Clinical experience with carinal resection

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Presentation transcript:

Clinical experience with carinal resection John D. Mitchell, MD, Douglas J. Mathisen, MD, Cameron D. Wright, MD, John C. Wain, MD, Dean M. Donahue, MD, Ashby C. Moncure, MD, Hermes C. Grillo, MD The Journal of Thoracic and Cardiovascular Surgery Volume 117, Issue 1, Pages 39-53 (January 1999) DOI: 10.1016/S0022-5223(99)70468-X Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 1 Technique of end-to-end anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 2 Technique of end-to-side anastomosis. Note that the created opening is entirely in cartilaginous wall, to provide rigidity to the anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 3 Resection with formation of a “neocarina.” This technique is applicable for small, centrally placed tumors where only a limited resection is required. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 4 Carinal reconstruction with a moderate amount of airway resected. In these cases, the trachea may be anastomosed end to end with either the right or left mainstem bronchus, with the contralateral bronchus reimplanted into the side of the trachea. The diagram at the upper right shows the more commonly used technique. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 5 Carinal reconstruction with an extensive amount of airway resected. In these cases, the right mainstem bronchus is preferentially brought cephalad to the trachea for end-to-end anastomosis, with the left bronchus reimplanted into the bronchus intermedius (upper right diagram). This reconstruction is greatly facilitated by a right hilar release. The reverse procedure (lower right diagram) is rarely performed due to the immobility of the left main bronchus. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 6 Carinal resection plus resection of the right upper lobe. After end-to-end anastomosis between the trachea and left mainstem bronchus, the bronchus intermedius is reimplanted into either the trachea (upper right diagram) or left mainstem (lower right diagram). Although this method was used more frequently in this series, significant morbidity has been noted with the trachea–bronchus intermedius anastomosis, presumably because of latent tension on the anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 7 Carinal (sleeve) pneumonectomy. The trachea and contralateral (in this case, left) bronchus are brought together in an end-to-end anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 8 Resection of the carina after pneumonectomy. These procedures are usually completed through a right thoracotomy approach, regardless of the side of previous pneumonectomy. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 9 The various types of carinal reconstruction. The numbers in the circles represent the number of cases with each reconstruction. A-C, Carinal resection without concomitant pulmonary resection. D-F, Carinal plus lobar resection. G, Right carinal pneumonectomy. H, Left carinal pneumonectomy. I-J, Carinal resection after previous pneumonectomy. K, Carinal resection and reconstruction with left lung exclusion. L-M, Partial carinal resection and reconstruction. The Journal of Thoracic and Cardiovascular Surgery 1999 117, 39-53DOI: (10.1016/S0022-5223(99)70468-X) Copyright © 1999 Mosby, Inc. Terms and Conditions