INDICATIONS/CONTRAINDICATIONS

Indications

The term “sleeve lobectomy” refers to en bloc removal of an anatomic lobe of the lung with a contiguous, circumferential section of mainstem bronchus. Thus, a right upper lobe sleeve resection refers to performance of a right upper lobectomy with the adjacent portion of the right mainstem bronchus. The section of mainstem bronchus is freed by sharp, transverse division of the more proximal right mainstem and distally the bronchus intermedius, with subsequent end-to-end reconstruction. This technique may be applied to any lobe. “Bronchial sleeve resection,” such as with resection of the bronchus intermedius, spares the parenchyma completely with isolated removal and reconstruction of the airway.

Indications for right upper lobe sleeve lobectomy include the presence of an obstructing lesion at the orifice of the right upper lobe, or within the mainstem bronchus immediately adjacent to the right upper lobe orifice, such that simple lobectomy would lead to incomplete resection of the lesion. Primary nonsmall cell lung cancer and other low-grade bronchial malignancies (e.g., carcinoid tumor, mucoepidermoid tumor) form the bulk of these lesions. Occasionally, inflammatory stenoses involving the orifice of the lobe may occur—such as a tubercular stricture or long-term irritation by an inhaled foreign body—that is best treated with sleeve lobectomy. Finally, isolated trauma to or adjacent to the orifice of the right upper lobe may require sleeve lobectomy.

Indications for isolated sleeve resection of the bronchus intermedius are similar, yet the offending tumor or stricture should be distinctly separated from the takeoff of right upper and middle lobes, allowing for complete resection and reconstruction without compromising either orifice.

Contraindications

In patients with proximal right-sided airway obstruction due to malignancy, the technique of sleeve lobectomy allows the surgeon to offer a parenchymal-sparing approach to the patient, avoiding the morbidity and decreased functional status of a pneumonectomy. However, it is imperative that

operating surgeons follow the basic tenets of surgical oncology, ensuring complete resection with negative intraoperative bronchial frozen section margins and complete lymphadenectomy.

operating surgeons recognize and avoid reconstructive situations which predispose the patient to failure at a later date.

Regarding the first point, intraoperative assessment of margins negative for invasive malignancy is essential. Further, some locally advanced tumors, either by direct extension or nodal involvement, may be best served by pneumonectomy. The second point refers to the untenable situation where the airway reconstruction—due to poor anastomotic technique, excessive tension, or other factors—is likely to fail (stenose) in the weeks and months ahead, leading significant morbidity and further high-risk interventions.

PREOPERATIVE PLANNING

The preoperative planning for a sleeve lobectomy involving the right upper lobe is similar to planning for a standard lobectomy with a few additional caveats. Again, the questions remain: Is complete resection feasible? Is safe reconstruction of the airway possible? The surgeon should carefully examine the preoperative imaging studies to assess the feasibility of sleeve lobectomy. In the setting of carcinoma, this includes the length and degree of airway involvement, assessment of vessels adjacent to the bronchus, and pattern of suspected nodal disease. Preoperative flexible bronchoscopic examination is vital before a sleeve resection, and should be performed by the surgeon planning the subsequent resection. Careful assessment of the length and pattern of airway involvement is crucial, and may require repeated bronchial biopsies to rule out submucosal extension of carcinoma and better define the proposed lines of airway resection.

For isolated lesions involving the bronchus intermedius, a similar approach applies. Special attention must be paid to potential involvement of the adjacent pulmonary artery, and whether the disease process encroaches on either the orifice of the right middle lobe or superior segment of the right lower lobe. This latter point is important, as the surgery will require a clean line of division across the distal bronchus intermedius to allow for safe and feasible reconstruction.

SURGERY

The vast majority of right upper lobe sleeve resections still involve thoracotomy, and the techniques described below will pertain to this approach. Intubation with a left-sided double-lumen tube is standard, along with preoperative placement of an epidural catheter for postoperative pain management. Patients should receive prophylactic intravenous antibiotics within 1 hour of skin incision, and the antibiotics are typically continued for 24 hours. Arterial and other monitoring lines are optional, although due to the potential length of the case a bladder catheter is recommended. Staging mediastinoscopy may be performed immediately prior to the sleeve lobectomy, depending on surgeon’s preference.

Positioning

The patient is placed in a left lateral decubitus position standard for right posterolateral thoracotomy. Because much of the exposure for the airway assessment, resection, and reconstruction is from the posterior aspect, some surgeons may find it helpful to position the patient slightly favoring a dorsal approach. Careful attention is paid to padding pressure points and other typical features of thoracotomy positioning. A standard prep and drape is utilized.

Technique

Right Upper Lobe Sleeve Resection

Right upper lobe sleeve resection proceeds in a manner similar to standard lobectomy, with division of the pulmonary vein and segmental pulmonary arterial branches. Aspects of the major and minor fissures pertaining to the right upper lobe are completed with a stapler. Nodal tissue adjacent to the right upper lobe orifice is dissected free, or swept up with the specimen. This leaves the bronchus as the sole remaining attachment point to the right upper lobe.

Tapes are placed around the right mainstem bronchus and bronchus intermedius. The surgeon should avoid excessive circumferential dissection of the airway, which may lead to relative ischemia at the anastomotic site. It is occasionally helpful to dissect free the ongoing pulmonary artery trunk adjacent to the bronchus intermedius to facilitate exposure. In a similar manner, the azygos vein may be divided as it crosses the distal trachea to better visualize the proximal right mainstem. The prospective lines of bronchial division are envisioned (Fig. 34.1). In certain cases, this decision is made easier with intraoperative bronchoscopy, using a fine gauge needle to correlate the endoscopic findings with observations noted within the operative field. It is important that the bronchus be divided perpendicular to the long axis of the airway, to facilitate subsequent reconstruction (Fig. 34.2). In the setting of malignancy, intraoperative frozen section assessment of proximal and distal airway margins is essential to rule out invasive tumor. Nodal dissection, if not completed already, should preferably be done prior to airway reconstruction.

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