Non-intubated combined with video-assisted thoracoscopic in carinal reconstruction

Abstract

Carinal reconstruction is a difficult technique combined with video-assisted thoracoscopic surgery (VATS). It has a high requirement on the operator's skills in operating thoracoscope and meanwhile requires the close cooperation from anesthesiologists. Tracheal intubation and ventilator-assisted ventilation are key steps to ensure the success of surgery. However, tracheal intubation itself may influence the exposure of surgical field and increase the difficulty of anastomosis. In close cooperation of anesthesiologists, we did not perform tracheal intubation; rather, we carried out non-intubated complete VATS carinal reconstruction in a patient with adenoid cystic carcinoma (ACC) of the lower trachea. The awake complete VATS carinal reconstruction was successfully performed. The anastomosis lasted about 36 hours, and the whole surgical procedure lasted 230 min. The intraoperative blood loss was about 80 mL. The patient recovered well 100 min after surgery. A semi-solid diet began 6 hours following the surgery. This non-intubated anesthesia method makes the surgery easier, especially during the anastomosis of stumps. It is feasible and safe to apply this anesthesia technique in carinal reconstruction.

Keywords: Tracheal mass; awake; carinal reconstruction; video-assisted thoracoscopic surgery (VATS).

Figure 1

Chest computed tomography (CT) showed a nodule measuring about 1.7 cm × 1.4 cm located at the lower trachea, 1 cm away from the carina.

Figure 2

Pore sites 1–3: [1] observation port: in the 6^th intercostal space at anterior axillary line, about 12 mm in length; [2] auxiliary operation port: at posterior line, 10 mm in length; [3] main operation port: in the 4^th intercostal space between anterior axillary line and mid-axillary line, about 4 cm in length.

Figure 3

Nerve block. (A) Intercostal nerve block; (B) vagus nerve block.

Figure 4

Handling of the azygos vein using vascular cutter/stapler.

Figure 5

Dissociate the structure near the tumor. (A,B) Dissociate the thoracic trachea, carina, and left and right main bronchi; (C) suspend the proximal end of thoracic trachea; (D) lift the thoracic trachea using retraction cord.

Figure 6

Snip the end of trachea. (A) The distal end is 1 cm away from the mass; (B) transect and suspend the right main bronchus; (C) suspend the left main bronchus; (D) transect the left main bronchus.

Figure 7

Transection at the site 1 cm away from the upper edge of the tumor.

Figure 8

The tracheal and bronchial stump before anastomosis.

Figure 9

Continuous anastomosis of the lower trachea and left main bronchus using 2–0 Prolene sutures.

Figure 10

The orifice with the diameter about 1.2 cm was remained for the right main bronchus.

Figure 11

Continuous anastomosis of the orifice and the right main bronchus using 2–0 Prolene sutures. A to C for the posterior wall and D to F for the anterior wall.

Figure 12

Tie the stitches after continuous suture and a double check by the bronchoscope.

Figure 13

The air leak can be founk in the anastomotic leak testing.

Figure 14

The computed tomography (CT) reconstructed image of the trachea and the main bronchus on the 12^th day postoperative.

Figure 15

Non-intubated combined with video-assisted thoracoscopic in carinal reconstruction (1). Available online: http://www.asvide.com/articles/911