In thoracic surgery, in order to facilitate the operation, placement of a double-lumen endotracheal tube is needed to ensure the isolation of lungs. During the process, the occurrence of tracheobronchial injuries (TBI) is quite difficult to treat, and sometimes even life-threatening. The causes include the lack of experienced anesthesiologists, accidental injuries associated with operating of surgeon, anatomical malformations of tracheal bronchi in themselves, repeated intubation, and excessive balloon inflation, etc.
1 General Materials and Methods
1.1 General Materials It has been reported previously in the literature that the incidence of airway injury caused by double-lumen endotracheal intubation was very low, about 0.2%[1]. Airway injury is a rare complication, and sometimes a relatively small bronchial tear associated with that is not easy to be found. In this paper, the authors counted the occurrence and treatment of all 3 cases of bronchial rupture in 1000 cases of pulmonary surgery from June 2016 to July 2019 in our hospital.
All 3 patients are female, with a maximum age of 74 years, a minimum age of 54 years, and a median age of 60.6 years. The tallest is 163cm, the lowest is 150cm, and the average height is 158.3cm. The heaviest is 74kg, the lightest is 59kg, and the average weight is 65kg. All the 3 patients were diagnosed to have lung occupying lesions by preoperative computed tomography(CT) examination. The pathological diagnosis of percutaneous needle biopsy was confirmed as peripheral lung cancer, of which 2 patients were lung cancer of right lower lobe and 1 patient was lung cancer of right upper lobe. No indicate of distant metastasis was revealed with PET-CT in preoperative examination of 3 patients; no obvious surgical contraindications was indicated in lung function, cardiac function, electrocardiogram, coronary CT angiograph; pulmonary blood vessels, trachea and bronchi can be dissected, which can be seen on chest enhanced CT; and no new organisms, stenosis or something else was observed in trachea and bronchi through preoperative fiberoptic bronchoscopy. In terms of comorbidities, there were 1 patient complicated with rheumatoid arthritis, with receiving long-term immunosuppressive agents, 1 patient with coronary heart disease, and the other one with no comorbidity. With preoperative discussions by multidisciplinary team(MDT) , all 3 patients were identified to have surgical indications and no obvious surgical contraindications.
The anesthesiologists for 3 cases are experienced of more than 20 years. General anesthesia was induced by Sufentanil, Propofol, Rocuronium Bromide, and Etomidate. Before intubation, on comprehensive consideration of above-mentioned height and weight of patients and measurements of the bronchial diameter on the preoperative chest CT imaging, double-lumen bronchial tube No.35 was prepared for 2 patients and No.37 for the other one. Once the tip of the tube had passed through the cords, the guidewire was removed, and then the tube was rotated 90 degrees counterclockwise and went forward. The intubation process was smooth and no resistance was encountered during placement. Finally, the position of the tube was confirmed by the fiberoptic bronchoscopy. After the whole intubation, patient took the left lateral position. After changing body position, the position of the tube was confirmed again, with no bleeding in the airway, at this point, the intubation was satisfactory.
Because of the preoperative pathological diagnosis to identify clearly lung cancer, all 3 patients underwent right lower lobectomy and systemic lymph node dissection with Uniportal VATS. The operative position was taken in the left lateral position, and the incisions, with a length of approximately 3cm, were located at the fourth intercostal space on the right side, anterior axillary line or mid-axillary line. Lymph node dissection covered lymph nodes of group 2, 4, 7, 8, 9, 10, and 11. Group 7 was resected as following: after the right lung collapsed, clamp the gauze pad with the oval clamp to press the lung towards anterior mediastinum in order to fully reveal the posterior mediastinal structure. The posterior mediastinal pleura was then opened with an ultrasonic knife to reveal the subcarinal structure for the dissection of lymph nodes Group 7. In this paper, it was founded that there were a longitudinal rupture of the left mainstem bronchus, with a length of 3cm, and balloon of the tracheal intubation inside to 3 patients after the posterior mediastinal pleura opening. Patients had obvious emphysema under the posterior mediastinum, but the balloon of tracheal intubation was intact (Figure 1).
1.2 Methods Repair process: Continued Uniportal VATS left mainstem bronchial repair under the original single-port incision. The subcarinal structure was fully dissociated to reveal the left and right mainstem bronchus. The azygos vein arch was dissected by using a linear stapler, and then the esophagus near the carina was fully dissociated and pulled towards anterior mediastinum. After fully revealing the ruptured site of left mainstem bronchus, it was sutured with knotless 3-0 stratefix spiral continuously (Fig. 2, Fig. 3). The following points should be noted while suturing: 1. Suture from the distal end of the ruptured site to the proximal end; 2. Choose knotless 3-0 stratefix spiral with a radian of 1/2C to shorten the operation time as much as possible; 3.During the suturing process, pay extra attention to the suction of blood and exudation on operated site of chest, so as not to flow into the contralateral bronchus through the bronchial rupture; 4. While suturing, closely cooperate with the anesthesiologist, that is, when insert the needle, the tracheal tube should be retracted by 0.5cm to leave space for suturing; after removing the needle, the tracheal tube is pushed forward towards the distal end of the endotracheal tube to completely block the bronchial rupture. This is to not only satisfy the requirement for suture but also ensure the ventilation of the contralateral lung and the collapse of lung on the operated side. After completing the suturing, no obvious air leak was observed during water testing and lung inflation.