A new approach to left sleeve pneumonectomy: complete VATS left pneumonectomy followed by right thoracotomy for carinal resection and reconstruction
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Left sleeve pneumonectomy is a challenging operation that requires individualized approaches. Here, we present a new minimally invasive combined thoracoscopic approach.
A 61-year-old woman was diagnosed with tracheobronchial adenoid cystic carcinoma. The tumor originated from the left main stem bronchus, and tumor with carinal involvement was observed. We judged that complete resection would be possible via left sleeve pneumonectomy. However, because tumor involvement with the esophagus and descending aorta was suspected, evaluation of resectability in advance was necessary. After confirmation via examination thoracoscopy of no involvement with the surrounding organs, complete VATS left pneumonectomy was performed and followed by right thoracotomy for carinal resection and reconstruction.
When thoracoscopic surgery becomes mainstream, this minimally invasive combined thoracoscopic approach might be an optimal option for patients who require left sleeve pneumonectomy.
KeywordsLeft sleeve pneumonectomy New approach Tracheobronchial tumor
Fluorodeoxyglucose-positron emission tomography
Left sleeve pneumonectomy
Video-assisted thoracoscopic surgery
Several approaches to left sleeve pneumonectomy (LSP) have been reported owing to anatomical restrictions in the left thoracic cavity. In addition to bilateral thoracotomy, left thoracotomy alone and median sternotomy, the clamshell approach has recently been reported as useful. Because each approach has advantages and disadvantages, treatments should be individualized . As thoracoscopic surgery is becoming more mainstream, new, less invasive approaches to extended surgery, such as LSP, are required. Here, we present a new minimally invasive combined thoracoscopic approach and its benefits.
LSP is one of the most challenging operations in thoracic surgery, and surgical approaches need to be individualized. Bilateral thoracotomy and median sternotomy are often favored;  however, as thoracoscopic surgery becomes mainstream, newer and less invasive approaches for extended surgery, such as LSP, are employed.
Cases for which LSP is indicated are generally locally advanced malignant tumors that often involve surrounding organs, and proper assessment is critical. If tumor invasion to the surrounding organs is suspected and preservation of the left lung cannot be expected upon initial diagnosis, this minimally invasive combined thoracoscopic approach has several advantages. With initial left-sided VATS, resectability can be evaluated in advance and in a less invasive manner than with thoracotomy. Confirmation of no invasion to the surrounding tissue makes left pneumonectomy beneficial. Right thoracotomy provides safety and precise anastomosis at the time of carinal reconstruction.
An initial right thoracotomy could be considered, but it is difficult to evaluate tumor involvement in the left thorax . Initial right thoracotomy requires tube intubation through the narrowed left main stem bronchus with tumor invasion. It is difficult to insert a large caliber tube enough to maintain ventilation and oxygenation. In recent years, the usefulness of the clamshell approach for carinal reconstruction has been reported,  but it has several disadvantages, such as poor visibility of the esophagus and descending aorta and the requirement of extensive detachment of respiratory muscles. The disadvantage of poor visibility is similar in anterior approaches such as the transsternal and hemi-clamshell approaches. However, our approach requires a position change, and there are also disadvantages relative to providing ventilation during airway anastomosis, which is complicated and difficult to address in an emergency. In our case, small volume ventilation from the surgical field provided precise anastomotic maneuvering. Because of the difficulty of laryngeal release, this approach is not suitable when the resection length of the trachea is relatively long.
This minimally invasive combined thoracoscopic approach might be an optimal option for patients who require left sleeve pneumonectomy.
Availability of data and materials
Data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study.
All authors performed rigid bronchoscopy treatment and surgery. TF drafted the manuscript. All authors read and approved the final manuscript.
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Informed consent was obtained from the patient for the publication of this case report.
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