Techniques for carinal resection and reconstruction are described below, in order of increasing complexity.1,5-8
Lesion Confined to the Carina. Restitution of the carina by suturing the right and left main bronchi together and approximating these to the end of the trachea is an attractive concept, but is frequently impossible without tension (Figures 29-1A-D). The reason is that once the right and left main bronchi are sutured together, the left bronchus is held by the halter of the aortic arch, and most of the length for reapproximation must come from devolution of the trachea to the newly formed bifurcation. This length is obviously limited since most of the mobility is obtained by flexion of the neck. This type of reconstruction is, therefore, safely possible only for a small tumor or lesion located precisely at the carina. As previously noted, laryngeal release does not translate to relaxation at the carina (see Chapter 28, "Reconstruction of the Lower Trachea [Transthoracic] and Procedures for Extended Resection").
Lateral traction sutures are placed in the midlateral line of the trachea on either side and in the mid-lateral lines of the right and left main bronchi. The medial walls of the right and left main bronchi are sutured together with a series of interrupted 4-0 Vicryl sutures, placed so that the knots are tied outside of the lumen (see Figures 29-1B,C). Anastomosis of the trachea to the new bronchial bifurcation is done in
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