Step 1
Surgical Anatomy
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Tracheal blood supply is segmental, requiring minimal circumferential dissection to reduce the risk of anastomotic strictures and dehiscence ( Fig. 7-1 ).
Figure 7-1
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Detailed understanding of the surrounding vital structures is imperative for safe carinal resections ( Fig. 7-2 ). The superior vena cava, vagus nerve, azygos vein, esophagus, and innominate artery are all adjacent to the trachea on the right. On the left, the recurrent laryngeal nerve and aortic arch are the two main structures within the dissection field.
Figure 7-2
Step 2
Preoperative Considerations
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The pulmonary and cardiac fitness of the patient must be determined. Complete pulmonary function tests, and possibly ventilation and perfusion scans, are necessary to determine whether the patient will tolerate the procedure and potential pulmonary parenchymal resection. It is prudent to obtain cardiac imaging (echocardiography, sestamibi and thallium stress tests, technetium-99m sestamibi [MIBI] scans, or stress echocardiography) for the older patient who may have co-morbid conditions.
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Computed tomography scan of the chest (with three-dimensional reconstruction if available) is obtained to delineate the extent of disease and help determine the type of resection required (carinal with or without pulmonary resection), the length of tracheal resection, and adjacent structures that might be involved.
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Positron emission tomography imaging should be used to determine whether extrathoracic disease is present, which would preclude the patient from being a surgical candidate.
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Epidural anesthesia for intraoperative and postoperative pain management may reduce postoperative pulmonary complications.
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The approach to the intraoperative management of the airway should be discussed between the anesthesiologist and the surgeon.
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Most carinal resections are best approached via a right posterolateral thoracotomy. A left posterolateral thoracotomy facilitates left pulmonary parenchymal resections. With disease that crosses the midline, a clamshell incision (bilateral anterior thoracotomies with transverse sternotomy) may be useful. Limited carinal resections can be performed via a median sternotomy.
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Bronchoscopy must be performed before resection to confirm location and extent of tumor.
Step 3
Operative Steps
1
Incision
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Depending on the type of resection required, the patient may be in left lateral decubitus, right lateral decubitus, or supine position.
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A standard right posterolateral thoracotomy is performed, sparing the serratus anterior. Entry through the fourth interspace allows for exposure of the distal trachea and carina. Care should be taken to preserve the intercostal muscle to use as a muscle flap to protect the anastomosis.
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A clamshell incision, through either the third or fourth interspace, allows for the best exposure when performing a left carinal pneumonectomy. The incision should follow the inframammary folds and peak at the level of fourth interspace across the sternum.
2
Airway Management
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Single-lumen endotracheal intubation is performed using a full length endotracheal tube (ET), which is advanced into the left mainstem bronchus to isolate the right lung, if possible.
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Implement cross-field ventilation using sterile anesthesia tubing and a small-caliber re-reinforced ET (e.g., 6 French armored tube) into the left mainstem bronchus after transection and retraction of the ET tube.
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Complete resection of the carinal mass is undertaken. Anastomotic sutures are placed, moving the cross-field tube as necessary for exposure. Once complete, the ET tube is advanced back into the left mainstem bronchus.
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Alternatively, this may be accomplished with jet ventilation, using a small 8 French suction catheter for cross-field ventilation or advancing it through the retracted ET tube. The entire resection and anastomosis can be completed with minimal difficulty because the size of the jet ventilation catheter rarely interferes with your exposure ( Fig. 7-3 ). Once complete, the ET tube is advanced below the anastomosis.
Figure 7-3
3
Simple Carinal Resection
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Tumor must involve less than a 1-cm section of the trachea, right mainstem bronchus, and left mainstem bronchus.
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Minimal lateral dissection of the trachea is undertaken. The azygos vein is transected, the pleura incised, and the anterior pretracheal fascial plane dissected to mobilize the proximal trachea. The lung is retracted anteriorly for exposure ( Fig. 7-4 ). The subcarinal lymph nodes are excised. Circumferential dissection is required only at the level of the carina, with special care taken to identify and preserve the left recurrent laryngeal nerve. After lateral traction sutures are placed, the left mainstem bronchus distal to the lesion is transected. Margins should be assessed by frozen section.
