Tlorax, 1979, 34, 616-620

Resection of proximal left main bronchus carcinomaR ABBEY SMITH AND B K NIGAM

From the Cardiothoracic Unit, Walsgrave Hospital, Coventry, UK

ABSTRACT A carcinoma at the orifice of the left main bronchus is generally consideredinoperable. Since 1963, in six patients, we have mobilised the transverse aortic arch and, workingabove the aortic arch, cut the left main bronchus off the trachea and closed the stump. Theoperation is completed as a pneumonectomy; it is referred to as a supra-aortic pneumonectomy.The indications, technique, and results are described.

Opinions differ concerning the operability of car-cinoma in the proximal 2 cm of the left mainbronchus (fig 1). Some surgeons consider such amalignant tumour to be inoperable. It is difficultto estimate the proportion of surgeons who holdthis belief, because so little has been written aboutthe difference in prognosis between carcinoma ofthe origin of the right and that of the left mainbronchus. For instance, Lee (1972), in a compre-hensive review of factors affecting operability andresectability of lung carcinoma, does not specifya difference, perhaps because it is too obvious toneed emphasising.

Fig 1 Sketch of trachea, carina, and both mainbronchi, viewed from in front. Stippled portion ofleft main bronchus is area of doubtful operability.

In some cases of left pneumonectomy by con-ventional means, main bronchus division will beacross malignant tissue and healing may be un-satisfactory. Stump recurrence can occur, althoughclinical signs of this may be delayed for manyyears. Also, the bronchoscopic indications of in-operability of left main bronchus carcinomas arenot well defined. Fixity or proximity of the tumourto the carina, the exact site of origin within thebronchus, and the degree of invasion of the im-mediate peribronchial tissues, are matters ofopinion rather than of fact. Experience will enablethe surgeon to decide whether in a particular caseall macroscopic carcinoma can be resected by theconventional approach to the bronchus as itemerges below the aortic arch.A number of our early attempts at conventional

left pneumonectomy for carcinoma of the proxi-mal left main bronchus were not successful oftenenough for us to continue to use the conventionalapproach. Maxwell Chamberlain (1964) recom-mended passing a tape around the trachea and,by pulling on this tape in the line of the bronchus,he could expose the full length of the left mainbronchus and cut it off the lateral wall of thetrachea. We have never been able to obtain aclear view of the tracheal wall and the carinaworking below the aortic arch and, should such aview be obtained, we should have little confidencein the soundness of the stump closure because theaortic arch obstructs the view. The stump is at thebottom of a narrow, deep hole. The posterior wallof the tracheobronchial tree is so friable and easilytorn that exposure must be adequate for a properclosure of the stump to be effected. Exposure ofthis area in the cadaver confirmed that an excel-lent exposure of the carina and the lower 2 cmof the left lateral tracheal wall can be obtained by

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Resection of proximal left main bronchus carcinoma

mobilisation and downward retraction of theaortic arch.

Indications for supra-aortic pneumonectomy

The indication for considering the use of thismethod is a tumour (malignant or benign) in theleft main bronchus which an experienced surgeondecides cannot be resected by conventional leftpneumonectomy. The method has been used insix patients during the past 15 years; it is there-fore rarely needed but is invaluable when thecorrect indications for its use exist.

The Operation.

A Robertshaw double lumen endobronchial tubemust be placed in the right main bronchus. Thepatient is placed in the prone (Overholt) positionon the operating table. The fifth left rib is widelyresected, the pleural cavity entered, and full ex-

posure obtained by using a Finochietto ribspreader. Resectability is confirmed. The oeso-

phagus is usually adherent to the inner margin ofthe left main bronchus and the carcinoma may

also be adherent to the adventitial wall of theaorta in the concavity of the arch. An intraperi-cardial approach has been necessary for access tothe major hilar vessels and satisfactory control ofthe left pulmonary artery and the left superiorpulmonary vein (table). The mediastinal pleura is

incised along the convexity of the aortic arch for6 cm, centred on the origin of the left subclavianartery. The superior intercostal vein is ligated anddivided as are the first three aortic branches distalto the left subclavian. The ligamentum arteriosumand the vagus nerve as it lies on the posterior wallof the left main bronchus are divided; the vagusis picked up and dissected to show the left re-

current laryngeal nerve, which is carefully pre-served. The pleura is freed from the arch to thepoint where it is reflected off the bronchus. Thetumour may be indented by the aortic arch, butwe have never seen actual invasion of the wall ofthe aorta. The first finger is passed around thearch to its medial surface and the carina palpated;the carina and the right main bronchus can easilybe seen by retraction of the arch, using a Cum-ming's aortic retractor (fig 2). The oesophagus,especially if it has been pulled to the left sidebecause of its fixity to the carcinoma, may impedefull exposure: this can readily be corrected bypledget retraction of the oesophagus.As the first step in the lung removal, a decision

is made whether to cut the bronchus off at thetracheobronchial angle or to secure the hilarvessels. We prefer to cut the bronchus and closethe stump before completing the pneumonectomy.Before starting the amputation of the bronchus itis wise to confirm, by making a small initial cut inthe trachea, that no leak is present suggestingmalfunction or malposition of the Robertshaw

Details of six supra-aortic pneumonectomy operations

Patient Age at Date of Histological Site of Other structures Method ofsecuring Other Period of Resultoperation operation type affected affected hilar vessels treatment survival

nodes (yr)

1 41 1963 Squamous Nonecell

2 51 1963 Squamouscell

Hilar

3 55 1968 Anaplastic Medias-large cell tinal

4 56 1976 Squamous Hilarcell

5 54 1976 Squamous Hilarcell

6 54 1978 Squamous Hilarcell

Left atrial wall Ligature PA. Clamp Noneand suture atrial wall

Left atrial wall Ligature PA. Clamp Noneand suture atrialwall

Superficialmuscle fibresof oesophagusNone

Clamp and suture NonePA. Clamp andsuture both PVsClamp and suture NonePA. Ligature bothPvs

None Clamp and suture Radio-PA. Clamp and therapysuture superior PV.Ligature inferior PV

Adventitia of Clamp and suture Noneconcavity of PA. Clamp andaortic arch suture both PVs

11 Died 1974. Cerebro-vascular accident:confirmed by necropsy

14 Died 1977. Secondprimary carcinomalung (see fig 4):confirmed bynecropsy

2 Died 1971. Localextension ofcarcinoma

3 Alive and well

Died 1978. Localextension of carcinoma

I Alive and well

Each operation an intrapericardial pneumonectomy. Average age at operation 51 8 years.PA=Pulmonary artery; PV=Pulmonary vein.

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R Abbey Smith and B K Nigam

tube in the right main bronchus. When main-tenance of the anaesthetic gas pressure is indis-putably confirmed, the initial cut is extended fromthe lower lateral wall of the trachea to a pointclose to the carina. If the carina itself is incisednarrowing of the right main bronchus may occurwhen the tracheobronchial stump is closed. Inter-rupted linen thread sutures mounted on atraumaticneedles are used. The left main bronchus contain-ing the carcinoma is pulled out below the aorticarch. A portion of bronchus at the line of transec-tion may be sent for frozen section and histologicalexamination. The pneumonectomy is then com-

Fig 2 Sketch of operative procedure;patient in prone position. Anintrapericardial pneumonectomy has been

-~ - performed. Left subclavian artery is being-= ~ retracted to show suture line in trachea.

Intact recurrent laryngeal nerve can beseen looping around ligamentumarteriosum.

pleted intrapericardially. It has been found neces-sary to clamp and suture either the pulmonaryartery or the vein, or both, because of carcinomaaffecting the extrapericardial portion of thesevessels and doubts about the safety of simpleligation.The oesophagus must be retracted and protected

at all stages of the operation. It is the organ mostat risk of inadvertent damage. The thoracic duct,never identified in any of the six cases, lies behindand slightly to the left of the oesophagus at aorticarch level; the recurrent laryngeal nerve can beseen in the space between the oesophagus and the

Fig 3 Portable radiograph of chest taken30 minutes after completion of supra-aortic pneumonectomy. Unusual positionof aortic arch is a characteristicappearance. Arch returns to its normalposition within first two weeks afteroperation.

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Resection of proximal left main bronchus carcinoma

trachea. The opening in the pericardium, if largerthan 2-5 cm in its greatest width, is closed withDacron strips. The chest wall is closed withoutdrainage of the space and the pressure adjusted toa mean negative pressure.A routine chest radiograph is taken immediately

after operation with the patient sitting up; fig 3illustrates the typical appearances. Fluids bymouth are withheld for the first 24 hours or untiloperative damage to the oesophagus is excluded.Aspiration of the pneumonectomy space shouldbe undertaken within the first 24 hours and theaspirate examined for evidence of contaminationof the space by oesophageal contents. We preferthis method of management to the insertion of atube into the space at the time of pneumonectomy.

Five of the six patients left hospital without

complications before the 14th day after operation.Patient 4 (table) developed a chylous leak into thepneumonectomy space and a total of 3200 ml ofbloodstained chyle was aspirated during the firsttwo weeks. No other treatment was required, andthe patient returned home three weeks afteroperation. This trivial complication is the onlyone observed.No voice changes from left recurrent laryngeal

nerve damage, and no interference with stumphealing from division of the two left bronchialarteries (which are branches of the descendingaorta arising immediately distal to the left sub-clavian) were noted.The site and number of aortic branches that

can be divided without causing spinal cord damagevary and damage may depend on several factors.

Fig 4 Chest radiograph of patient 2 (table) taken 14 years after supra-aortic pneumonectomy,showing second primary lung carcinoma in right upper lobe. Pleura of pneumonectomy spaceis calcified.

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There were no sequelae from compression of theleft subclavian artery by the aortic retractor.

Results

The results are summarised in the table and figs4 and 5: they justify the continued use of themethod for the young patient whose cardio-respiratory function is sufficient to tolerate pneu-monectomy and when, because of the particularposition of the carcinoma in the left main

R Abbey Smith and B K Nigam

bronchus, the alternative is to regard the lesion asunresectable.

ReferencesChamberlain, J M (1964). Personal communication.Lee, Y-T N (1972). Prognostic factors in surgical

treatment of bronchogenic carcinoma. Surgery,Gynecology and Obstetrics, 135, 961-975.

Requests for reprints to: R Abbey Smith, Car-diothoracic Unit, Walsgrave Hospital, CoventryCV2 2DX.

Fig 5 Tracheogram of patient 1 (table)taken five years after supra-aorticpneumonectomy. Absence of a "stump"of left main bronchus is illustrated;resection of left main bronchus is asradical as is possible. Sixth left rib inerror for fifth was resected in thispatient.

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