Carinal resection

Abstract

Tracheobronchial tumors with involvement of the carina represent a challenging problem in the pulmonary surgery. Carinal resection is referred to removal and reconstruction of the airway itself, whereas concomitant removal of the lung parenchyma (usually a whole lung) is termed as carinal pneumonectomy. Thorough preoperative workup of these patients is mandatory. Meticulous surgical technique and aggressive postoperative management is required for the best outcomes in these difficult cases. In the paper authors review surgical technique, evaluation and management of this challenging patient population.

Tracheal and carinal resections in the treatment of non-small cell lung cancer: a trend to a minimally invasive approach

“…Involvement of N2 is of special consideration. Evaluation of the mediastinal lymph nodes prior to surgery is better done by endobronchial ultrasound (EBUS), as it avoids scarring and fibrosis around the trachea, adding more difficulty to an already complex tracheal and carinal mobilization during the definitive surgery (10). For this reason, mediastinoscopy is usually reserved to be performed at the same surgical time as the definitive surgery to rule out persistent N2 disease after neoadjuvant therapy and can even help facilitate the dissection that will be necessary to mobilize the trachea for the anastomosis.…”

“…For carinal resections, double-lumen endotracheal tubes are usually used for lung isolation during the beginning of the procedure (12), although some groups also advocate the use of single lumen tubes that are advanced to the main-stem bronchus (7,10). In the same fashion as in tracheal resection, after airway is transected the opposite bronchus is intubated across the operative field or a HFJV catheter is advance from the endotracheal tube and into the selected bronchus to keep oxygenation during the anastomosis (9) (Figure 1).…”

“…Distal trachea and carinal resections are approach by uniportal VATS through the right hemithorax in a posteriorly place incision in the 3 rd or 4 th intercostal space, allowing a more comfortable access to the posterior mediastinum (10,40). Instrumentation mimics the disposition in open surgery, with the camera (eyes) always in the upper part of the incision and carrying the dissection with bimanual instrumentation (Figure 2).…”

“…In the postoperative period, the patient must be preferably extubated in the operating room to avoid positive pressure ventilation in the new airway anastomosis. With an enhanced recovery after surgery protocol (ERAS) implemented with early mobilization, good pain control and respiratory chest physiotherapy, atelectasis, and pneumonia secondary to mucocilliary clearance disruption can be avoided (6,10,49).…”

Two cases of carina resection for bronchogenic tumor with lung parenchyma sparing: A brief report

“…Cancer involving the carina without systemic or lymphatic metastases are uncommon but not rare [[1], [2], [3]]. Most of these patients were diagnosed at an advanced stage and were likely to be no longer candidates for surgical resection [1].…”