Robotic-Assisted Carinal Reconstruction Using Cross Table Ventilation—A Novel Surgical Technique

This video is part of CTSNet’s 2024 Innovation Video Competition. Watch all entries into the competition, including the winning videos. 

Carinal reconstruction remains a technically challenging procedure for thoracic surgeons due to the complexity of airway resection and management. It is typically performed in the setting of tumor resection affecting the carina and distal trachea. 

Inflammatory myofibroblastic tumors (IMTs) are rare mesenchymal neoplasms that predominantly affect younger adults and children. Pulmonary IMT accounts for only 0.04-0.2 percent of all lung tumors and is considered a locally aggressive sarcoma with limited metastatic spread to tissues. Carinal resection and reconstruction are the definitive management for tumors invading the trachea and carina. 

Airway management of patients undergoing surgical resection of tumors involving the carina is extremely challenging. This is due to an open, shared airway and the need for single-lung ventilation to facilitate surgery. Common modalities used for intra-operative ventilation include cross table ventilation, veno-venous extracorporeal membrane oxygenation (ECMO), and cardiopulmonary bypass. Cardiopulmonary bypass is usually avoided due to the requirement of full heparinization, which increases the demands on a technically challenging procedure, in addition to its contraindication in oncologic resections. Furthermore, ECMO is not readily available in most thoracic units. This leaves cross-table ventilation, which involves retracting the oral endotracheal tube followed by direct intubation of the bronchus across the sterile surgical field. The purpose of this technique is to enable the surgeon to repair and reconstruct the carina while maintaining lung ventilation. Once the anastomosis is complete, the endotracheal tube can be re-advanced into the bronchus. This method is commonly used for open thoracotomy and sternotomy cases but has never been reported for minimally-invasive procedures. 
 
In this case, the authors present a 39-year-old male who was diagnosed with an inflammatory myofibroblastic tumor invading the left main bronchus and proximal bronchus intermedius. The right upper lobe bronchus was found originating directly from the trachea. After a multidisciplinary team (MDT) discussion and patient counseling, the patient was scheduled for robotic-assisted resection of the tumor with carinal reconstruction using cross-table ventilation. 
 
To the best of the authors’ knowledge, cross-table ventilation has never been used for minimally-invasive robotic carinal reconstruction. Only a few case reports have presented robotic-assisted airway repair though these have shown to be effective and reproducible with good postoperative patient outcomes. In addition, only one previous case has attempted tracheal reconstruction via robotic-assisted surgery, however, that procedure was performed using ECMO. This technique is, therefore, the first of its kind to combine cross-table ventilation with robotic surgery, overcoming the challenges associated with ECMO. 
 
Cross-table ventilation is an effective and practical method for intra-operative ventilation during carinal reconstruction resulting in minimal post-surgical complications and timely recovery. Further research is required to confidently ascertain the role of robotic-assisted cross-table ventilation on long-term patient outcomes; however, initial results are reassuring. Nevertheless, the replacement of ECMO with cross-table ventilation opens opportunities for thoracic centers with no additional corporeal circuits to push the boundaries for carinal reconstruction procedures. 

References

1. Kovach SJ, Fischer AC, Katzman PJ, Salloum RM, Ettinghausen SE, Madeb R, et al. Inflammatory myofibroblastic tumors. J Surg Oncol. 2006;94(5):385-91.
2. Demir Ö F, Onal O. Surgical treatment outcomes of pulmonary inflammatory myofibroblastic tumors. Ann Thorac Med. 2022;17(1):44-50
3. Goel K, Bansal A, Roy AB, Chaturvedi A, Gupta N | Anaesthetic Management of Carinal Tumour Using Cross-table Ventilation | Journal of Anaesthesia and Critical Care Case Reports | January-April 2022; 8(1): 06-08
4. Sehgal S, Chance JC, Steliga MA. Thoracic anesthesia and cross field ventilation for tracheobronchial injuries: a challenge for anesthesiologists. Case Rep Anesthesiol. 2014;2014:972762
5. Matsuura N, Igai H, Kamiyoshihara M. Carinal resection and reconstruction: now and in the future. Transl Lung Cancer Res. 2021;10(10):4039-42
6. Caso R, Khaitan PG, Shults CC, Watson TJ, Marshall MB. Simulation for Technical Challenge: Complete Portal Robotic Distal Tracheal and Left Main Stem Resection and Reconstruction on ECMO. CTSNet. December 2018. Available at: doi:10.25373/ctsnet.7388969.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.