“Double Sleeve” (Vascular and Bronchial) Lobectomy

Introduction

“Double sleeve” (vascular and bronchial) lobectomy is a challenging and complex procedure, but a reasonable alternative to pneumonectomy in patients with centrally located tumors involving the pulmonary artery and bronchus.

Case report

A 52-year-old female smoker was diagnosed with an 8 cm left upper lobe non-small cell carcinoma, with vascular and bronchial involvement. Flexible bronchoscopy confirmed that the orifice of the left upper bronchus was fully occluded by the tumor mass. The patient agreed to a left upper lobe resection through a left hemiclamshell approach.

Surgical Procedure

A left hemiclamshell incision was made through the 4th intercostal space. Digital palpation confirmed the presence of an 8 cm mass occupying most of the upper lobe and involving the anterolateral wall of the pulmonary artery. A pericardiotomy was performed to expose and control the main pulmonary artery (PA), which was isolated and encircled with a vessel loop. The superior pulmonary vein was isolated and transected using an endostapler (vascular reload). The fissure was divided between the upper and lower lobe. The tumor did not involve the pulmonary artery branches to the lingual segment, which were isolated and divided with the endostapler. The left main bronchus and the lower lobe bronchus were dissected and cleared, with dissection of the subcarinal lymph node and the interlobar and peribronchial lymph nodes. The main PA was occluded using a vascular clamp, and the superior segmental and basilar arteries of the lower lobe were occluded using a double vessel loop. Before clamping the PA, 2.500 units of heparin were given intravenously to prevent clotting. The main bronchus and left lower lobe bronchus were transected with a blade (sleeve resection). The main PA was tangentially transected with scissors (partial vascular sleeve) to remove the left upper lobe en-bloc. A bovine pericardium patch was used to reconstruct the PA. The patch was sutured with a monofilament non-absorbable continuous suture (Prolene 5/0) in two different rows. The clamp from the main PA was slowly opened and no bleeding from the vascular suture was found. A bronchial anastomosis was performed using a running, non-absorbable suture (Prolene 3/0) for the cartilaginous and membranous portions.

A Doppler ultrasonography of the pulmonary artery was performed at the end of the procedure to demonstrate the presence of normal blood flow. Frozen section confirmed that all surgical margins were clear. The patient recovered well. The chest tube was removed on the fifth postoperative day.