Right-Sided Approach for Left Main Bronchial Sleeve Resection: A Resource-Optimized Strategy for Central Airway Tumors

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This video demonstrates a technically challenging right-sided approach for a left main bronchial sleeve resection in a 27-year-old patient who presented with a chronic cough for six months. On bronchoscopy, a nodular infiltrative growth was identified in the left main bronchus, approximately one cm from the carina, involving approximately 50 percent of the circumference. A biopsy confirmed adenoid cystic carcinoma, which is a rare, slow-growing malignancy with a predilection for perineural spread, and surgical resection with clear margins was planned. 

A uniportal video-assisted thoracoscopic surgery (VATS) approach was initiated. The resection began with mobilization around the esophagus and the azygos vein, which was divided to enhance visualization of the tracheobronchial bifurcation.  

The procedure required a conversion to a posterolateral thoracotomy for tactile assessment and improved exposure. The incision was extended along the same plane in the fifth intercostal space, and a posterolateral thoracotomy was performed. Dissection continued along the trachea, with critical landmarks identified, including the carina and the right and left main bronchi, which were meticulously dissected. A subcarinal lymphadenectomy was performed for both oncological clearance and anatomical access. Both the carina and the proximal 3 cms of the right and left mainstem bronchi were circumferentially meticulously dissected.  

The left main bronchus and the right main bronchus were isolated and looped for adequate exposure. The bulge in the left main bronchus corresponded to the tumor. At this juncture, an intraoperative bronchoscopy was performed to confirm the position of the tumor before excision. After confirming the site of the tumor, dissection began at the level of the carina and extended into the left main bronchus using sharp dissection. The tumor was meticulously resected under direct vision, and separate margins were taken to ensure the resection was R0.  

After the tumor was adequately resected, a unique challenge was encountered during airway reconstruction. A standard cross-field ventilation with a flexometallic tube hindered exposure and suture placement. In the absence of jet ventilation, a 16-gauge cannula was innovatively used for high-flow oxygen insufflation.  

This low-cost, effective alternative enabled uninterrupted anastomosis while maintaining adequate oxygenation to the left lung. This step helped eliminate the need for extracorporeal membrane oxygenation (ECMO), which is a major constraint in resource-limited settings. Regarding ECMO for airway procedures, it can be a valuable resource, but it does not come without potential downsides and risks.  

The bronchial resected margins were sutured using continuous 4-0 delayed absorbable sutures. Intraoperative bronchoscopy was performed once again to confirm tension-free airway reconstruction. A chest X-ray showed expanded lungs on postoperative day one. The patient was extubated on the table and transferred to the intensive care unit (ICU), later being discharged on postoperative day four. Final histopathology revealed adenoid cystic carcinoma with free margins and no lymph node involvement. 

References

1. Cerfolio RJ, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Mainstem bronchial sleeve resection with pulmonary preservation. Ann Thorac Surg. 1996;61:1458-62; discussion 1462-1463.
2. Iriarte F, Abbas AE, Petrov R, Bakhos CT, Su S. Right transthoracic approach for robotic left main stem bronchus sleeve resection. JTCVS Techniques. 2021 Dec 1;10:572–4.

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