INDICATIONS

There are several reasons as to why LLL sleeve resections are rarely done when compared to sleeve resections involving other lobes (Table 38.1). The first and most obvious reason is that lung cancers located in the LLL are overall less common than those located in other lobes. Secondly, some surgeons feel that left-sided sleeve resections are technically more difficult than those on the right because there is no bronchus intermedius on the left side. A third argument is that patients with LLL tumors and N1 disease will often have metastatic nodes in the nodal sump area (along the lower border of the LUL bronchus) and that in such cases, sleeve resection may be oncologically less adequate an operation than pneumonectomy. A fourth reason is that left pneumonectomy is well tolerated and, indeed, the operative mortality associated with left pneumonectomy may not be much higher than that observed after lobectomy. The final argument is that some surgeons think, whether it is real or hypothetical, that the left superior pulmonary vein may become kinked during bronchial reconstruction, thus impairing venous return from the LUL.

Although every one of those arguments has some merit, we think that LLL sleeve resection is as valid an operation as that of other types of bronchoplasties when complete resection can be achieved. We also think that left-sided sleeve resections are not more technically difficult than those on the right side and, indeed, they are often easier. Kinking of the superior pulmonary vein is a potential complication, which is more hypothetical than real.

SURGERY

As for tumors located in other lobes, the possibility and feasibility of LLL sleeve resection is usually determined during diagnostic bronchoscopy where the tumor is seen as being located at the origin of the LLL bronchus often extending proximally toward the bifurcation between upper and lower lobes (Fig. 38.1). In such cases, it is generally clear that standard lobectomy will not be able to achieve an R₀ status.

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