Techniques of Performing Left Carinal Pneumonectomy

Abstract

Carinal pneumonectomy and reconstruction remains one of the most technically demanding of all thoracic surgery procedures. Bronchoplastic techniques refined from tracheal surgery and sleeve lobectomy have made carinal pneumonectomy possible, but successful outcome of this procedure depends on multiple factors such as patient selection, thorough preoperative evaluation, anesthetic management, meticulous surgical technique, and focused postoperative care. The first comprehensive approach to carinal resection and reconstruction was presented by Grillo and coworkers in 1963 and by Grillo in 1982. 1-3 Most carinal resections are done for right-sided tumors because of the anatomy of the right upper lobe and shorter length of the right main stem bronchus. The proximity of right upper lobeorificetothecarinacanresultinextensionofrightupper lobe tumors to the carina, whereas left-sided bronchogenic tumors rarely extend to the carina without simultaneous extension to other unresectable structures. Right carinal resection is performed through a right posterolateral thoracotomy that gives a perfect exposure to carina, the right main stem bronchus, and the proximal left main stem bronchus. Left carinal pneumonectomy is performed much less commonly andisalsotechnicallyamorechallengingproceduresincethe exposure of the lower trachea and right main stem bronchus are covered by the aortic arch. However, the procedure can be performed via different approaches depending on the extension of the tumor.