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ROBOTIC LEFT MAINSTEM AND CARINAL SLEEVE RESECTION ON V-V ECMO
Camille Yongue, MD, Robert Cerfolio.
NYU Langone Health, New York City, NY, USA.
BACKGROUND: This patient presented with hemoptysis and shortness of breath. She was found to have an adenoid cystic carcinoma. On her pre-operative CT scan, there was a 5cm partially obstructing L mainstem mass. After rigid bronchoscopy and laser ablation, the mass was 1cm. She presented to us for a robotic left mainstem and carinal sleeve resection from the right chest.
METHODS: We chose a right sided robotic approach to resect the proximal and mid left main stem bronchus on right internal jugular and right femoral venous ECMO. As shown in the video, right femoral and right internal jugular vein cannulas were placed and position was confirmed with transesophageal echocardiography. We positioned with the right side up, and inserted our standard robotic ports. We mobilize the right and left mainstem and proximal trachea to take tension off the anastomosis. This includes mobilizing the trachea off the innominate artery and resecting the azygous vein. We demonstrate how we locate the lesion bronchoscopically and use a penrose drain for additional retraction. We place a retention suture in the cartilaginous part of the airway to prevent retraction. We send bronchial and tracheal margins from the 12, 3, 6, and 9 o’clock positions from the proximal and distal ends of the sleeve. Adenoid cystic tumors have creeping lymphatics, so attaining negative margins may be challenging but removal of all visible disease is key. The anastomosis is done robotically with two barbed running sutures. We check the anastomosis bronchoscopically and in this case with a submersion test. Estimated blood loss was 25cc and total operative time was 2hrs 10min.
RESULTS: This patient had an excellent result with her chest tube removed that evening and she went home on post operative day 1.
CONCLUSIONS: This video highlights the many detailed technical aspects of a left mainstem and carinal sleeve resection from the right chest. Key points include complete mobilization of the trachea and bronchus, attaining multiple proximal and distal margins, anastomotic technique and expected post operative course. This can be done safely and expeditiously on ECMO with minimal blood loss.
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