An unusual way of lung isolation performed using a bronchial blocker passed via partially resected larynx for thoracoscopic esophagectomy

Sir,

Lung isolation techniques are usually performed via devices introduced orally through the intact larynx and trachea. We are reporting a case where an unusual way of lung isolation was performed using a bronchial blocker passed via the partially resected larynx for thoracoscopic esophagectomy.

A 50-year-old male had presented with stridor and dysphagia, and indirect laryngoscopy revealed left vocal cord palsy. Computed tomography (CT) showed soft tissue mass continuous with the lower pole of the right lobe of thyroid gland in the right upper paratracheal region extending into the tracheo-esophgeal groove with infiltration of trachea and hypopharynx with paratracheal nodes and circumferential wall thickening of distal thoracic esophagus extending up to gastro-esophageal junction. He was diagnosed with synchronous papillary thyroid cancer and adenocarcinoma of esophagus and was posted for total thyroidectomy, laryngectomy, esophagectomy with gastric pull-up and pectoralis major myocutaneous flap reconstruction.

The plan of anesthesia was general anesthesia with endotracheal intubation and controlled ventilation. Following intravenous induction with propofol and muscle relaxation with suxamethonium under C-MAC videoscope guidance, oral intubation was done with 8.0 mm flexometalic cuffed endotracheal tube (ETT). Anesthesia was maintained with isoflurane in air oxygen mixture (1:1) with positive pressure ventilation and intermittent boluses of intravenous morphine and vecuronium. Two large bore intravenous catheters, arterial line, and triple-lumen central venous catheter were secured. Initially, thyroidectomy was completed. During laryngectomy when the larynx was partially resected, oral ETT was removed and a new cuffed ETT 8.0 mm was introduced through the tracheal stoma.

However, for dissection of the thoracic part of the esophagus by thoracoscopy, the patient was required to be in the prone position with lung isolation. We decided to use a bronchial blocker for lung isolation as a double-lumen tube (DLT) was bulky and difficult to manage in the prone position. A new 8.0-mm cuffed ETT was then introduced orally using C-MAC videoscope, and when the distal end came out through the surgical site, surgeons guided it into the partially resected larynx [Figure 1] and pushed it further down till it came out through the distal end of the larynx. The ETT in the tracheal stoma was then deflated and removed. The distal end of the new orally introduced ETT was inserted into the trachea guided by the surgeon, and the airway was secured. A bronchial blocker (EZ blocker, 7Fr, 75 cm) was introduced and proper positioning was confirmed with a pediatric fiberoptic bronchoscope. The right lung was isolated, and thoracoscopic esophagectomy was done in the left lateral position.

Figure 1: Distal end of ETT being guided to the partially resected laryngeal inlet

Lung isolation is required to facilitate surgical exposure during specific intrathoracic surgeries. For this purpose, bronchial barrier devices like DLTs or bronchial blockers are commonly employed to separate the lungs to enable each lung to function as a separate unit. Bronchial blockers have several benefits over DLTs. A bronchial blocker can be quickly inserted through a single-lumen tube, which is technically easier than DLT.[¹²³] The smaller profile of a single-lumen tube makes surgical dissection of the airway and esophagus easier and safer during thoracic esophagectomy.[⁴] A bronchial blocker avoids postoperative ETT exchange if postoperative ventilation is planned.[⁵] It is concluded that lung isolation can be successfully performed through the partially resected larynx for thoracoscopic esophagectomy.

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Conflicts of interest

There are no conflicts of interest.