Successful lung-sparing carinal reconstruction after induction chemoradiotherapy for carinal cancer via median sternotomy: Reefing bronchial membrane technique

A transsternal approach was selected for lung-sparing carinal resection and reconstruction, followed by omentopexy. After median sternotomy, the pericardium was opened vertically, and the trachea was exposed between the superior vena cava and ascending aorta. Right pulmonary arterial mobilization enabled excellent exposure of the carina and proximal main-stem bronchi. A 23-gauge needle was inserted through the trachea at the level of the planned division line, and simultaneous bronchoscopy was conducted for internal examination for a safe proximal margin. Resection began with transverse division of the trachea at 2 rings above the carina. Cross-field ventilation was established via direct intubation of the left main bronchus. The following procedure was performed for intermittent apnea: carinal tumor along with the subcarinal lymph nodes was resected en bloc having free surgical margins, as confirmed by frozen sections. After minimum airway mobilization to avoid devascularization, reconstruction began by creating a neocarina by suturing the medial cartilaginous portion of both the main bronchi together, using a running 4-0 polydioxanone suture (PDS). During end-to-end anastomosis of the neocarina to the trachea, excessive tension was observed on the anastomosis, which could result in tearing of the vulnerable membranous portions (Figure 2, A). Therefore, we resutured and fully approximated the vulnerable posterior membranous portions of both mainstem bronchi with 4-0 PDS running sutures, thereby eliminating the vulnerable membranous portion in the distal airway edge. This technique resulted in 90° rotation of both main bronchi and shorter airway distance for posterior wall anastomosis (Figure 2, B). Reefing the vulnerable membranous portion enabled successful end-to-end anastomosis with a running suture on the posterior wall and interrupted sutures on the anterior wall using 4-0 PDS (Figure 2, C and D). Finally, the airway anastomosis was wrapped around by a pedicled omentum (Video 1).

There was no sign of sputum retention, and the postoperative course was uneventful, with satisfactory airway healing (Figure 2, E), and the patient was discharged on postoperative day 16. Pathologic findings revealed a good response to preoperative chemoradiotherapy, with only a 2-mm viable residual tumor (Ef2). Six months' postsurgery, there was no sign of recurrence and no respiratory symptoms (Figure 2, F).