After proximal arterial control has been obtained, we continue our dissection superiorly and enter the plane of the right upper lobe bronchus (Fig. 7.2). The lung is retracted anteriorly, and we continue our dissection in the bifurcation between the right upper lobe bronchus and the bronchus intermedius. A “crotch” lymph node is a consistent finding in this location. This node is elevated away from the bifurcation to reveal the PA branch to the superior segment of the right lower lobe. Once this branch is identified, the posterior portion of the fissure is completed with a linear stapler. This approach avoids extensive parenchymal dissection in the fissure. The bronchus intermedius is encircled just distal to the right upper lobe take-off, and an umbilical tape is placed to aid in dividing the airway at the appropriate time. Up to this point, we have not made
any irreversible maneuvers. A complete inspection is carried out to ensure that all diseases including nodal disease can be removed. Once complete resectability is confirmed, we begin by ligating and dividing the PA branches to the right upper lobe. Similarly, the venous drainage is divided with a vascular stapler taking care to preserve the middle lobe venous drainage. The minor fissure is completed with a linear stapler. The main stem bronchus is encircled at its origin, and an umbilical tape is placed. Before committing to the sleeve resection, it is often productive to divide the right upper lobe bronchus at its origin to see whether the tumor can be cleared with a negative bronchial resection margin. This is especially important with carcinoid tumors, in which the endobronchial component may be attached only at one point and the lesion simply pulled out leaving a clear bronchial margin. Once the bronchus has been opened, the decision to proceed with sleeve resection may be made based on the findings either grossly or microscopically.

To begin the sleeve resection, we divide the main stem bronchus with a No. 15 blade just proximal to the right upper lobe take-off. Similarly, the bronchus intermedius is divided just distal to the right upper lobe take-off (Fig. 7.3). For upper lobe sleeve resections, these cuts must be perpendicular to the long axis of the airway and placed between cartilaginous rings so as to result in a clean cut. An angled division of the bronchus is to be avoided. The proximal and distal airway margins are cut from the specimen and the true margin inked by the surgeon. We personally take the margins to the pathologist so that proper orientation can be demonstrated prior to frozen-section examination. Once we have documentation that the resection margins are free of tumor, the reconstruction is begun. Microscopic tumor present at a bronchial margin requires additional resection of the involved area or possibly pneumonectomy.

We perform the bronchial sleeve anastomosis in an interrupted manner. The key to a successful bronchial sleeve anastomosis is a pneumostatic wellapproximated, tension-free repair that accounts for any size discrepancy between ends by precise suture placement. We do not take a “tuck” in the proximal airway to make up for a size discrepancy. Rather, we make up the size discrepancy along the entire circumference of the anastomosis by precise suture placement.

When performing an interrupted anastomosis, we use 4-0 oiled, absorbable, braided suture. The first suture is placed in an “outside-to-in” fashion at the junction of the cartilaginous and membranous bronchi. The suture is not tied but is secured to a suture guide. Additional sutures are placed at 2-mm intervals to complete the first half of the cartilaginous anastomosis (Fig. 7.4). Once the midpoint of the cartilaginous bronchus is reached, we begin tying the sutures starting at the corner. The surgeon “crosses” the next suture in the series to relieve tension while the assistant ties. The cartilaginous anastomosis is completed from the midpoint down to the opposite corner in a similar manner. The lung is retracted anteriorly to reveal the membranous portion of the bronchus. The membranous portion of the anastomosis is completed with interrupted sutures. The chest is filled with saline, and the anastomosis is tested to 20-cm water inflation pressure. Needle hole air leaks are ignored; however, air leaks between the cut edges of the bronchus, if small, are reinforced with simple interrupted sutures. A large area of leaking may require the entire anastomosis to be redone.

We wrap all anastomoses with intercostal muscle (Fig. 7.5), but occasionally we use an omental or pericardial fat
flap. Although ossification of the intercostal muscle flap can occur, it does not necessarily cause problems; in fact, the bronchus has very limited intrinsic motility and a stable caliber. If the intercostal muscle flap is loosely applied around the bronchus, even if some retraction occurs, there is no reason why the hardening caused by ossification should produce stenosis. When the sleeve resection is planned preoperatively, the intercostal pedicle flap may be prepared before the insertion of the rib retractor to avoid crushing the intercostal vascular bundle, and is prepared at full thickness, encompassing a wide pleural flap. The flap is slid backward around the bronchial anastomosis, between it and the PA. The flap is then turned until its pleural side is in contact with the bronchial anastomosis, and the pleura is secured to the bronchus by interrupted sutures.