Thoracoscopic carinal resection and reconstruction in a patient with mucoepidermoid carcinoma

Abstract

Video clip is available online.Resection of any tumor that involves the carina requires a thoracotomy because of technical difficulties in airway management and carinal reconstruction. 1 This report presents the first known case of thoracoscopic carinal resection and reconstruction in a patient with a carinal tumor. CLINICAL SUMMARYA 39-year-old woman rearing 2 children had hemoptysis. Radiologic images showed a carinal tumor without any other associated diseases ( Figure 1). A transbronchial biopsy revealed carcinoma. Thoracoscopic surgery was planned to allow the patient an early return to her normal life.One-lung ventilation was established using an endobronchial blocker tube. Thoracoscopic carinal surgery was begun while viewing only a video monitor, without rib spreading, through an access window measuring 4.0 cm in length that was placed in the third intercostal space on the anterior axillary line and 2 additional 1.2-cm diameter ports placed in the sixth intercostal spaces on the auscultatory triangle and the midaxillary line. Hilar and mediastinal lymph node dissections were performed after division of the pulmonary ligament. The left main bronchus and the trachea were mobilized by blunt dissection. The traction 4-0 monofilament sutures of both the left bronchus and the trachea were extracted to the outside of the body using the Endo Close device (Tyco Healthcare, Norwalk, Conn) through the third and seventh intercostal spaces on the midaxillary line, respectively. The carina measuring 4.0 cm in length with the involved area was then removed with adequate margins that were pathologically negative for malignancy. Anastomosis between the trachea and the left bronchus was primarily performed in an end-to-end fashion with 3-0 absorbable monofilament sutures after reduction of the tension by drawing the traction sutures. The right main bronchus was then implanted below the first anastomosis in an end-to-side fashion. The anastomoses were FIGURE 1. Computed tomographic scans of the chest showing an abnormal mass approximately 2.6 cm in diameter involving the carina. A, Axial view. B, Coronal view. From the Departments of Thoracic Surgery a and Anesthesiology, b Shin-Kokura Hospital, Federation of National Public Service, Personnel Mutual Aid Associations, Kitakyushu, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support.

New era of “resection of the carina and lower trachea”

“…Due to increasing experience in VATS lung resection, VATS bronchoplastic surgery is currently being attempted in experienced centers (3)(4)(5)(6)(7)(8), though it has not been widely applied owing to technique difficulty. When performing VATS, the lack of depth perception and counterintuitive movement make surgeons uncomfortable when dealing with critical structures.…”

“…Complete resection and reconstruction of the carina or trachea with VATS and airway management remain challenging. Only few reports of VATS tracheal or carinal resection and reconstruction have been published (3)(4)(5)(6)(7)(8). Li and colleagues examined the feasibility of VATS in the treatment of benign and malignant diseases involving the carina and trachea, and made comparisons with relevant techniques (3).…”

Minimally invasive resection and reconstruction of the intrathoracic trachea and carina

“…Furthermore, no additional manipulations including the possible need for an additional incision for introduction of the cross-field ventilation tube are needed (11,(14)(15)(16)(17). However moderate ventilation of the lung on the operative site may be observed which may affect optimal exposure, especially when using a minimally invasive approach.…”

Contralateral thoracoscopic lobectomy in postlobectomy patients

“…A 12 mm incision was made in the sixth or seventh intercostal space in the auscultatory triangle. Access thoracotomy was performed in the fourth intercostal space in the anterior axillary line (3 to 5 cm) (12).…”