Robotic-Assisted Tracheobronchoplasty: A Quick Way to Fix the Airway

Tracheobronchomalacia (TBM) is a disease characterized by narrowing of the central airways, including the trachea and mainstem bronchi. Clinically, symptoms such as cough and dyspnea on exertion can make the diagnosis of tracheobronchomalacia difficult, and clinicians are often misled into diagnosing patients with recurrent pneumonia prior to making an accurate diagnosis. Fortunately, tracheobronchoplasty offers rapid relief of symptoms, and patients generally do well after this minimally invasive procedure. In this video, the authors present a reproducible technique for a robotic-assisted tracheobronchoplasty procedure resulting in rapid improvement of symptoms attributed to severe central airway collapse. 
 
The patient was placed in a left lateral decubitus position, and the right chest was prepped and draped. After confirming that the right lung was deflated, a 1 cm incision was made over the anterior axillary line at the ninth intercostal space. The chest cavity was entered safely, and under direct visualization of the camera, all other trocars were placed. 
The lung was swept medially to expose the posterior hilum. The pleura reflection of the lung and esophagus was identified and dissected to expose the bronchus intermedius. After identifying a Level 10 lymph node, the bronchus intermedius was mobilized proximally, and the Level 10 lymph node was excised. Dissecting proximally along the bronchus intermedius, a Level 7 lymph node was identified. Dissecting and excising the entirety of the Level 7 lymph node allowed for the identification and exposure of both the right and left mainstem bronchus. Dissecting distally along the right mainstem allowed for the identification of the bifurcation of the bronchus intermedius and the right upper lobe bronchus. Dissecting distally along the left mainstem bronchus led to the left pleura/lung. At this point, the trachea was dissected proximally up to the azygous vein. 
 
The azygous vein was then dissected and divided using an EndoGIA gray load. Next, the posterior membranous trachea was dissected and exposed by continuing dissection along the tracheoesophageal groove. The entire posterior membranous trachea was then exposed, and the trachea was mobilized all the way up into the thoracic inlet. The superior vena cava (SVC), phrenic nerve, and esophagus were all safely dissected . 
 
At this time, umbilical tape was placed in the chest cavity, and this tape was used to measure the length of the posterior membranous trachea, the right mainstem bronchus, and the left mainstem bronchus for sizing the mesh. A 2.2 cm x 9 cm polypropylene mesh was placed in the chest cavity to reconstruct and plicate the posterior membranous trachea. Interrupted 4-0 Vicryl sutures were placed to secure the mesh to the left cornu of the trachea, extending distally to the carina using vertical mattress stitches. The right cornu of the trachea had mesh secured along its entire length in the same fashion. Two interrupted 4-0 Vicryl sutures were placed between the tacking stitches to plicate the redundant posterior membranous trachea all the way down to the carina in a horizontal mattress fashion. Next, the bronchoplasty was performed. A mesh measuring 1.8 cm x 2.2 cm was inserted into the chest cavity. Using the same suturing method as described for securing the tracheal mesh, a polypropylene mesh was secured to both the posterior membrane of the right and left mainstem bronchus, allowing for excellent plication of both mainstem bronchi. 
 
A multilevel intercostal nerve block using 0.5 percent Marcaine was then performed along the entire length of the chest cavity. Next, a chest tube was placed to overlie the posterior medial recess of the chest cavity. The lungs were then inflated, and the incisions were closed in standard surgical fashion, with additional securing of the chest tube in standard surgical fashion. 

References

1. Lazzaro, R., Kontopidis, I., & Medina, B. D. (2023). Just breathe: 12-step robotic tracheobronchoplasty. JTCVS Techniques, 21, 239–243. https://doi.org/10.1016/j.xjtc.2023.05.020

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