TROUBLESHOOTING IN MINIMAL ACCESS SURGERY
|Year : | Volume
| Issue : | Page :
Thoracoscopic pericardial patch repair of iatrogenic major bronchial injury during oesophagectomy
Srikanth Gadiyaram, Murugappan Nachiappan
Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bengaluru, Karnataka, India
|Date of Submission||07-Feb-2022|
|Date of Decision||19-May-2022|
|Date of Acceptance||27-May-2022|
|Date of Web Publication||11-Jul-2022|
Department of Surgical Gastroenterology and MIS, Sahasra Hospital, New No. 30, 39th Cross, Jayanagar 8th Block, Bengaluru - 560 082, Karnataka
Source of Support: None, Conflict of Interest: None
Tracheobronchial injuries are rare but dreaded and potentially lethal complications of oesophagectomy. The reported literature on tracheobronchial injuries in thoraco-laparoscopic oesophagectomy is sparse. They may be detected either intraoperatively or in the post-operative period. Those tracheobronchial injuries detected intraoperatively usually need conversion to an open procedure for appropriate management. The surgical approaches and the methods employed for closure depend on the size and location of the rent. The methods of surgical repair include primary closure, gastric patch closure, pericardial patch, pleural patch, pedicled intercostal muscle flap, dural graft and synthetic polytetrafluoroethylene grafts. Herein, we report a thoracoscopic repair of a major bronchial injury encountered in a patient during thoracoscopic oesophagectomy using a pericardial patch. To the best of our knowledge, this is the first report of a thoracoscopic repair of a bronchial injury using a pericardial patch.
Keywords: Major bronchial injury, pericardia patch, thoracoscopy
| ¤ Introduction|| |
Tracheobronchial injuries are rare but potentially lethal complications of oesophagectomy. The reported incidence of these injuries varies over a wide range, from 0.4% to 10%., The literature on the incidence of tracheobronchial injuries in thoraco-laparoscopic oesophagectomies is sparse. We report a major bronchial injury encountered in a patient during thoracoscopic oesophagectomy in the prone position and the use of a pericardial patch for its repair.
| ¤ Technical Report|| |
A 56-year-old female presented with complaints of dysphagia and a sense of food bolus impaction. An upper gastrointestinal endoscopy revealed a proliferative growth in the mid-thoracic oesophagus, which on biopsy was a squamous cell carcinoma. After staging, the management plan of neoadjuvant therapy, followed by surgery was discussed with the patient. After an informed consent, the patient underwent neo-adjuvant chemoradiotherapy. She had a complete response to neoadjuvant chemoradiotherapy on the follow-up positron-emission tomography-computerised tomography. She underwent a four-port thoraco-laparoscopic oesophagectomy in a prone position under general anaesthesia. During thoracoscopic mobilisation of the oesophagus, dense adhesions were noted in the region of the mid-thoracic oesophagus adjoining the trachea-bronchial complex secondary to the neoadjuvant therapy. During the dissection, there was an iatrogenic injury that resulted in a defect measuring 5 mm by 7 mm in the left main-stem bronchus adjacent to the carina [Figure 1]a. We decided to use the pericardium to close the rent as the primary closure would result in narrowing of the bronchial lumen. A superiorly placed pericardial flap of 8 cm in length and 2.5 cm in width was created with scissors, beginning at an appropriate place on the pericardium to allow the flap to reach the site of the bronchial defect without tension [Figure 1]b. At the defect, three interrupted 3-0 Vicryl sutures were placed. The pericardial flap was translated over the defect, and sutures were tied over the pericardial flap to establish a patch closure of the defect [Figure 1]c and [Figure 1]d. Fibrin glue was applied over the closure. The closure was assessed for air leakage. A chest tube was left in place. The rest of the procedure proceeded as usual in a minimally invasive manner. The gastric conduit was taken to the neck and a side-to-side stapler anastomosis was made. The total operative time was 385 min. Postoperatively, she was electively ventilated for 24 h. The chest tube did not show any air leak and was removed on the 3rd post-operative day after confirming lung expansion. She was discharged on the 7th post-operative day.
|Figure 1: (a) Rent in the left main-stem bronchus (arrow), close to the carina 'C'. Right main-stem bronchus 'RB' and pericardium 'P' are also seen, (b) Pericardial patch 'PP' taken up to the rent (arrow) exposing the myocardium 'M', (c) sutures taken in the membranous part of the left main-stem bronchus, (d) Pericardial patch repair. 'PP' Pericardial patch, 'M' Myocardium, 'RB' Right main-stem bronchus, 'C' Carina, 'P' Pericardium|
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The steps of the closure are illustrated in [Figure 2]a and [Figure 2]b and [Figure 3]a, [Figure 3]b, [Figure 3]c.
|Figure 2: (a) Dorsal view of the trachea-bronchial tree in relation to the heart and the great vessels, (b) rent in the left main-stem bronchus close to the carina|
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|Figure 3: (a) Vicryl sutures placed at the defect, (b) superiorly based pericardial flap transposed to the area of the defect, (c) sutures are tied over the pericardial flap closing the defect in the bronchus|
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| ¤ Discussion|| |
Tracheobronchial injuries are rare but potentially lethal complications of oesophagectomy. Risk factors include older patients, upper or mid oesophageal tumours, squamous cell carcinomas, neoadjuvant radiation, peri-tumoural inflammation and extended mediastinal lymphadenectomy.,
In transhiatal oesophagectomies, the injury is detected by a sudden loss of airway resistance and difficulty ventilating the patient, whereas in transthoracic oesophagectomies, the rent in the trachea or bronchus and the underlying endotracheal tube can be identified, as in our case. Immediate attention is to be paid to ventilation, and this can be achieved by passing the tube beyond the rent into the left mainstem bronchus if a single-lumen tube is used. Care should be taken to ensure that the rent is not increased in size by this procedure. In transhiatal surgery, a change in patient position with conversion to thoracotomy may be required.
Management options depend on the time of detection and location of the injury; those detected intraoperatively require surgical repair. The approach to surgical repair is based on the location of the injury. Upper tracheal injuries are managed through the cervical incision with or without a sternal split, whereas lower tracheal, carinal or bronchial injuries require a thoracotomy., To the best of our knowledge, this is the first report of a thoracoscopic repair of a bronchial injury.
The methods of surgical repair in the reported literature include primary closure, gastric patch closure, pericardial patch, pleural patch, pedicled intercostal muscle flap, dural graft and synthetic polytetrafluoroethylene grafts.,,,, Although the gastric conduit can be used as a patch for an extensive longitudinal laceration and for smaller rents, they carry a risk of spontaneous breakdown and aspiration given the gastric conduits already precarious blood supply., Pericardial, pleural patch and pedicled intercostal muscle flaps seem the best options available for repair in cases where a primary repair cannot be undertaken, either due to the inability to achieve a tension-free repair or the risk of stenosis of the lumen. Pericardial patch graft is easier to use given the proximity of the pericardium to the area of injury.
In the event of a failed repair, patients can present with major or minor air leaks along with signs of mediastinitis and systemic sepsis. They carry a high mortality rate. A select few, with no signs of infection and no impairment of oxygenation and a fully expanded lung, can be managed conservatively. Non-operative management includes advancing the tube beyond the rent or using covered stents., Surgical repair would depend on the haemodynamics of the patient and an unstable patient would require optimisation with temporising measures before an attempted closure with the above-mentioned methods.
Prevention of these injuries should be the goal of every surgeon. Some measures that could be implemented are deflation of the cuff during mediastinal manipulation; avoidance of hyperinflation of the cuff; dissection under vision in the case of mid-oesophageal tumours where pre-operative imaging suggests proximity to the tracheobronchial region; and careful use of energy sources in proximity to the membranous part of the trachea.
| ¤ Conclusions|| |
Iatrogenic tracheobronchial injuries are rare but dreaded complications of oesophagectomy. These injuries can be efficiently and safely repaired using the thoracoscopic route in the presence of expertise. We were able to successfully manage a major bronchial injury thoracoscopically with a pericardial patch. Careful and limited use of energy sources during dissection of the thoracic oesophagus and mediastinal lymphadenectomy can safeguard against the occurrence of such injuries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]