A 63-year-old man was referred to our hospital for sputum with blood for 1 month. Enhanced chest computed tomography (CT) showed a 5.2 × 4.6 cm diameter mass in left upper lobe nearing the hilum, obstructing the left main bronchus and invading the anterior trunk of apical and anterior segment. Bronchoscopy revealed bronchiostenosis caused by a diffusely growing neoplasm in the opening of left upper lobe, invading the orifice of lower lobe, submucosally extending upward to 4 to 5 cartilage rings of the left main bronchus and to the level of the carina (Figure 1). The biopsy pathology results of the neoplasm were squamous cell carcinoma and the result of the left main bronchus was heterogeneous cells.

Surgical technique

The patient was anesthetized with total intravenous anesthesia technique. A right-sided double-lumen endotracheal tube was placed for right lung ventilation. The patient was placed in right lateral decubitus position. A 4-cm incision was made in the fourth intercostal space along the left anterior axillary line for camera and all the operative instruments.

First, the mediastinal pleura was opened and the mediastinal structure was inspected to evaluate the mobility of the tumor and the possibility of radical resection. No tumor infiltration into the left recurrent laryngeal nerve, esophagus, or descending aorta was observed.

After that, the left pulmonary artery, superior-, and the inferior-pulmonary veins were divided inside the pericardium with a 45 mm white reload EndoGIA (Covidien Medtronic) stapler. Next, the left main bronchus was divided near its opening circumferentially by scissors, and the left lung was removed in a protective bag.

Four traction sutures of 3-0 Prolene (Ethicon) were placed, one on the distal trachea, another three on the posterior and anterior walls of the right main bronchus, respectively, to improve the exposure of distal trachea and the right main bronchus. Thereafter, the tracheal intubation tube was pulled back in the trachea to enable the circumferential dissection of the right main bronchus at its orifice. The carina was removed after dissecting the trachea at one ring above the carina (Figure 2). Proximal and distal margins were confirmed to be negative by intraoperative frozen section.

Surgical techniques. (a) The view of left hilum after dividing left pulmonary vessels. (b) Cutting off the left main bronchus by scissors. (c) The view of left hilum after left pneumonectomy. (d) Four traction sutures placed on the distal trachea and the right main bronchus. (e) Cutting off the right main bronchus at its orifice by scissors. (f) Dissecting the trachea at one ring above the carina. (g) The tube used for high frequency ventilation was sending into the right main bronchus for ventilation after complete resection of the carina. End-to-end anastomosis between remnant trachea and the right bronchus was performed with running sutures. (h) The view of completed anastomosis. LMB, left main bronchus; PA, pulmonary artery; RMB, right main bronchus; SPV, superior pulmonary vein

An end-to-end anastomosis was performed by running sutures with two needles 3-0 Prolene in a clockwise direction, with a spacing of 2–3 mm. After applying several sutures at the posterior part of the anastomosis, the rest of the anastomosis was completed in the opposite direction. Last, the stitches were tightened gradually from back to front and tied. During this process, a 5 L/min high-frequency jet ventilation was introduced to the right main bronchus through the right-sided double-lumen endotracheal tube for ventilation. Significantly, the diameter discrepancy between trachea and bronchus was managed by telescoping the right main bronchus into the trachea to avoid air leakage.

After confirming no air leakage under water, a part of the pericardium was moved to avoid cardiac incarceration and was used to wrap the anastomosis. Please find more details in Surgery Video from Supporting Information.

Surgical outcome

The total operative time was 220 minutes with 65 minutes for airway reconstruction. The estimated intraoperative blood loss was 300 mL. A chylothorax complication occurred after surgery and lymphangiogram and thoracic duct embolization were performed. On the postoperative day 20, the drainage volume was reduced to <200 mL, and the thoracic drainage tube was removed.

The final diagnosis was squamous cell carcinoma of the tumor (T3N1M0, IIIA, IASLC 8 edition) with a negative result for the surgical margins and lymph nodes except hilar nodes (10) and interlobar nodes (11). Three months after the surgery, the follow-up bronchoscopy revealed good healing of the anastomosis (Figure 3). No signal of tumor recurrence was observed by follow-up examination 1 year after the surgery.

Bronchoscopy 3 months after surgery