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Ann Thorac Surg 1998;65:1198-1199
© 1998 The Society of Thoracic Surgeons
a Department of General Thoracic and Vascular Surgery, University of Parma, Via Gramsci, 14, 43100 Parma, Italy
e-mail: lospagg{at}tin.it
To the Editor
We read with great interest the article by Brutel de la Riviere and associates [1] about transsternal closure of bronchopleural fistula after pneumonectomy.
The technique favored for closure of a bronchopleural fistula depends mainly on the time of its presentation after operation. Immediate and early bronchopleural fistulas are better treated by reamputation of the bronchial stump followed by mattress suture or myoplasty through the previous thoracotomy. In other cases, various approaches are used, mostly depending on surgeon’s habit or preference.
The approach proposed by Abruzzini [2] in 1961 has important advantages widely reported and discussed elsewhere [3]. However, the transsternal access might result in increased surgical risk especially in debilitated and infected patients. Thus, we developed a miniinvasive Abruzzini-like technique with the aim to achieve the same results of traditional approach without its invasivity.
The patient is placed in the supine position, and general anesthesia with selective one-lung ventilation is given. The surgical technique consists of three simultaneous approaches: (1) cervical video-mediastinoscopy, (2) right anterior mediastinotomy, and (3) parasternal thoracoscopic port.
In the case of right fistula repair, the anterolateral part of the trachea toward the carina and the main bronchi are dissected using the video-mediastinoscopy as routinely performed during a diagnostic cervical mediastinoscopy. This tunnel will be used to assist the dissection through the anterior mediastinotomy and to guide the advancement of a roticulator endoscopic stapler device toward the carinal area and to reamputate the bronchial stump close to the tracheal bifurcation. A 3- to 4-cm parasternal vertical skin incision is performed on the third costal cartilage, which is isolated and then excised. Through this access, with gentle blunt dissection, the extrapleural mediastinal fat is dissected with the mediastinoscope as a guide and avoidance of entering the right pleural cavity. The pericardial reflection next to the superior vena cava is sectioned, the origin of this vessel is carefully isolated, and it is encircled with a lace. The upper border of the right main pulmonary artery then can be visualized.
To enlarge the operative field, a thoracoscopic port is placed through a 1- to 2-cm skin incision in the third left intercostal space on the parasternal line. This access permits the surgeon to introduce a 10-mm/0° videothoracoscope and endoscopic forceps to grasp the aortic adventitia and retract it toward the left hemithorax to improve the surgical vision of the carinal region. At this point the dissection is carried on through the right anterior mediastinotomy under direct view and using the headlamp and the camera for illuminating the surgical field.
To uncover the carina and to visualize the inferior margin of the fistulous right main bronchus, the right pulmonary artery stump needs to be pulled down by a retractor. The inferior and posterior wall of the right bronchial stump is then gently isolated and encircled with a tape, care being taken not to open the right pleural space during this maneuver.
The video-mediastinoscope is drawn back and a silicone chest tube is left in the cervical tunnel to facilitate the advancement of the endoscopic stapler that is inserted from the cervical incision. Once the tip of the endoscopic stapler reaches the tracheal bifurcation under direct control, its head is rotated 45° toward the carina, the anesthetist is asked to withdraw as high as possible the double-lumen tracheal tube to render the suture absolutely tension-free, and the bronchial stump is transected as proximally to the right main bronchus origin as possible. A myoplasty might be associated using the pectoral major muscle in the case of short bronchial stump or to reinforce the suture line.
For left fistula repair, the principles and the surgical accesses are identical to those for fistula on the right, but the pretracheal tissue blunt dissection is oriented mostly to the left border of trachea toward the fistulous left bronchial stump to better mobilize this structure, the aorta is mobilized to the left as much as possible, and once the lower trachea has been isolated, a single stitch is sutured on the anterior wall and the trachea is retracted toward the right hemithorax. These maneuvers ensure a sufficient space to isolate by an endoscopic dissector the origin of the left main bronchus and, as previously described, the left stump can be reamputated by an identical roticulator stapler introduced through the cervical incision.
Our technique should provide a safe approach to the tracheal bifurcation for bronchial stump reamputation after pneumonectomy with complete control of vascular mediastinal components. It represents a modified minimally invasive version of the Abruzzini technique not requiring a transsternal access, and it is performed without entering the empyema cavity. We hope other thoracic surgeons will find this video-assisted technique useful, although further clinical study is obviously mandatory to assess its efficacy in vivo for the treatment of bronchopleural fistula after pneumonectomy.
References
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