Carinal resection

Carinal resection is a challenging procedure that is rarely performed and which requires both strict attention to technical details and good patient selection. Therefore, all cases should undergo detailed anatomic assessment including imaging and bronchoscopy as well as pre-operative functional evaluation in order to select adequately the candidates. Tumors that involve the carina but do not require lung resection might be approached either by right thoracotomy or by sternotomy. Tumors that extend more distally in the left main stem bronchus are more easily approached through median sternotomy. When resection of the right lung or of the right upper lobe is anticipated, the better access is through a right thoracotomy. A very important aspect of the carinal surgery is to assure that airway reconstruction is tension-free to reduce the possibility of complications as dehiscence or stenosis, so release maneuvers as the development of a pretracheal plane and the hilar release are essential. Patients who undergo limited resection of the carina may have their airway reconstructed by the means of a “neocarina”. In this technique, the right and left main bronchus are sutured together and then attached to the distal trachea. When the right lung is resected altogether with the carina, it is necessary make an end-to-end anastomosis of the left main stem bronchus to the distal trachea. Patients in which the carina was resected altogether with right upper lobe sparing the middle and lower lobes undergo a more complicated reconstruction including an end-to-end anastomosis of the left main bronchus to the trachea and an end-to-side anastomosis of the intermedius bronchus to an opening in the left main bronchus.