Video-assisted thoracoscopic surgery (VATS) for central airway tumors: VATS carinal resection and reconstruction

This review article focuses attention on the feasibility of airway management and technical strategies for complex anastomosis during carinal reconstruction under the video-assisted thoracoscopic surgery (VATS) approach. Between April 1992 and March 2017, English studies published worldwide were retrieved from a listing of bibliographic references obtained from the National Institutes of Health using the specific keywords “vats”, “thoracoscopic”, “carinal”, and “reconstruction”. Technical issues specific to the VATS approach, including airway management, port strategy, reduction of anastomotic tension, extent of resection, modes of reconstruction, suturing techniques, types of suture thread, and prophylactic wrapping are discussed in this review. VATS carinal resection and reconstruction remain challenging due to the limited modes of carinal reconstruction as well as problems specific to the VATS approach, such as airway management, reduction of anastomotic tension, and suturing techniques. However, VATS carinal surgery with or without anatomic pulmonary resection may be feasible using certain devices, such as high-frequency jet ventilation (HFJV) using a blocker tube, effective traction using endoscopic devices, and continuous suture techniques, and should be performed either by or with skilled and experienced VATS surgeons. In addition, non-intubated anesthesia and a uniportal strategy for VATS carinal surgery may be feasible at centers with a great deal of experience. The current indications for VATS carinal surgery are quite narrow and include the second diameter of the lesion ≤5 cm, minimal invasion to the surrounding organ, and extent of resection ≤4 cm between the lower trachea and contralateral main bronchus.