The importance of parenchymal preservation during pulmonary surgery was realized over 50 years ago when descriptions of bronchial resection and reconstruction were first published.^1–3 Since then, considerable technical refinement and anatomic insight have expanded indications for lung-sparing operations. Bronchoplastic resections form one category of these procedures with a unique set of indications. These operations are technically more demanding than standard anatomic pulmonary resections, although, the additional time spent performing these procedures is justly rewarded in considerable functional lung preservation.

The terms bronchoplasty and bronchoplastic resection have been applied to a wide variety of operations of main or lobar bronchi. The operations usually involve a concomitant parenchymal resection; resection and reconstruction of the bronchus alone is quite rare. Bronchoplasty refers to resection and reconstruction of a lobar bronchial orifice (e.g., right upper lobe) without removing a segment of main bronchus. This is in contradistinction to a “sleeve” resection in which a circumferential portion (or sleeve) of a central bronchus is included as part of the operation. Because of the gaps that sleeve resections create in the target airways, release maneuvers (to reduce tension on the anastomosis) are usually necessary.

The standard indication for bronchoplastic resection is an endobronchial lesion emanating from either the main bronchus itself or a lobar bronchus with main bronchus encroachment. The extent of the diseased area must allow for safe reconstruction when margins are considered. Etiology is often a low-grade neoplasm such as typical carcinoid or mucoepidermoid cancer⁴ or, rarely, isolated bronchial stenosis secondary to granulomatous disease, trauma, caustic injury, foreign body, or benign neoplasm.^5,6 Bronchoplastic resections can be applied to more invasive cancers, that is, non–small-cell lung cancer (NSCLC) or metastases, when trying to spare lung parenchyma in a patient with marginal pulmonary function. While lung is preserved, oncologic principles, namely, achieving a complete resection (including a negative margin), must not be compromised.⁷ Positive margins are not an acceptable alternative to complete resection.

The issue of N1/N2 lymph node involvement clearly complicates the decision to proceed with a lung-sparing bronchoplastic resection versus pneumonectomy or bilobectomy. To date, there are no data to suggest that larger parenchymal resections provide a higher cure rate for stage II or stage III lung cancer. Therefore, bronchoplasty can be performed for stage II or stage III lung cancer as long as a complete resection can be obtained. In addition, data from several European studies of neoadjuvant chemotherapy and/or radiation therapy suggest that a bronchoplastic resection can be performed without additional morbidity. Of note, radiation therapy completed more than 3 months before the resection considerably increases the technical difficulty and should be considered high risk. Few definitive contraindications exist for bronchoplastic or sleeve resection techniques as long as the patient’s performance status allows. One should know in advance whether pneumonectomy is an option in case the sleeve is technically not feasible.

Bronchoscopy is universally required for operative planning. Flexible video bronchoscopy offers a slightly less morbid alternative for diagnosis and initial palliative therapy than does traditional rigid bronchoscopy, though both are acceptable methods to access and treat the central airways. For patients presenting with obstructing pneumonia, airway patency should be restored using endobronchial techniques (i.e., laser, cautery, pneumatic or rigid dilation); any infection should be effectively drained and treated before proceeding with a planned resection.

Noninvasive imaging includes chest computed tomography scan (CT) and, for NSCLC, a PET scan. To complete the staging process, mediastinoscopy should be performed for all lung cancers before attempting a sleeve. If performed at the same setting as the planned resection, mediastinoscopy can be used to mobilize the mainstem bronchi and trachea and serve as an important release strategy. If N2 lymph node involvement is found (for patients with lung cancer), the patient is usually offered induction therapy before the resection or treated definitively with chemoradiation.

Epidural analgesia is recommended to optimize pain control and pulmonary toilet. Ipsilateral lung isolation usually is obtained with a contralateral double-lumen tube and not a single-lumen tube with bronchial blocker.

All bronchoplastic procedures include reconstruction of the airway. Familiarity with parenchymal and vascular anatomy is essential. No consensus exists regarding the optimal suture type or technique one should use, and personal preference prevails with regard to these details. We favor the use of monofilament material.

Finally, my personal preference is to buttress all bronchoplasty reconstructions. Transposed tissue pedicles include thymic (epicardial) fat pad, pleura, pericardium, and occasionally, muscle flap. The most common muscle pedicle is adjacent intercostal, though some do not recommend wrapping this type of flap circumferentially for anecdotal concern of heterotopic ossification from retained periosteum. Serratus anterior can also be used as a buttress for reconstructions after induction chemoradiation therapy.

Bronchotomy Closure

The most basic bronchoplastic technique is hand-sewn closure of a bronchial stump divided close to its takeoff from the mainstem bronchus. Often, a flap of membranous airway can be turned back over the open stump and sewn in place with interrupted 4-0 monofilament suture (Fig. 75-1). This maneuver is predicated on having enough uninvolved membranous airway. As with all of these procedures, intraoperative frozen section analysis of the margins must be performed. Some short bronchial stumps can be closed by simple anteroposterior reapproximation (Fig. 75-2). The surgeon must assess the quality of the tissue and have a sense of the tension under which the bronchus is reapproximated. Closely spacing the interrupted sutures helps to distribute tension but will not compensate for a marked mismatch. Airway compliance should be assessed carefully before considering a bronchotomy closure. In older patients, calcium within the anterior bronchial rings can make simple closure of a tight bronchial stump more risky, and surprisingly, the more complex sleeve resection is often the safer operation. Conversely, in younger patients, even if a small amount of the mainstem bronchus is plicated during the closure, results are typically excellent. Only rarely should primary closure be attempted after wedge bronchotomy (Fig. 75-3). Although this type of reconstruction can be performed with minimal tension, the resulting kink in the airway can lead to obstruction postoperatively. Intraoperative bronchoscopy is an important tool to assess the geometry of the airway after reconstruction and judge the suitability of the reconstructed anatomy.

Bronchial Sleeve Resection

Most bronchial sleeve resections occur in the context of parenchymal (lobar) resection. Rarely, pathology isolated to the left mainstem bronchus or bronchus intermedius mandates an isolated resection of the airway alone.

Important factors to consider are (1) will the operation result in a complete resection, (2) can the repair be constructed tension-free, and (3) if not, what are the fallback options? To this end, the etiology of the disease becomes important. Specifically, for lung cancer, accurate staging is mandatory. Also, a history of prior chest surgery makes complete mobilization of the lung more difficult, and a previous coronary artery bypass may complicate a hilar release. A mediastinoscopy performed several weeks before will make it difficult to mobilize the carina and distal trachea for right-sided resections. Finally, can the patient tolerate a bilobectomy or pneumonectomy if the planned bronchoplastic resection cannot be completed safely or with an adequate margin?

Any lobar resection can be accompanied by a sleeve of resected bronchus. Left-sided resections are more challenging because the aortic arch and heart tend to limit exposure. Mediastinoscopy is useful not only from a cancer staging standpoint but also in mobilizing the proximal left and right mainstem bronchi and carina. The surgeon must confirm the anatomy of the airway lesion with bronchoscopy.

Right Upper Lobe Sleeve Resection

Right upper lobe sleeve resection is the most common and straightforward sleeve resection. A left-sided double-lumen tube is placed during induction of anesthesia, and the patient is positioned for a lateral thoracotomy. Muscle-sparing techniques can be used to enter the hemithorax at the fourth or fifth interspace. Some trapezius and posterior latissimus musculature may require division if the fourth interspace is entered. An intercostal muscle pedicle can be harvested for later use.