For stitching the wall of the trachea, overlaying the tracheobronchial anastomoses use nodal single stitches with a synthetic atraumatic thread, which are applied transversely at a distance of 3 mm from each other through all layers. The knots are tied outside, outside the lumen of the trachea. The suture area is covered by the mediastinal pleura. Yu.N. Levashev et al. (1990, 1994) to reliably strengthen the line of bronchial and tracheal sutures, they suggest using a large omentum. Mobilized strand of omentum on pedicle due to the gastroepiploic artery it is carried out behind the sternum, followed by its introduction into the pleural cavity through the mediastinal pleura or in the costal-diaphragmatic angle in front. The distal end of the greater omentum is covered by a line of a tracheal or tracheobronchial suture. The authors point to the high efficiency of this method of preventing the failure of tracheobronchial sutures.
The clinic performed 76 different types of tracheobronchial resections for lung cancer, of which 73 pneumonectomy and 3 lobectomy: 58 patients underwent resection of the tracheobronchial angle and lateral wall of the trachea, 10 patients had carina and lateral wall of the trachea and 8 had a circular resection of the trachea bifurcation . In only 25 patients, tracheal resection was solitary. In the majority of patients, 51 (67.1%), they were multiple, i.e. included resections of various extrapulmonary structures and organs of the chest cavity: vascular-atrial, mediastinal-esophageal, parietal-diaphragmatic type, in various combinations thereof. The tumor process in all patients was characterized by the presence of multiple lymphogenous mediastinal metastases.
Of the 76 operated patients, 68 had right-sided resections of the lungs. Only 8 patients underwent left-side resections, which accounted for only 10.5% of the total number of resections of this type. Basically, these were resections of the left tracheobronchial angle and side wall of the trachea — in 6 patients, and only in 2 patients – resection of the carina and the side wall of the trachea.
Such differences in the incidence of right- and left-sided tracheobronchial resections are due to at least two circumstances. First, the location of the left main bronchus in the immediate vicinity of the aortic arch, pulmonary trunk
artery causes the frequent spread of the tumor to these anatomical structures and, thus, makes it impossible to perform a radical surgery. Secondly, and this is apparently the main reason, the features of topographic-anatomical relationships in this area, cause technical difficulties for surgical manipulations in the field of trachea bifurcation from the left-sided access.
In the literature there is a large number of publications in which the authors report dozens of successful outcomes with resections of the trachea bifurcation, and the technique of such surgical interventions is described in detail. However, the analysis of these works shows that with the same frequency of tumor localization in the right and left main bronchi with tracheal lesions — 14 and 17%, 8.2 and 9.6%, respectively; left-sided pneumonectomy with tracheal bifurcation resection is performed only in a small number of patients — from 5% to 13.8%, and some authors consider inoperable patients with such a localization of the tumor.
Thus, performing resection of the bifurcation of the trachea and the left main bronchus with left-sided tumor localization remains an unsolved problem. Thus, in Russian fundamental works devoted to tracheobronchial surgery, the technique of right-sided pneumonectomy in combination with resection of the trachea bifurcation and the imposition of an anastomosis between the trachea and the left bronchus was described in detail, however, there is absolutely no mention of the possibility of such an operation on the left.
Currently, the vast majority of left-sided pneumonectomy, most often for various benign tumors or malignant neoplasms with a limited lesion volume, is performed in conjunction with resection of the trachea bifurcation from the left-sided rear access. The operation involves resection or intersection of the 2-3– rib, mobilization of the arch and the descending part of the aorta by bandaging and crossing 4– pairs of intercostal arteries. Sometimes they use transsternal access to the trachea bifurcation. The technique of two-stage surgery for tumor lesion of the left main bronchus and trachea wall is described. At the first stage, the trachea bifurcation is resected and the tracheobronchial anastomosis is applied from the right-sided access with closure of the stump of the left main bronchus. Then, after three weeks, the second stage is performed – left sided pneumonectomy.
At advanced stages of lung cancer with a lesion of the left main bronchus and trachea, performing extended pneumonectomy with resection of the trachea bifurcation using the proposed methods seems to us very problematic. The experience of performing extended combined pneumonectomies conducted in the clinic from anterior-lateral access suggested that it was possible to perform a tracheal bifurcation resection even with such an immediate access. The key point ensuring good accessibility of all anatomical structures is the mobilization of the aortic arch by crossing the arterial ligament. When performing mediastinal lymphadenectomy, it is almost always possible to isolate the tracheobronchial, bifurcation, paratracheal and para-aortic groups of lymph nodes.At the same time, the left tracheobronchial angle, the trachea bifurcation and the right main bronchus stand out and become quite accessible for resections.
These observations have led to more detailed studies of the possibility of performing left-sided pneumonectomy in combination with resection of the trachea bifurcation and the imposition of an anastomosis between the trachea and the right
bronchus from the left side anterior-lateral access. Studies have been conducted on 20 male corpses. The technique of operative intervention was tested, the parameters of operational access were investigated: depth, angle of operational action, their dependence on the width of the “aortic window”.
A thoracotomy was performed in the 4th row of anterior-lateral access with the intersection of the 4th cartilage. Next, a typical pneumonectomy was performed, with separate ligation of the lung root vessels. A bronchial fixator was placed on the left main bronchus, the lower bronchus was crossed and the lung was removed. Then the arterial ligament was isolated and crossed. The width of the “aortic” window was significantly increased, which made it possible to freely isolate and mobilize the right main bronchus and tracheal bifurcation (Fig. 50). Bias, becoming more mobile, the aortic arch in the cranial direction made it possible to isolate the distal trachea over 4–7 cartilaginous semirings. Further, the trachea was mobilized throughout the indicated length on the last cartilaginous semiring, and a taped suture was placed above the expected resection level. Similarly, they pierced and took the right main bronchus on the sutures-holders. After its mobilization and placing a rubber holder under it, the bronchus is well brought out into the wound, access to the right tracheobronchial angle is opened. Then circularly crossed the trachea and the right main bronchus along its mouth. The drug was removed. With the help of suture-taped, the edges of the trachea and the right main bronchus were brought closer together. The anastomosis between the right main bronchus and the trachea was applied according to the generally accepted method, with technical difficulties,compared with the imposition of the tracheobronchial anastomosis with the left main bronchus from the right-sided access, was not noted.
The depth of the wound in our observations ranged from 16 to 23 cm, averaged 19.5 ± 0.7 cm (M ± m), V = 11.3%. The angle of operational action was from 100 to 140, averaged 120 ± 2.0, V = 5.3%. The best parameters of the operative field were noted in persons of hypersthenic physique.
In the experiment, 10 left-side pneumonectomies were performed with resection of the trachea bifurcation and imposition of the tracheobronchial anastomosis from left-sided access in mongrel dogs of different sexes and body weights. The purpose of the experiments was both the development of the technique of surgical intervention and the study of the specifics of providing artificial ventilation of the lungs at the stage of tracheobronchial anastomosis. The location of the right primary bronchus does not allow the use of the shunt-breathing method, which is widespread in the tracheobronchial resections, but the use of HFIDL completely solves this problem, which was confirmed in the experiments. All experimental animals remained alive, removed from the experiment as scheduled. Marked uncomplicated during the healing of the anastomosis.
Thus, anatomical and experimental studies, as well as clinical experience of surgical interventions on the distal trachea, prove the fundamental possibility of performing pneumonectomy and circular resection of the trachea bifurcation from the left anterior-lateral access.