With Pulmonary Resection

No resection of pulmonary tissue accompanies the three techniques described above. The following sections describe either concurrent or prior removal of lung tissue in addition to resection and reconstruction of the carina.

Carinal Resection with Right Upper Lobectomy. Tracheal or carinal tumors or fibrotic processes easily extend down the short right main bronchus sufficiently far to involve the right upper lobe bronchus. This may necessitate removal of the upper lobe in addition to the carina. Bronchogenic carcinoma in this location may also involve the main bronchus and carina (see Chapter 8, "Secondary Tracheal Neoplasms"). If carinal pneumonectomy is not elected, or is functionally impossible, the carina, right main bronchus, and right upper lobe may be removed, sometimes with the middle lobe as well (Figure 29-4A). The middle and lower lobes or the lower lobe alone may be salvaged and reimplanted into the bronchial tree, usually into the left main bronchus (Figure 29-4B). Elevation of the bronchus intermedius, and even more so of the right lower lobe bronchus, to the side of the trachea very often creates excessive tension, risking separation or stenosis. This will occur despite intrapericardial mobilization (which should always be done), because of the absent span of the right main bronchus. Furthermore, since reconstruction requires end-to-end anastomosis of the trachea to the left main bronchus, the excision must not leave a gap greater than 4 cm between the trachea and the left main bronchus, or excessive tension on this anastomosis will result.

Dissection is commenced as previously described. The pulmonary artery and superior pulmonary vein are dissected in anticipation of the lobectomy or lobectomies required and also to determine that there is no tumor involvement, either of the arteries or of adjacent lymph nodes, which would make it unwise or impossible to attempt a conservative lung sparing procedure. Hilar dissection is completed anteriorly and posteriorly, tapes are placed around the trachea above the lesion and around the left main bronchus, and the bronchus intermedius is cleared appropriately. The requisite branches of the pulmonary vein and artery to the upper lobe or upper and middle lobes are doubly ligated and divided. If the middle lobe is also to be removed, the middle lobe bronchus is divided and closed with 4-0 Vicryl sutures. Care is taken not to strip the bronchus intermedius of its overlying vasculature and connective tissue. The bronchus intermedius is divided below the upper lobe bronchus. If the tumor extends to the middle lobe bronchus, it is usually not possible to salvage the lower lobe, since the superior segmental orifice lies opposite the middle lobe bronchus. Rarely, oblique bronchial resection can be done, but this presents potentially greater difficulties for anastomosis.

In cases of lobar reimplantation after carinal resection, the hilum must be mobilized intrapericar-dially to obtain enough length to reattach the lower lobe with minimal tension. It is usually easier to divide the left main bronchus first, after placement of lateral traction sutures, and institute cross-field intubation and ventilation of the left lung. This allows the right lung to collapse, facilitating completion of dissection. After excision of the specimen, which includes the upper lobe (or lobes) and the carina in continuity, end-to-end anastomosis is performed between the trachea and the left main bronchus. Anastomotic integrity is checked under saline. The bronchus intermedius or lower lobe bronchus is drawn upward with its 3-0 traction sutures to determine whether it can be implanted into the side of the left main bronchus without excessive tension. Initially, I implanted the bronchus intermedius or right lower lobe bronchus into the side

Trachea Ventilator

figure 29-4 Resection of the carina and right upper lobectomy or bilobectomy (right upper and middle lobes). The gap between the trachea and left main bronchus should be less than 4 cm. A, Lines of resection are indicated. If the middle lobe parenchyma is involved by contiguity, it is also resected. The middle lobe bronchus is closed, allowing salvage of the bronchus intermedius above the superior segmental bronchus. B, The trachea is anastomosed end-to-end to the left main bronchus. The bronchus intermedius is anastomosed as shown to the medial wall of the left main bronchus, with the aid of right hilar mobilization. Although the bronchus intermedius sometimes will reach the side of the trachea, danger from excessive tension makes the anastomosis shown to be preferable, even though its execution is more difficult. If an anastomosis to the left main bronchus also appears questionable, right pneumonectomy is preferable, assuming the patient can tolerate loss of the right lung.

figure 29-4 Resection of the carina and right upper lobectomy or bilobectomy (right upper and middle lobes). The gap between the trachea and left main bronchus should be less than 4 cm. A, Lines of resection are indicated. If the middle lobe parenchyma is involved by contiguity, it is also resected. The middle lobe bronchus is closed, allowing salvage of the bronchus intermedius above the superior segmental bronchus. B, The trachea is anastomosed end-to-end to the left main bronchus. The bronchus intermedius is anastomosed as shown to the medial wall of the left main bronchus, with the aid of right hilar mobilization. Although the bronchus intermedius sometimes will reach the side of the trachea, danger from excessive tension makes the anastomosis shown to be preferable, even though its execution is more difficult. If an anastomosis to the left main bronchus also appears questionable, right pneumonectomy is preferable, assuming the patient can tolerate loss of the right lung.

of the trachea. Although this succeeded in a number of patients, it also led to serious or lethal complications in too many others, due to excessive tension. These complications included obstruction of the implanted right bronchus, stenosis, separation, and hemorrhage. Anastomotic tension, in this case, is by its nature much greater than that developed by anastomosis of the right main bronchus to the trachea.

Implantation of the smaller bronchus intermedius into the relatively narrow left main bronchus, while maintaining anesthesia via an ET in the left main bronchus, can be difficult. This is another situation in which high-frequency ventilation is useful.

Tissue for the second layer is prepared and brought in beneath the anastomoses, but it is not sutured in place until after testing the anastomoses under saline.

If the patient can tolerate a pneumonectomy, it may be the safer course for many.

Carinal Resection and Right Pneumonectomy. Resection of the carina with the right lung is most frequently done for bronchogenic carcinomas involving the origin of the main bronchus or the carina.9-11

If the tumor does not extend very far up the trachea, the operation is conceptually and mechanically relatively easy to perform (Figure 29-5). While physiologically, the operation should be the equivalent of a right pneumonectomy, it has been general experience that mortality was much higher for this operation than for a simple pneumonectomy, largely due to "postpneumonectomy pulmonary edema." Its etiology remains unclear, although attention to minimizing barotrauma appears to be helpful.12

The patient is selectively intubated into the left main bronchus with an extra-long flexible-tipped ET. Mediastinoscopy should be performed prior to embarking upon such a resection to be certain that the patient is potentially curable. This is best done under the same anesthesia as that for resection. When lymph nodes are not involved and the only limitation to resection is involvement of the origin of the main bronchus or carina, these patients should really be classified as stage IIIA carcinoma of the lung rather than stage IIIB. If lymph nodes are involved, the procedure is only justified in the setting of a study protocol.

Most of the technical points have already been discussed. Resectability is determined by careful exploration of the mediastinum and examination early in the operation of the origin of the pulmonary vessels, if necessary, intrapericardially. If more than 4 cm of trachea will have to be resected, the surgeon must be wary of excessive anastomotic tension, and question the feasibility of surgery. I try to avoid radical mediastinal lymph node dissection to minimize possible injury to the blood supply of the trachea or to lymphatic drainage from the remaining lung. When it is clear that resection can be done from the vascular standpoint, the trachea is circumferentially dissected at the level of the expected division and the left main bronchus at its origin. The left main bronchus is usually divided first after placement of traction sutures, so that intubation may be carried out and ventilation continued in the left lung. Tracheal division is sometimes accomplished before mediastinal dissection has been completed. Traction on the divided bronchus and tracheal end of the specimen facilitates residual dissection. Dissection must be done carefully to avoid injury to the left recurrent

Tracheal Resection

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