Ann Thorac Surg 2000;70:987-989
© 2000 The Society of Thoracic Surgeons
How to do it
Wedge carinal resection for closure of the main bronchus after pneumonectomy
Hossein Fahimi, MDa,
Filip Casselman, MDa,
Massimo A. Mariani, MD, PhDa,
Wim Jan van Boven, MDa,
Henry van Swieten, MD, PhDa
a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
Address reprint requests to Dr van Swieten, Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
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Abstract
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Closure of the bronchial stump after pneumonectomy can be challenging. Some special situations such as tumor extension, technical pitfalls, or poor tissue quality of the bronchial stump may preclude safe closure of the airway with standard techniques. We describe here a technique of wedge carinal resection that provides the surgeon an alternative whenever the standard closure of the stump is inapplicable. This technique has been successfully used in a series of 4 patients.
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Introduction
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Closure of the bronchial stump after pneumonectomy can be technically challenging. Some special situations such as proximal tumor extension into the carina, technical pitfalls, or poor tissue quality of the bronchial stump may preclude safe closure of the airway. These special situations may render standard closure techniques [1, 2] inapplicable. The alternative techniques of tracheal resection and reconstruction have been proposed [3, 4] to address some of these technical problems.
We describe here a technique for closure of the bronchial stump after pneumonectomy, the wedge carinal resection. The proposed technique provides the surgeon a reliable alternative and helps to prevent bronchopleural fistula whenever the standard bronchial closure is inapplicable or is not advisable. This technique has been successfully used in a series of 4 patients in our department during 1999.
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Technique
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After completion of the pneumonectomy, the bronchial stump is exposed. Whenever the bronchial stump is too short, is invaded by the tumor, or otherwise damaged in such a way that a safe closure cannot be accomplished, the following steps are taken. A conical shaped piece ("wedge") of approximately 2 x 1.5 cm of the carina is resected (Fig 1), leaving as much tissue as possible at the posterior side of the airway, the pars membranacea. If needed, the position of the double lumen tube can be adjusted at this point. Thereafter, the main bronchus of the opposite side is easily approximated to the trachea by a slight rotational movement (Fig 2). The anastomosis of the airway begins at the posterior side, suturing the redundant pars membranacea to itself with a double-armed 5 to 0 polypropylene suture. The two needles are passed inside out, leaving the knot outside the airway, posterior to the trachea. The anterior aspect of the anastomosis is then completed using interrupted 3-0 polyglyactin sutures (Fig 3). By approximating the cartilaginous resection edges, one can evaluate the excess membranous wall and can include it in the suture. To improve exposure (especially on the left side, which is slightly more difficult), the first interrupted suture is placed in the apex of the wedge and pulled toward the surgeon by the assistant. The sutures are placed when the patient is ventilated. When oxygen saturation is adequate, the ventilation is interrupted and the tube pulled back. The surgeon then ties the sutures, which takes a couple of minutes. The tube remains proximal to the anstomosis and the ventilation is restarted once the anastomosis is complete. In our patients we did not use intermittent ventilation or high-frequency ventilation. We also did not use any traction sutures to secure the anastomosis.
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Fig 1. Drawing showing the tumor localization in the right main bronchus (patients 2 and 3). The dotted line indicates the cutting edges of the wedge resection. The resection is made on the anterior aspect of the airway, involving the rings of the pars cartilaginea. The posterior part of the airway (pars membranacea) remains largely intact.
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Fig 2. The wedge resection of the carina is performed. The arrows indicate the rotation needed to approximate the two edges of the airway. The pars membranacea is shown intact. The angle of the trachea at the end of the wedge resection (apex of the triangle) also remains intact, avoiding subsequent traction on the anastomosis.
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Fig 3. Final aspect after anastomosis, showing the interrupted sutures placed in the part cartilaginea of the reconstructed airway.
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Patients and results
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From January to December 1999, 4 patients were operated on using the wedge carinal resection (Table 1). In one patient (patient 1), the pars membranacea of the bronchial stump was damaged during standard closure of the stump, leaving insufficient tissue to accomplish a safe closure. In the other 3 patients the indication for wedge resection of the carina was proximal tumor invasion. A sleeve lobectomy was not considerd for patient 2 because of distal extension of the tumor toward the left lower lobe bronchus.
In all patients, the intraoperative bronchoscopy revealed a widely patent lumen after completion of the anastomosis. No twisting or "kinking" of the lumen was observed. The anastomosis was checked under water before the end of the procedure and was completely air-sealed. Postoperatively, no bronchopleural fistula occurred.
ne patient (patient 1) died 30 days postoperatively due to overwhelming pneumonia with subsequent septic shock. However, a bronchoscopy performed 1 day before his death revealed a widely patent anastomosis without any fistula. The other 3 patients (patients 2 to 4) were discharged after an uneventful postoperative course, and are alive and doing well up to the present. There was no local recurrence during the follow-up period.
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Comment
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To our knowledge, the wedge carinal resection with rotational approximation has not been described yet. This technique can, in some cases, avoid the need of an extended tracheal resection such as a sleeve resection, which obviously is technically more demanding. If necessary a complete sleeve pneumonectoy may be preferred, to provide an increased margin of resection. The wedge carinal resection allows one to preserve the continuity of the pars membranacea and the angle of the trachea (Fig 2). This reduces traction on the suture line and respects the continuity of the vascularization of the trachea, thereby increasing the chance of prompt airway healing. In our series, we did not encounter anastomotic problems or bronchopleural fistulas.
In conclusion, the wedge carinal resection with rotational approximation is easy and enables the surgeon to accomplish a secure bronchial stump closure on both sides, whenever either the characteristics of the tissue or the shortness of the stump may seriously endanger a safe airway closure. Because of the small number of patients reported, it is hard to make any conclusions about the mortality and long-term results of this technique.
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Acknowledgments
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We thank Carlo Savini, MD, for the illustrations.
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References
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Wright C.D., Wain J.C., Mathisen D.J., Grillo H.C. Postpneumonectomy bronchopleural fistula after sutured bronchial closure. J Thorac Cardiovasc Surg 1996;112:1367-1371.[Abstract/Free Full Text]
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Bloom N.D. Trachea. In: Beattie E.J., Bloom N.D., Harvey J.C., eds. Thoracic surgical oncology, 1st ed. New York: Churchill Livingstone–Year Book, 1992:273-281.
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Pinsonneault C., Fortier J., Donati F. Tracheal resection and resconstruction. Can J Anaesth 1999;46:439-455.[Medline]
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Mitchell J.D., Mathisen D.J., Wright C.D., et al. Clinical experience with carinal resection. J Thorac Cardiovasc Surg 1999;117:39-52.[Abstract/Free Full Text]
Accepted for publication April 5, 2000.
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