Bronchoplasty Technique

Updated: Apr 19, 2018
  • Author: Dharani Kumari Narendra, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Approach Considerations

Rigid and flexible bronchoscopies are performed to delineate the anatomy and degree of bronchial involvement. Operative strategies are based on frozen section results from biopsies.

The type of bronchoplastic procedure in individual cases is selected according to the location and extent of the pathologic lesion; modifications are performed according to the operative findings. The most commonly performed bronchoplastic procedure is a sleeve lobectomy. The principal aim of the procedure is to conserve as much of the healthy lung tissue as possible, while providing satisfactory cancer clearance.


Open Thoracotomy

A standard posterolateral thoracotomy is used for all bronchoplasties. Standard surgical technique is used for lobectomy until the bronchus is encountered. [1, 2, 16]

The area of involved bronchus is carefully dissected to preserve peribronchial blood supply. Proximal and distal points of transection are determined, and the bronchus is precisely divided. Additional segments of proximal and distal margin are removed for frozen section evaluation to confirm absence of tumor involvement.

Full-thickness traction sutures of 2-0 Vicryl are placed proximally and distally in the midlateral position of the bronchus and are left in place at the completion of the procedure. The anastomosis is performed in open fashion to allow precise placement of sutures commencing posteriorly. Anastomotic sutures of 4-0 Vicryl are placed so that the knots are outside the lumen. They are placed 3 mm deep and spaced accordingly to accommodate any size discrepancy that exists between the bronchi.

With the traction sutures pulled together and tied, each individual anastomotic suture is tied in the reverse order of placement. Once the anastomosis is completed, saline solution is placed in the pleural cavity, the lung is re-expanded, and the anastomosis is checked for air leaks. The anastomosis is wrapped with either pericardial fat or pleural flap or intercostal muscle flap for additional buttressing.

Flexible bronchoscopy is required at this time to confirm the alignment, patency, and adequacy of the anastomosis. Chest tubes are placed and connected to a water-seal device with suction.


Video-Assisted Thoracoscopic Surgery

Video-assisted thoracoscopic surgery (VATS) is an option for most patients with thoracic pathology. This technique has been shown to have better outcomes, less pain, and shorter recovery than the open approach. [17, 18, 19] VATS is a better alternative to thoracotomy and is performed under general anesthesia using a camera and 2 trocar ports. The VATS technique is very similar to the open technique, except endoscopic instruments are used to retract and dissect and visualization is via an image obtained with the thoracoscope projected on a screen. [20, 21]

A standard thoracoscopy is performed with 2-3 10-mm incisions: a camera port is placed in the anterior axillary line in the seventh or eighth intercostal space; an anterior port is placed between the latissimus dorsi and pectoralis major muscles in the fourth or fifth intercostal space; and a posterior port is placed adjacent to the scapula in the fifth or sixth intercostal space.

Through working thoracoscopy ports, an exploratory thoracoscopy is performed. Subsequently, the anterior thoracoscopy incision is extended to create a 3- to 5-cm muscle-sparing access incision to proceed with VATS lobectomy or wedge bronchoplasty or sleeve resection and allow for removal of the specimen. As in open lobectomy, the pulmonary vein branches from the targeted lobe are identified and dissected before their division using an endoscopic stapling device. Pulmonary artery branches and the bronchus are identified, dissected, stapled, and divided in a similar manner.

The specimen is removed from the pleural space using a plastic bag to avoid port-site contamination. After the lobectomy or sleeve resection is completed, a hilar and mediastinal lymphadenectomy or lymph node sampling is performed. Ends of bronchial stump are sent for frozen section to ensure tumor-free margin. Bronchial stump anastomosis is challenging, especially in VATS, because of limited access. Continuos sutures should be tied. A sliding knot technique combining with hitch and bend knots as described by Nakanishi is helpful. [5] The incisions are closed after a chest tube is placed in the inferior thoracoscopy port. The chest tube is connected to the water seal device.


Balloon Bronchoplasty

Bronchoscopic balloon dilation is a simple, nontraumatic, minimally invasive, safe, rapid method to dilate a stenosis and restore adequate airflow. It may be used with fluoroscopic guidance over a guide wire or under direct vision. It does not require general anesthesia.

Balloon bronchoplasty is most commonly used with high long-term success for nonmalignant causes of airway stenosis, but it is also used in malignant diseases.

The balloon should be silicone based and able to provide radial force. The inflation syringe must have a pressure gauge, and knowledge of burst pressure must be observed. The balloon is usually filled with saline until full deployment is reached with the help of a pressure-measuring syringe, to a prespecified pressure unit ranging from 6-12 atm in adults. Inflation diameter ranges from 4-20 mm, with a length of 4-8 cm. The final desired diameter is usually the normal diameter immediately proximal or distal to the stenosis. Each dilation can be maintained for 15-60 seconds and repeated 2-3 times, with sequentially larger-diameter balloons (see the image below). If the cartilage has been compromised, a stent is needed to support the airway. [22]

Post balloon dilation. Post balloon dilation.

Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in pulmonary function testing (PFT) results. [23, 24]


Thermal Bronchoplasty

Thermal bronchoplasty requires 3 separate outpatient bronchoscopic procedures 3 weeks apart; one for each lower lobe of the lung and another for both upper lobes.

Using a flexible bronchoscope, an Alair catheter is deployed into the airways, and controlled radiofrequency energy is delivered to a wire basket attached to the top of the catheter using the Alair controller system, in which thermal energy warms the lining of targeted airways to reduce airway smooth muscle (ASM) mass. Bronchial thermoplasty is intended to reduce, debulk, or partially eliminate smooth muscle tissue (see the images below). [25, 26]

Alair controller and catheter. Alair controller and catheter.
Alair catheter deployed in the subsegmental bronch Alair catheter deployed in the subsegmental bronchus.