Median sternotomy as an approach to the mainstem bronchi is mainly indicated in the surgical treatment of bronchopleural fistula after pneumonectomy.^3,5,14 It will allow the surgeon to work in tissue planes undisturbed by previous surgery. Other indications include mainstem bronchial tumors, requiring only sleeve resection of the bronchus. In patients with more extensive resection of the carina, the disadvantage of not being able to mobilize particularly the left main bronchus precludes this approach. However, on the right side, pericardial release and full mobilization of the hilum can be accomplished safely. Rare indications include patients requiring complex completion pneumonectomy where, as a first step, transsternal ligation of the main vessels and bronchial closure will permit safe removal of the remaining lung through a (second) lateral incision. Although the main carina can be approached though the left as well as through the right chest, the advantage of full access to mediastinal lymph nodes¹³ as well as less incisional discomfort favor this technique particularly in tumors on the left side.^6,7 Also, carinal resection without sacrifice of pulmonary parenchyma is preferably done via median sternotomy.^4,11

Median sternotomy will allow preparation of the major omentum by slightly extending the incision into the abdomen. The omentum, brought up into the chest via the pericardial sac, can easily reach the main carina and plays a major role in supportive surgical techniques to promote healing of bronchial suture lines.

Median sternotomy as an access to the pulmonary hilum was first described by Padhi and Lynn,⁸ who at the same time reported the anterolateral approach. Abruzzini¹ described the transsternal route to the main bronchi without opening the peri- cardium, while Perelman¹⁰ subsequently popularized the technique, incorporating Bogush’s advice to go through the pericardium. Recently, Azorin and coworkers² reported a video-assisted surgical closure of a postpneumonectomy bronchopleural fistula, approaching the main carina as in cervical mediastinoscopy. Adequate length of the stump seems to be an essential prerequisite for this approach.¹⁶

In this chapter, the management of persistent mainstem bronchopleural fistula after pneumonectomy using this approach is described. For more conservative strategies, see reports by Pairolero and coworkers⁹ and Puskas and colleagues.¹²