Bronchovascular Sleeve Resection

Double sleeve (bronchovascular) lobectomy is a feasible alternative to pneumonectomy if a complete resection can be achieved in patients with centrally located non–small cell lung cancer (NSCLC) involving both the bronchus and the pulmonary artery (PA).

Traditionally, this technique has mainly been performed through a posterolateral thoracotomy, because of the high complexity of the airway anatomy and of arterial reconstruction. Technical advances and more experience gained in video-assisted thoracic surgery (VATS) over the past few decades have allowed some surgeons to achieve proficiency in performing double sleeve lobectomies by VATS.[1, 2]  The introduction of robotic-assisted technology in thoracic surgery has spurred interest in performing more complex operations, and a few cases describing double sleeve resections with a robotic approach have been reported.[3, 4, 5]

Double sleeve lobectomy is indicated for NSCLC requiring bronchial and arterial reconstruction for R0 resection, such as in the following circumstances:

• Primary tumor involving the ongoing pulmonary artery and the bronchial wall
• Bulky peribronchial and perivascular metastatic nodal disease inseparable from the ongoing pulmonary artery and bronchial wall.

 

Contraindications to double sleeve lobectomy are as follows:

• Complete resection (R0) not achievable by bronchovascular sleeve resection
• Metastatic disease to lung (ie, the lung is not the primary site)
• Recurrent lung cancer
• Small cell lung cancer
• Metastasis to mediastinal (N2) lymph nodes (relative contraindication)

Preoperative planning includes the following:

• History and physical examination, including past history of radiation exposure and thoracic procedures
• Chest radiograph
• Chest CT scan with IV contrast
• PET scan
• MRI of the brain with IV contrast (brain CT with IV contrast if the patient has severe claustrophobia)
• Bronchoscopy
• Pulmonary function test
• Lung perfusion quantitation scan (calculate predicted postoperative lung function)
• Pathologic evaluation of mediastinal lymph node status via endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) or cervical mediastinoscopy

Patient Preparation

Anesthesia

Endotracheal intubation is performed using a single-lumen endotracheal tube (SLETT). Bronchoscopy is performed to identify the exact location and extension of the endobronchial tumor when present. The condition of the mucosa, including any erythema or nodularity, should be noted and biopsies taken if indicated to determine future margins of resection.

Lung isolation is usually obtained by exchanging the SLETT for a double-lumen endotracheal tube (DLETT) under bronchoscopic guidance to avoid accidental trauma to the endobronchial tumor Correct placement of the endotracheal tube is confirmed. Some surgeons may elect to use an endobronchial blocker if the endobronchial tumor is distal to the mainstem bronchus.  

Open Approach

Incision selection

Posterolateral thoracotomy is the standard incision, but lateral or vertical axillary thoracotomy have been described. Before inserting the rib retractor, the intercostal muscle flap is prepared. The periosteum, along with intercostal muscle, is separated from the rib while avoiding injury to the neurovascular bundle. The intercostal muscle is detached from its insertion to the upper border of the lower (6th rib) and near its anterior insertion. After checking blood flow in the intercostal arteries, the anterior end of the pedicle is ligated. The rib retractor can be introduced now. Alternatively, a pleural or pericardial flap can be used to buttress the bronchial anastomosis.

For centrally located tumors involving the upper lobes, the superior pulmonary vein (SPV) is divided for better access to the pulmonary artery (PA). The PA is dissected intrapericardially or extrapericardially to achieve a good stump for anastomosis. 

Bronchial dissection is performed, with care taken to preserve the lateral wall bronchial blood supply. After selecting a tumor-free margin, straight transection of the bronchus is performed with the knife. The PA is clamped proximally. To clamp the left PA at its origin, transecting the ligamentum arteriosum may be necessary. The PA is not clamped distally, but to avoid back flow, the inferior pulmonary vein (IPV) is clamped. After careful dissection, the PA is transected proximally and distally to the tumor to achieve a tumor-free margin.

The specimen is removed en bloc and examined under the microscope. Both proximal and distal margin of bronchus and pulmonary artery must be tumor free.           

Following tumor excision, bronchial and PA reconstruction is performed. In general, performing bronchial reconstruction first avoids trauma to the PA anastomosis and allows better visualization of the bronchial stump. Some surgeons perform arterial reconstruction first if a pericardial patch is required for reconstruction, to reduce arterial clamping time.

Bronchial reconstruction

Transection of the inferior pulmonary ligament or semicircular transection of the pericardium can be performed to reduce the tension on the bronchial anastomosis. End-to end anastomosis can be performed by either interrupted or continuous suturing, using absorbable 3-0 or 4-0 monofilament sutures. Healing of the bronchial anastomosis seems not to be affected by the suturing technique.[6, 7]  Care is taken to avoid injury to bronchial vessels.  

After bronchial reconstruction, the anastomosis is submerged in saline, and the lung is inflated with airway pressure of 25-30 cm H2O to check for air leak. If any air leak occurs, more sutures should be placed to reduce the leak. After ensuring that no air is leaking, the anastomosis is covered with an intercostal muscle, pleural, or pericardial flap.[8]

Pulmonary artery reconstruction

Before PA sleeve resection, 3,000-5,000 units of heparin are given intravenously. Depending on time of procedure, a heparin IV bolus is repeated hourly. Heparinization is not reversed during the resection.

After reconstruction of the bronchus, PA anastomosis is performed. It can be achieved by simple end-to-end anastomosis if feasible or by pericardial/allograft conduit. To create the pericardial conduit, a pericardial leaflet larger than the arterial defect is cut in front of the phrenic nerve. The pericardium shrinks after cutting. The pericardium is wrapped around a 28-30 Fr chest tube and trimmed to match the size of the defect. The pericardial conduit is sutured to the vessels with epicardial surface in the lumen. A 5-0 to 6-0 nonabsorbable monofilament suture is used for continuous suture technique. The arterial clamp is removed, and the anastomosis is checked for any leaks. 

The thoracotomy incision is closed by standard technique. Bronchoscopy should be performed through the endotracheal tube to check for the patency of the bronchial anastomosis.

Video-assisted thoracic surgery (VATS) approach

Few authors have reported a double sleeve lobectomy using a VATS technique. The majority of these cases are described for centrally located left upper lobe tumors. The procedure generally mirrors that of open surgery. Mediastinal and hilar lymph nodes are removed and the main stem bronchus is fully mobilized. The main PA and the superior pulmonary vein are mobilized. The pulmonary fissure is then dissected to mobilize the interlobar PA, followed by transection of the superior pulmonary vein with an endostapler.

One minute after intravenous injection of 1500 U of heparin, the main PA and interlobar PA are clamped with two atraumatic endoscopic bulldog clamps. The upper lobe is then removed after proximally and distally transecting both the artery and the bronchus. Bronchovascular margins must be confirmed as negative by intraoperative frozen section.

Incision selection

In general, the same incisions as for VATS lobectomy are used, following the common principle of avoiding rib spreading. From 1 to 4 incisions have been used, with similar outcomes reported.[9] The 3-incision approach often consists of a 2.0-cm incision at the 7th or 8th intercostal space with mid-axillary line as the camera port; 3-4 cm utility incision at the 4th intercostal space with middle axillary line; and a 1-cm incision in the auscultatory triangle.

Bronchial and pulmonary artery reconstruction

Bronchial anastomosis is usually done first before vascular anastomosis, utilizing 3–0 Prolene or PDS suture. The suturing is carried out using a long endoscopic needle holder through the utility port. Continuous running suture is more commonly described, starting at the mediastinal side of the bronchus, sequentially followed by the posterior and anterior walls. The lateral bronchial wall is sewn up last so the two ends of the stitch come together for knot tying. Patency of the bronchial anastomosis is confirmed by intraoperative bronchoscopy and leak test under water.

The arterial sleeve anastomosis is performed thereafter by using a monofilament non-absorbable continuous suture (Prolene 4-0) in two different rows, with a similar method as for the bronchus. Both suture lines are tied together at the anterior part of the anastomosis using a thoracoscopic knot pusher. The edges of the anastomosis are everted to enhance arterial intimal interface and maximize the opening of the anastomosis. The distal bulldog clamp is opened to allow back bleed, and the clamp from the main PA is slowly opened. The bronchial anastomosis is then buttressed with a pericardial fat pad flap to be isolated from the vascular suture.

Robotic approach

Incisions and position of da Vinci system

The majority of available literature describes this technique using the da Vinci Surgical SI System (Intuitive Surgical, Sunnyvale, CA, USA).[3, 4, 5, 10]  The newer-generation Xi system offers a more flexible and mobile platform, thin arms, and instruments with greater range of motion, which may facilitate performing these complex operations.  A commonly described port position is for all 4 robotic arms to be located on the 7th or 8th intercostal space with the most posterior port about 4 cm from the spine and the distance between ports 8-10 cm. An assistant port is placed anteriorly immediately above the diaphragm insertion.

Bronchial and pulmonary artery reconstruction

VATS techniques for bronchial and vascular anastomosis have been adopted for the robotic approach. The robotic high-resolution 3D camera and needle drivers with 7 degrees of endowrist movement in a stable console offer a great advantage over traditional VATS.

Patients are extubated postoperatively. Patients are typically monitored inthe intensive care unit (ICU) for 24-48 hours, and prophylactic anticoagulation is continued. Patients should receive aggressive chest physiotherapy and early ambulation. Adequate analgesia is critical to prevent atelectasis and pneumonia. Protocols for enhanced recovery after thoracic surgery that include multimodality analgesia have been created to reduce opiate use during the postoperative period. Several groups of thoracic surgeons are moving away from routinely using thoracic epidural analgesia. Instead, long-acting liposomal bupivacaine is administered for intercostal nerve block.[11]

Short-term complications

To the best of our knowledge, Huang et al have reported the largest case series of double VATS sleeve lobectomy to date.[12]  Thirteen patients (median age, 60 years; range, 43-67 years) underwent VATS double sleeve lobectomy. The median operative time was 263 minutes (range, 218-330 minutes), and median blood loss was 224 mL (range, 60-400 mL). Median PA clamp time was 72 minutes (range, 44-143 minutes). Postoperative length of stay was 10 days (range 7-20 days), including ICU stay of 1 day (range 1-2 days). Median chest tube drainage was 5 days (range 3-8 days). One patient (7.7%) developed pneumonia after surgery. There were no deaths at 30 days. Median duration of follow-up was 6 months (range 1-26 months). No local recurrences or distant metastasis were reported.

Zhu et al compared the outcomes of uniportal and biportal VATS sleeve lobectomy in 11 patients. Patients who underwent biportal VATS sleeve lobectomy had shorter median operative time (255 minutes vs 288 minutes) but greater median blood loss (200 mL vs 75 mL) compared with patients who underwent uniportal VATS sleeve lobectomy. No anastomosis-related complications or perioperative mortality occurred. There was no difference in the median postoperative stay.[13]

Pan et al, reporting perioperative outcomes in four robotic double sleeve lobectomy cases, have published the largest robotic series.[4, 5] The mean console operation time was 149 min (range 128–189 min). The mean intraoperative blood loss was 125 mL (range, 100–200 mL). No case was converted to thoracotomy, and no postoperative complication occurred. The median postoperative hospital stay was 8 days (range 7–10 days). Follow-up ranged from 8 to 20 months.

Few authors have evaluated postoperative complications and oncologic outcomes for robotic sleeve lobectomy in comparison with VATS and open surgery. Using propensity score matching, Qiu et al evaluated 188 patients who underwent robotic (n =49), VATS (n=73), or open (n= 66) sleeve lobectomies. After weighted matching that retained all patients, this study found no statistical difference in 90-day mortality or morbidity among the 3 groups. Patients in the robotic group had less bleeding (P > 0.050).[10]