Various ventilation techniques during carinal resection have been described including sterile cross-field ventilation [8, 11], high-frequency jet ventilation (HFJV) [9, 10, 14], and apneic hyperoxygenation [12]. Because most reports of carinal resection come from single institutions, comparative studies have not been conducted. There may be an increased rate of acute respiratory distress syndrome (ARDS) with HFJV [9] although this observation has not been supported by other groups [10]. Planned cardiopulmonary bypass (CPB) is not routinely required and emergency use of CPB is uncommon [11]. There may be a decreased incidence of barotrauma-related ARDS with apneic hyperoxygenation [12].

For anatomic reasons, right-sided carinal resections are more common than left-sided procedures [7, 11]. Whereas right-sided carinal resection is approached preferably via right posterolateral thoracotomy, the much less common left-sided carinal resection may be approached via left thoracotomy or bilateral anterior thoracotomy [7]. Median sternotomy [11, 12] affords access to carinal resection alone and to resections combined with right or left parenchymal resections.

In order to achieve a tension-free anastomosis, the majority of authors limit tracheobronchial resection to 4 cm [7, 11, 15]. This distance refers to the maximal resectable airway length that still allows acceptable tension between trachea and left main bronchus. Hilar release of the left main stem bronchus by pericardial circumcision of the pulmonary veins is useful to reduce anastomotic tension but laryngeal release does not transfer additional tracheal length to the carina [11]. The use of a guardian stitch (a stitch between the chin and anterior chest wall to prevent neck extension postoperatively) varies among institutions. Anastomotic complications increase with each additional anastomosis; end-to-side reimplantation of a main or intermedius bronchus has a greater incidence of leak and separation. Variation in postoperative morbidity and mortality by length of trachea resected is not described in these series. At least 13 configurations for reconstructing the carina have been described [7] and the choice of anastomosis is dictated by the anatomy of the individual resection.

Resection and reconstruction of various other mediastinal structures including the pulmonary artery, left atrium and superior vena cava were included in several series [11, 14, 15]. Evidence for increased mortality with more extensive resections is not presented but may be assumed if vascular anastomoses are added. Involvement of these structures by the primary tumor is not a contraindication to carinal resection.

The most frequent causes of early postoperative death in these series were anastomotic complication and respiratory failure due to ARDS. The mortality of anastomotic dehiscence or ARDS approach or exceed 50 % [11, 13]. A higher incidence of anastomotic complications appears to correlate with operative mortality (Table 45.2). Greater anastomotic complexity must therefore be balanced with the aim to preserve lung parenchyma. In the majority of published cases a viable tissue wrap (usually pericardium or intercostal muscle) is used to protect the anastomosis [7, 14, 15]. Comparative rates of anastomotic dehiscence or stenosis with or without a wrap are not described.