Figure 45.1 A: Tumor involving right upper lobe, mainstem and distal trachea allows point of transection. B: Reimplantation into side of trachea. Arrow trachea to left mainstem anastomosis. C: Reimplantation into side of left mainstem. Arrow trachea to left mainstem anastomosis.

Patient Selection

Given the substantial perioperative risk, careful patient selection is of utmost importance. Our routine preoperative workup includes complete staging by PET scan, and brain MRI. We consider nodal disease of more than two N2 stations to be a contraindication for surgical resection, unless the patient is young and otherwise healthy. We perform a direct examination of the tracheobronchial tree via rigid bronchoscopy to assess the precise extent of disease into distal trachea, carina, and right mainstem bronchus before proceeding with surgical resection. In terms of lung function, ideally even marginal patients have to be able to at least theoretically tolerate a right pneumonectomy. However, carinal right upper lobectomy is possible and probably indicated for patients who can tolerate only a right upper lobectomy. Quantitative VQ scan is therefore, an important part of our preoperative workup.

SURGERY

We perform bronchoscopy in every patient at the time of planned resection to confirm tumor extent and location in relation to distal trachea, carina, mainstem bronchi, and bronchus intermedius. We then place the patient in supine position with hyperextension of the neck. We perform a standard mediastinoscopy in all patients to assess mediastinal lymph nodes, and to free the pretracheal plane extending to carina and left and right mainstem bronchus. This step provides us with additional mobility of trachea and left mainstem bronchus necessary to allow reconstruction under minimal tension. After completion of mediastinoscopy, a long cuffed single-lumen tube is advanced into the left mainstem bronchus under bronchoscopic guidance. The cuff is inflated and the right lung is isolated. The patient is then positioned in left lateral decubitus position, and prepped and draped for standard posterolateral thoracotomy. In these challenging cases, we routinely remove the fifth rib to maximize exposure. We divide the inferior pulmonary ligament and free the entire lung from any adhesions. We subsequently perform a complete hilar release to maximize mobility of the right middle and lower lobe (Fig. 45.2). After careful examination of vascular and airway anatomy, we divide the azygos vein, and dissect the trachea at this level circumferentially. We pay attention to stay close to the trachea to avoid injury of the left recurrent laryngeal nerve. It is most at risk in encircling the distal trachea. To determine the optimal level of division it helps to pull the endotracheal tube back into the trachea, transilluminate using a flexible bronchoscope, and use a TB needle to mark the precise location and proximal extent of the tumor. At this stage, we then mark the proximal and distal tumor extent by placing superficial 4-0 silk sutures on the outside of the airway. Before proceeding with a right upper lobectomy in usual fashion, we perform a full hilar release (Fig. 45.2). We release the inferior pulmonary ligament dissecting the pleura anteriorly and posteriorly. We also circumferentially incise the pericardium around the pulmonary veins. These maneuvers maximize mobility of the right middle and lower lobe, and help to minimize tension in the reconstruction that follows. Care must be taken not to interfere with the blood/lymphatic supply of the right bronchus intermedius. We try to preserve a pedicle posteriorly along the bronchus intermedius and divide the pericardium inside this pedicle. In preparation for cross-field ventilation, we place a single long wire armed cuffed endotracheal tube into the field and pass ventilator tubing to the anesthesiologist. After division of pulmonary arterial branches, and the upper lobe vein, we divide the bronchus intermedius using a scalpel blade at the level of the distal marking suture. We then divide the distal trachea proximal to the tumor and the left mainstem bronchus just distal to the carina. After en bloc removal of the now completely dissected right upper lobe, we directly intubate the left mainstem bronchus and initiate cross-field ventilation of the left lung (Fig. 45.3). We dissect 1-mm margins of the distal trachea, left mainstem bronchus, and bronchus intermedius to confirm negative margins using frozen sectioning. 2-0 Vicryl traction sutures are then placed on both sides just anterior to the cartilagino-membranous junction in the distal trachea, and left mainstem bronchus (Fig. 45.4). We perform the first anastomosis between left mainstem bronchus and trachea using interrupted 4-0 Vicryl sutures with knots on the outside (Fig. 45.5

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