissection of any complexity, a posterolateral thoracotomy has been found to be more advantageous than a limited thoracotomy.

Submammary Sternotomy

figure 23-8 Bilateral thoracotomy incision. The skin incision (solid line) is submammary. The thorax is entered via the fourth interspaces with transverse sternotomy (dashed line). For initial exploration, the skin incision may be limited and only one hemithorax opened, adding transverse sternal division to widen the initial thoracotomy exposure. Pectoralis muscles are elevated with the skin flap to expose intercostal muscles.

incision providing the best exposure is a bilateral thoracotomy extending through the fourth interspace from one posterior axillary line to the other across the sternum, accomplished through a submammary incision (see Figure 23-8). In some cases where the feasibility of resection must be determined operatively, the right-sided portion of the incision is made initially, with transverse division of the sternum, but without opening the left pleura. This provides excellent exposure. The incision is completed when resectability is assured. The use of epidural analgesia postoperatively has minimized the significant impact of bilateral thoracotomy on respiration. Caution is still recommended. Bilateral thoracotomy was earlier used for cardiac surgery. We modified it for the purposes described. It was later applied to double lung transplantation.

An alternative approach to carinal resection with accompanying left pneumonectomy is median sternotomy (with right pleurotomy) plus a left-sided "T" (see Figure 23-3C). Earlier solutions to this problem included staged right and left thoracotomies, still occasionally useful in unusual circumstances. Perelman performed a right thoracotomy for excision of the carina and anastomosis, leaving the left lung in situ, with the bronchus closed.6 It became necessary to ligate the left pulmonary artery to avoid symptomatic shunting. The bronchial arteries nourished the remaining defunctioned left lung. This approach is no longer used.

Approach to cervicomediastinal exenteration of the larynx, trachea, and esophagus is described in Chapter 34, "Cervicomediastinal Exenteration and Mediastinal Tracheostomy."

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