The operative technique for bronchial and arterial sleeve resection is detailed in Chapter 30, "Main and Lobar Bronchoplasty." The standard approach is through a posterolateral thoracotomy. A lateral thoracotomy through a vertical incision along the anterior border of the latissimus dorsi muscle is the author's preference. The chest is explored and nodal sampling performed in lung cancer or carcinoid tumor to assess the extent of metastasis. If sleeve lobectomy is planned in a patient who would tolerate a pneumonectomy, a high level of confidence should exist about the absence of metastatic nodal disease. Such confidence requires sampling and intraoperative frozen section of abnormal and representative lymph nodes from the fissure and along the bronchus of the lobe to be preserved. To this point, the thoracic procedure is identical to a standard lobectomy.
The bronchus is isolated and divided. In tumors, this occurs with a single sharp incision through normal tissue. For tuberculous bronchostenosis, Kato and colleagues recommend transection close to or at the stenotic segment, with additional resection after examination of the bronchial lumen from the inside.23 Kato and colleagues state that the affected bronchus should have no residual malacia and emphasizes that "excessive tension at the anastomosis caused by extensive resection would do more harm than would a slight remaining stenosis." In neoplastic disease, frozen section analysis is obtained by sending a thin ring of tissue from the two ends of airway to be anastomosed. No attempt is made to tailor either end of the bronchus. Figure 16-2 describes the extent of pulmonary arterial resection in 14 patients reported by Ricci and colleagues.31
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