Bronchoplastic and Bronchovascular Procedures of the Tracheobronchial Tree in the Management of Primary Lung Cancer: Operative Procedures
Ligation and dissection of the pulmonary vein, mediastinal lymph node dissection, and ligation and dissection of pulmonary artery are carried out. On the right side, the azygos vein is resected. When dissection of the azygos vein is performed, it is done at the side of the superior vena cava to prepare it for use as a cover of the site of the suture line. The pulmonary ligament must be cut so that the lung can be mobilized upward. After placing stay sutures of 3-0 H-Cron at the proximal portion of bronchus and distal side of bronchus, the bronchus is resected. Although the location of the cancer can be determined preoperatively, pathologic examination of the bronchial stump should be made intraoperatively. cfm-online-shop.com
End-to-end anastomosis is delayed until the report of the pathologic examination is available. When the cancerous infiltration is identified in a bronchial stump, additional resection is carried out. Simple interrupted sutures of absorbable sutures of atraumatic needles (4-0 Dexon-S, Dexon-plus, Vicryl, Maxon, or PDS) are inserted through the submucosa without pulling the suture out in the lumen of mucosa. The knots are tied on the outside of the bronchial wall. For the membranous portion, full-thickness sutures should be used.
Several suture materials have been used over the years for the bronchial anastomosis. Since 1976, Dexon, a synthetic absorbable suture, has been used, and recently synthetic absorbable monofilament suture, Maxon (polyglyconate) or PDS (polydioxanone) are being used.
In performing bronchial suture, it is important to keep the mucosal surface smooth. The membranous portion is done in a final stage of anastomosis to adjust the caliber of the anastomotic lumen. In principle, lapping around the anastomosis is not performed. In bronchovascular procedures, after bronchial anastomosis has been done, the pulmonary artery is anastomosed. Prior to the arterial anastomosis, the position of anastomosed artery should be estimated cautiously to prevent distortion or bending of the artery anastomosed. A fiberoptic bronchoscope check of the anastomosed area of the bronchus should be made after its completion. Careful attention must be given to the removal of bronchial secretion with the fiberoptic bronchoscope during the early postoperative period. Regular bronchoscopic section is necessary in the early postoperative period.