Tracheobronchial Sleeve Resection Technique

The authors’ practice is to routinely perform bronchoscopy in all patients after the successful induction of anesthesia. This allows the surgeon to verify that a sleeve resection is a viable option and to obtain visual confirmation of the patient’s specific anatomy. Once the bronchoscopy is completed, the patient is positioned and the procedure can commence.

All pulmonary sleeve resections can be broken down into a few general steps, as follows:

• Dissection and exposure
• Isolation of vascular and airway structures
• Resection
• Airway and vascular anastomosis
• Closure

Because right upper lobectomy is the prototypical sleeve resection, it will be described first and used as the general model for the other lobar sleeve resections, with any significant differences between the procedures outlined where necessary. ^[17]  Resections of lesions at various locations, along with the postresection anatomy, are illustrated in the images below.

Minimally invasive approaches to sleeve resection have been described and are the subject of increasing study; however, they are not described in detail in this article. ^{[18, 19, 20, 21, 22]}

Upon entry into the chest, a detailed and complete exploration of the chest, including the chest wall and the entire lung, is performed. This ensures that no evidence of metastatic disease exists elsewhere within the chest, which would preclude continuing with resection. Next, the hilum is addressed (see the image below), and the pulmonary artery is dissected out and isolated; a right-angle clamp should be easily placed behind the structure, and a vascular loop or cord tape is passed.

This and every other aspect of dissection in these cases must be deliberate and complete. Failure to make it so will only ensure that later steps are more difficult. If any concern exists regarding the ability to obtain good proximal control of the artery, the authors do not hesitate to open the pericardium at this point and obtain control lateral to the superior vena cava.

Attention is then directed toward the right mainstem and the right-upper-lobe (RUL) bronchus, which are similarly dissected free. At the bifurcation of the RUL bronchus and the bronchus intermedius (BI), a solitary lymph node is typically found in the “crotch” area. Running deep to this node is the superior segmental branch of the pulmonary artery. The BI should now be easily isolated, and an umbilical tape may be passed around it to isolate the structure. The RUL is now isolated, and resection can take place.

The RUL vein is ligated. The truncus branch of the pulmonary artery is ligated. The fissure is completed by firing a linear stapler along its natural course. The remaining pulmonary artery branches are ligated. The mainstem bronchus is then sharply divided just proximal to the takeoff of the RUL bronchus; in a similar fashion, the BI is then divided just distally to the RUL takeoff. Division of the bronchus must occur perpendicularly to the long axis of the airway. Failure to do so may result in a difficult bronchial anastomosis later.

Frozen-section margins are then analyzed. A positive margin at this point requires further resection, including a possible conversion to a pneumonectomy.

Reanastomosis of the bronchus (main bronchus to residual BI) is then performed. There should be no tension on the anastomosis (this is essential), and no torsion or kinking should exist. A size discrepancy is expected, and consequently, precise suture placement is crucial for  making up this difference. Sutures are placed in either an interrupted fashion or a continuous fashion depending on surgeon preference (see the image below). Travel on one side should be proportional to travel on the other; this ensures an air-tight seal with proper adjustment for size discrepancy.

The chest is then filled with saline, and the seal is checked under a Valsalva maneuver. If no leak is detected, the authors proceed with the operation. Reinforcement of the anastomosis with a flap is controversial, though some surgeons do it routinely. Note that this flap is not what produces an air-tight seal; it is placed only to help prevent anastomotic breakdown.

Next, the patient’s chest is closed. In some centers, postoperative bronchoscopy is routinely performed at this point. Most patients can then be extubated.

As noted, an RUL sleeve resection is the classically described procedure; a right-middle-lobe (RML) sleeve resection is fairly uncommon. An RML resection is similar to a RUL resection in general terms, with attention turned to the middle-lobe vasculature and airway structures. However, it should be noted that in all of the described resections, proximal control is essential; accordingly, isolation of the main pulmonary artery is performed in almost all cases.

The vascular supply to the RML is less accessible than the that to the RUL. The vein lies anterior to the bronchus, and the artery is immediately posterior. Division of the distal airway is a critical step because the superior segmental bronchus lies opposite the middle-lobe bronchus and thus is angled to preserve the takeoff of the superior segmental bronchus. Consequently, division of the proximal airway must also be slightly angled to ensure a well-matched anastomosis.

As with right-side resection, proximal control is obtained first (see the image below). Obtaining control may be more difficult because of the shorter pulmonary artery on the left side; it also is inherently more hazardous because of the early takeoff of the apical-posterior branch.

In a left-upper-lobe (LUL) resection, much as in an RUL resection, the posterior fissure is completed with a linear stapler after identification all pertinent structures. Care is taken to avoid injuring the arterial branch to the superior segment of the lower lobe, which runs in this area. The venous and arterial branches are then divided, including branches to the lingula.

Division of the bronchus occurs just proximal and distal to the takeoff of the LUL. Division of the distal aspect is potentially hazardous because the takeoff of the superior segmental bronchus occurs a short distance from the LUL takeoff, and care must be taken not to injure this structure. The anastomosis is performed as previously described.

Resection of the more proximal airway (carina and distal trachea) understandably requires a sleeve-type anastomosis in all cases. For resection of the more proximal trachea, including larynx, a different set of considerations, workup, and techniques is implemented that is outside of the scope of this article.

To begin resection of the distal trachea or carina, a bronchoscopy is performed as noted above.

Adequate exposure and dissection are, again, essential to a safe and successful operation. Here, this begins with mobilization of the left pulmonary artery and aortic arch, with careful identification and preservation of the recurrent laryngeal nerve, or with dissection of the carina and mobilization of the right pulmonary artery and bronchus. After adequate dissection and isolation of the appropriate structures, umbilical tape is again passed to help with isolation.

One must be careful not to mobilize too much of the airway, because the vascular supply is tenuous. Typically a 3- to 4-mm area is dissected away from the pretracheal space; this is where the division takes place.

Because division of the airway occurs proximal to the bifurcation, traditional single-lung ventilation is impossible. To facilitate continued ventilation, a sterile circuit is passed onto the field and prepared to ventilate a single lung directly, something that requires a high level of communication with the anesthesia team. After division of the main bronchus, direct intubated is performed and ventilation across the surgical field obtained, or the JET ventilator can be used.

The classic approach for this procedure is to anastomose the distal trachea to the left main bronchus in an end-to-end approach, in a fashion similar to that described above. After this anastomosis is completed, the orotracheal tube is carefully advanced across the anastomosis for single-lung ventilation. To include the right lung in the airway, an end-to-side anastomosis is performed, either to the distal trachea or to the left mainstem bronchus (depending on available length), in a tension-free manner. (See the image below.)

This anastomosis is completed in a similar interrupted fashion. Of note, the placement of the tracheotomy or bronchotomy should be within the cartilaginous rings so as to provide strength to the anastomosis. Both anastomoses are traditionally then wrapped with a pedicled flap before closure of the chest. Various tracheal release maneuvers can also be performed if underlying anastomotic tension is observed.