INDICATIONS/CONTRAINDICATIONS

Left carinal resections are quite rare, likely due to the long length of the left main bronchus (LMB), thus eliminating lung cancers that extend toward the carina from requiring carinal resection like those on the right often do. Rare tumors that involve a long length of LMB and the distal trachea are the most common cancers that require left carinal pneumonectomy. Very rarely a local recurrence involves the LMB stump after left pneumonectomy and is resectable. The preoperative evaluation should eliminate those with metastatic disease or extensive mediastinal invasion. Most important in those with lung cancer is to not operate on patients with N2 disease since the outcome of resection of T4N2 lung cancers are so poor. Since the left lung is removed usually the patient should be able to tolerate that physiologically.

PREOPERATIVE PLANNING

Careful assessment of the preoperative imaging is performed to decide upon an approach for the individual patient. A left carinal resection can be performed via a left thoracotomy or a median sternotomy. A thoracotomy approach is favored if the lung resection is going to be difficult due to adhesions or tumor involvement of other structures that also need to be resected. If any significant amount of trachea is involved then it is usually easier to operate from the front. Patients with a very deep chest (from an anterior–posterior perspective) are harder to approach from the front. Operating from a sternotomy allows ready access for cannulation if cardiopulmonary bypass is under consideration (though it is rarely needed). In general I prefer the median sternotomy approach. Patients are carefully padded, sequential compression devices are placed on the legs and antibiotics are administered. Bronchoscopy is always performed to delineate the extent of the tumor and confirm the plan for resection based upon the imaging.

SURGERY

Median Sternotomy Approach

A long wire-reinforced single-lumen endotracheal tube is placed with the aid of bronchoscopy in the right main bronchus. A median sternotomy is performed and the aorta is separated from the pulmonary artery. The left pleura is opened and the chest explored to confirm absence of metastatic disease. The posterior pericardium is opened under the aorta and the distal trachea, right and left main bronchi dissected out (Fig. 46.1). The left pulmonary artery is dissected out along its course and the left recurrent laryngeal nerve carefully preserved. The left pulmonary artery is divided followed by the two pulmonary veins. The view of the airway is enhanced if a sling is paced around the aorta for careful retraction. The endotracheal tube is pulled back into the trachea and the trachea and proximal right main bronchus divided. A short sterile endotracheal tube is used to intermittently ventilate the right lung as needed. Alternatively a small catheter can be used for jet ventilation. The specimen is freed up from under the aortic arch and removed. The anterior aspect of the airway over the trachea and right main bronchus is bluntly dissected free in the pretracheal plane to enhance mobility. 2-0 Vicryl lateral stay sutures are placed about two rings deep at 3 and 9 o’clock in the trachea and right main bronchus. Then circumferential 4-0 Vicryl sutures are placed about 4 mm apart and 4 mm deep with the knots to be tied on the outside. Each suture is clipped to the drapes in successive fashion so as to organize this sizable number of sutures. When all sutures are placed the short endotracheal tube is removed from the right main bronchus and the long endotracheal tube re-advanced into the proximal right main bronchus. The chin is flexed by the anesthesiologist and the lateral 2-0 stay sutures are tied. The 4-0 sutures are then tied starting first on the anterior aspect where there is strong cartilage followed last by the membranous wall sutures (Fig. 46.2

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