1. Technical Innovations of Carinal Resection for Nonsmall-Cell Lung Cancer 
Paolo Macchiarini, MD, PhD, Matthias Altmayer, MD, Tetsuhiko Go, MD, Thorsten Walles, MD, Karl Schulze, MD, Ingeborg Wildfang, MD, Axel Haverich, MD, PhD, Michael Hardin, PhD 
The Annals of Thoracic Surgery 
Volume 82, Issue 6, Pages (December 2006)
DOI: /j.athoracsur
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Algorithm of eligibility to carinal resection for nonsmall cell lung cancer. *Only patients without involvement of more than two N2 nodal levels below station 2 and N3 lymph nodes were enrolled. (PET = positron emission tomography.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Operative view showing a median sternotomy with an Octopus (O) stabilizer retracting the heart to the right side, and the catheter (C) of apnoic oxygenation placed into the distal trachea, which allows oxygenation and undisturbed and uninterrupted placement of airway sutures. Retracting the heart to the right not only increases the surgical exposure of the affected left hilum, especially the dorsal aspect, but also improves the hemodynamic stability during the manipulation and securing of the pulmonary veins.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Illustration of the secondary end-to-side anastomosis of the right residual stump on the lateral aspect of the left main bronchus. (A) A double-ended polydioxanone (PDS; Ethicon, Sommerville, New Jersey) 3-0 or 4-0 suture is started on one or the other edges of the deepest or posterior aspect of the anastomosis, picking up the full layers of the respective bronchial walls, and inserting the needles from inside the lumen. It must be left untied to allow a number of stitches to be placed to complete the entire deepest aspect of the anastomosis before the reimplanting bronchus is pulled down onto the hosting structure. (B) The double-ended suture is then pulled tight, as the reimplanting and recipient lumens are parachuted. We recommend using the exact mucosa and stitch apposition through nerve hooks to avoid pursestring and narrows effects. (C) Several concentric interrupted 3-0 to 5-0 polyglactin (Vicryl; Ethicon) sutures are placed on the remaining quadrants 3 to 4 mm apart and 3 to 4 mm from the cut edge of the airway, leaving the membranous wall of the reimplanting bronchus until last to allow balancing of any anastomotic disparity and excessive traction on it. We found that placing small Vicryl sutures (eg, 5-0) on the membranous wall reduces the manipulation risks of injury. Once placement is completed, the wall and sutures are gently approximated, placing knots outside walls.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Drawing of the pericardiophrenic release (lateral view). In patients requiring a left carinal resection in which tension at the anastomosis might be anticipated, one can made at the end of the operation a surgical separation from the pericardium from the diaphragm by sharp dissection or electrocautery from ventrally to dorsally and between the two phrenic nerves. A further 2 to 3 cm can be gained in the immediate postoperative period. The hole needs to be drained for few days postoperatively.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions