Robotic-assisted carinal reconstruction using cross-table ventilation

Carinal reconstruction remains a technically challenging procedure for thoracic surgeons due to the complexity of airway resection and management. This is typically performed in the setting of tumour resection affecting the carina and distal trachea. Airway management of patients undergoing surgical resection of tumours involving the carina is highly challenging. This is due to an open, shared airway and the need for single-lung ventilation to facilitate surgery. Common modalities used for intraoperative ventilation include cross-table ventilation, veno-venous extra-corporeal membrane oxygenation and cardiopulmonary bypass. Cardiopulmonary bypass is usually avoided due to the requirement of full heparinization, which increases the demands of a technically challenging procedure, in addition to its contraindication in oncological resections. Extra-corporeal membrane oxygenation is not readily available in most thoracic units. This leaves cross-table ventilation, which is commonly used for open thoracotomy and sternotomy cases, but has never been reported for minimally invasive procedures.  Specifically, to the best of our knowledge, cross-table ventilation has never been used for minimally invasive robotic carinal reconstruction. We present a step-by-step video tutorial in performing surgical resection of a mediastinal tumour that was found invading the carina. This was performed in a young patient who underwent carinal reconstruction using a novel technique combining cross-table ventilation and robotic-assisted surgery.