Standard and extended sleeve resections of the tracheobronchial tree

Abstract

Anatomic resections with bronchial and/or vascular resections and reconstruction, so called sleeve resections were originally performed in patients with impaired cardio-pulmonary reserves. Nowadays, sleeve resections are established surgical procedures of first choice for tracheobronchial pathologies, whenever anatomically and oncologically feasible. Experienced thoracic surgeons have a broad surgical armentarium to avoid a pneumonectomy and the morbidity and mortality associated with it. Sleeve resections are associated with better outcomes in all aspects. Thus, sleeve resection is not an alternative for pneumonectomy and vice versa. In this review article we set out to provide a contemporary overview on this topic.

Keywords: Sleeve lobectomy; extended sleeve resection; pulmonary artery reconstruction (PA reconstruction); tracheobronchial surgery.

Figure 1

Standard sleeve resection of the right upper lobe. (A) Specimen after right sleeve lobectomy of the upper lobe en-bloc resection of the V. azygos and complete lymph node package of the upper zone (positions 2 and 4). (B) Initial two stitches of the bronchial anastomosis between the proximal main bronchus and distant bronchus intermedius. (C) Further sutures are placed from posteriorly to anteriorly and the knots are placed extra luminary. The sutures are left untied until all sutures are placed correctly. (D) Completed edge-to-edge bronchial anastomosis between the proximal main bronchus and distant bronchus intermedius.

Figure 2

Schematic representation of selected sleeve resections of the bronchus. (A) Right sleeve lobectomy of the upper lobe: Bronchial anastomosis between the proximal main bronchus and distant bronchus intermedius. (B) Right lower bilobectomy with Y-sleeve (extended sleeve resection type D): Bronchial anastomosis between the proximal main bronchus and upper lobe bronchus. (C,E) Extended sleeve type A: resection of the upper and middle lobes with segment 6 and anastomosis between the right main and the basal segmental bronchus. (D) Left sleeve lobectomy of the upper lobe: bronchial anastomosis between the proximal main bronchus and lower lobe bronchus. (E,C) Left Y-sleeve lobectomy of the lower lobe: bronchial anastomosis between the proximal main bronchus and upper lobe bronchus. (F) Extended sleeve type B: resection of the upper lobe and superior segment of the lower lobe and anastomosis between the left main bronchus and basal segmental bronchus. (G) Right sleeve pneumonectomy: anastomosis between the trachea and left main bronchus. (H) Left sleeve pneumonectomy: anastomosis between the trachea and right main bronchus.

Figure 3

Extended double-sleeve resection type B. (A) Specimen after sleeve resection of the upper lobe and superior segment of the lower lobe. (B) Autologous pericardium can be wrapped around a chest tube and sutured longitudinally to prepare a conduit of autologous pericardium for reconstruction of PA. (C) Bronchial anastomosis between the left main and basal segmental bronchi as well as prosthetic replacement of the PA with conduit of autologous pericardium between main PA and basilar segmental arteries. (D) Bronchoscopic view before discharge on the telescope anastomosis between the left main and basal segmental bronchi. PA, pulmonary artery.

Figure 4

Extended double-sleeve resection type E according to Bölükbas et al. (A) Intraoperative view after en-bloc resection of the middle lobe and segment 6 of the lower lobe. (B) Bronchial anastomosis between Bronchus intermedius and the basal segmental bronchus as well as vascular anastomosis between main PA and basilar segmental arteries. PA, pulmonary artery.

Figure 5

Left-sided sleeve pneumonectomy under veno-venous extracorporeal membrane oxygenation (ECMO). (A) Transsection of the right main bronchus via right thoracotomy. (B) Tracheo-bronchial anastomosis between the right main bronchus and distal trachea. (C) Specimen after completion of the sleeve pneumonectomy via left thoracotomy with view on the bifurcation and tumor in the left main bronchus. (D) Intraoperative view left-sided after prosthetic replacement of the pericardium.