Robotic-Assisted Tracheobronchoplasty for Tracheobronchomalacia

Tracheobronchomalacia is a degenerative condition of the central airways that that can result in excessive dynamic airway collapse (EDAC) upon expiration. Clinically, patients present with dyspnea on exertion, exercise intolerance, and/or recurrent pulmonary infections. Tracheobronchoplasty, or surgical stabilization by plication of the membranous airway with mesh, may improve symptoms in carefully selected patients (1).

In this case, a sixty-seven-year-old man with history of asthma and gastroesophageal reflux presented with four to five years of worsening dyspnea and exercise intolerance. He was diagnosed with tracheobronchomalacia following a dynamic CT scan that demonstrated a higher than 50 percent tracheal collapse upon expiration. Subsequent bronchoscopy noted a higher than 90 percent airway collapse with forced expiration consistent with severe EDAC. The patient experienced symptomatic improvement following trial of a custom silicon tracheal Y stent.

Surgeons performed a robotic assisted tracheobronchoplasty using three polypropylene mesh strips cut to a width of 16 mm for the bronchi and 24 mm for the trachea. Following exposure of the thoracic membranous trachea and bronchi, each mesh was secured to one edge of the cartilaginous airway with interrupted partial thickness 4-0 Vicryl sutures. The membranous airway was subsequently plicated to the mesh with rows of interrupted sutures. The free mesh edge was secured to the adjacent cartilaginous airway.

The patient was discharged on postoperative day three and recovered without complication. At the six month follow up his dyspnea had subjectively improved, as had his pulmonary function tests. This video provides important pearls and pitfalls regarding the technique for robotic assisted tracheobronchoplasty, allowing for more widespread dissemination of this contemporary procedure.

Reference(s)

Lazzaro R, Patton B, Lee P, et al. First series of minimally invasive, robot-assisted tracheobronchoplasty with mesh for severe tracheobronchomalacia. J Thorac Cardiovasc Surg. 2019;157:791–800.