Carinal Resection

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Patient election
T!e "ost co""on indication for carinal resection is a neo#las" $benign or "alignant%
involving t!e carina& T!e neo#las" "ay be #ri"arily trac!eal' arise fro" t!e carina
itself' or e(tend fro" t!e lung to involve t!e carina& )ll #atients "ust be rigorously
screened for "etastatic disease and "edical contraindications to suc! e(tensive surgery&
) careful evaluation of #ul"onary function' if lung resection is to be included' is
"andatory and s!ould include s#iro"etry and *uantitative ventilation #erfusion scans&
+ronc!osco#ic evaluation of t!e e(tent of disease is i"#erative& ,or a rig!t carinal
#neu"onecto"y $t!e "ost co""on carinal resection% t!e distance fro" t!e rig!t distal
trac!eal "argin to t!e #ro(i"al "edial left "ainste" s!ould not e(ceed 4 c" in "ost
cases& Resections t!at e(ceed t!is are li-ely to result in e(cessive anasto"otic tension&
.uidelines for ot!er resections are less /ell establis!ed and "ust be individuali0ed& )ll
#atients s!ould be /eaned fro" steroids and not re*uire "ec!anical ventilation& Prior
irradiation is a relative contraindication and s!ould be acco"#anied by o"ental
/ra##ing /!en carinal resection is considered&
1#erative te#s
Preference Card
+ronc!osco#e for intrao#erative use

2(tra long endotrac!eal tube for initial intubation

terile endotrac!eal tube for cross-field ventilation

3et ventilator on stand-by
Ti#s 4 Pitfalls
T!oroug! #reo#erative bronc!osco#y is necessary to select a##ro#riate candidates
for resection&
tage cancer #atients t!oroug!ly to ensure t!ere is no regionally advanced or
"etastatic disease&
Perfor" "ediastinosco#y under t!e sa"e anest!etic as t!e resection to #er"it
staging' evaluate resectability' and #er"it dissection of t!e distal trac!ea&
5se intrao#erative bronc!osco#y to guide air/ay incisions&
6a-e 7udicious use of intrao#erative fro0en section evaluation to assess "argins&
5se release "aneuvers to avoid anasto"otic tension&
6a-e sure t!e anasto"osis is free of air lea-s before co"#leting t!e o#eration&
8ra# t!e anasto"osis /it! vasculari0ed tissue&
Results
Results !ave been gratifying in recent years& T!e o#erative "ortality rate !as decreased
to less t!an 19:& ;ong-ter" survival in !ig!ly selected #atients /it! non-s"all cell lung
cancer !as a##roac!ed 45:&
Carinal Resection
Patient election
T!e "ost co""on indication for carinal resection is a neo#las" $benign or "alignant%
involving t!e carina& T!e neo#las" "ay be #ri"arily trac!eal' arise fro" t!e carina
itself' or e(tend fro" t!e lung to involve t!e carina& )ll #atients "ust be rigorously
screened for "etastatic disease and "edical contraindications to suc! e(tensive surgery&
) careful evaluation of #ul"onary function' if lung resection is to be included' is
"andatory and s!ould include s#iro"etry and *uantitative ventilation #erfusion scans&
+ronc!osco#ic evaluation of t!e e(tent of disease is i"#erative& ,or a rig!t carinal
#neu"onecto"y $t!e "ost co""on carinal resection% t!e distance fro" t!e rig!t distal
trac!eal "argin to t!e #ro(i"al "edial left "ainste" s!ould not e(ceed 4 c" in "ost
cases& Resections t!at e(ceed t!is are li-ely to result in e(cessive anasto"otic tension&
.uidelines for ot!er resections are less /ell establis!ed and "ust be individuali0ed& )ll
#atients s!ould be /eaned fro" steroids and not re*uire "ec!anical ventilation& Prior
irradiation is a relative contraindication and s!ould be acco"#anied by o"ental
/ra##ing /!en carinal resection is considered&
1#erative te#s
T!ere are a variety of
reconstructive #ossibilities
follo/ing carinal resection
$,igure 1%& C!oosing
a"ong t!e" de#ends on
t!e #atient<s s#ecific
anato"y and #at!ology&
6ediastinosco#y is
valuable in "obili0ing t!e
#retrac!eal s#ace'
dissecting t!e left
#aratrac!eal-
trac!eobronc!ial angle to
lessen t!e ris- of in7ury to
t!e left recurrent nerve' and
to sa"#le #otentially
involved "ediastinal
nodes& 6ediastinosco#y is
ideally #erfor"ed at t!e
ti"e of #lanned resection to
avoid scarring and
li"itation of "obility&
T!e surgical a##roac! for
"ost carinal resections is a
rig!t #osterolateral
t!oracoto"y& 6edian
sternoto"y for very li"ited
carinal resection and
e(tended cla"s!ell incision
for left carinal
#neu"onecto"y are
occasionally useful&
)nest!esia is best
conducted /it! an e(tra
long endotrac!eal tube t!at
can be advanced into t!e
left "ainste" bronc!us
during initial dissection&
=uring t!e resection and
anasto"osis' ventilation of
t!e left lung across t!e
o#erative field /it! a
se#arate sterile
endotrac!eal tube allo/s
Preference Card
+ronc!osco#e for intrao#erative use

2(tra long endotrac!eal tube for initial intubation

terile endotrac!eal tube for cross-field ventilation

3et ventilator on stand-by
Ti#s 4 Pitfalls
T!oroug! #reo#erative bronc!osco#y is necessary to select a##ro#riate candidates
for resection&
tage cancer #atients t!oroug!ly to ensure t!ere is no regionally advanced or
"etastatic disease&
Perfor" "ediastinosco#y under t!e sa"e anest!etic as t!e resection to #er"it
staging' evaluate resectability' and #er"it dissection of t!e distal trac!ea&
5se intrao#erative bronc!osco#y to guide air/ay incisions&
6a-e 7udicious use of intrao#erative fro0en section evaluation to assess "argins&
5se release "aneuvers to avoid anasto"otic tension&
6a-e sure t!e anasto"osis is free of air lea-s before co"#leting t!e o#eration&
8ra# t!e anasto"osis /it! vasculari0ed tissue&
Results
Results !ave been gratifying in recent years& T!e o#erative "ortality rate !as decreased
to less t!an 19:& ;ong-ter" survival in !ig!ly selected #atients /it! non-s"all cell lung
cancer !as a##roac!ed 45: