Robot-Assisted Reinforcement with a Free Pericardial Fat Pad for Double-Lumen Tube-Related Injury of the Left Main...

Tracheobronchial injury associated with double-lumen tube (DLT) placement is rare and typically diagnosed postoperatively. Intraoperative detection of subtle airway lesions is extremely uncommon. We report a case of DLT-related injury of the left main bronchus that was incidentally detected during robot-assisted thoracic surgery (RATS) and successfully reinforced with a free pericardial fat pad.

An 82-year-old man underwent robot-assisted left lower lobectomy and mediastinal lymph node dissection for suspected primary or metastatic lung cancer. During subcarinal lymph node dissection, a bronchial injury was identified at the distal end of the left main bronchus, at the junction between the membranous and cartilaginous portions. The bronchial wall showed a longitudinal laceration; the muscular layer was torn, but the mucosa remained barely intact. The balloon of the blue bronchial tube could be seen through the mucosa within the lumen. Bronchoscopy revealed a bronchial injury at the distal end of the left main bronchus, at the junction between the membranous and cartilaginous portions, likely caused by the DLT cuff. From the luminal side, mucosal redness and protrusion into the lumen-presumed to be caused by increased intrathoracic pressure-were observed, raising suspicion of disruption limited to the outer bronchial wall structures, such as the smooth muscle layer, with the mucosa spared. Following lobectomy, a free pericardial fat pad harvested from the anterior mediastinum was applied to the injured site with bioadhesive and sutured to be covered with mediastinal pleura. Postoperative bronchoscopy and CT revealed stable graft attachment without evidence of leakage or infection. The patient recovered uneventfully and was discharged on POD 7.

RATS enabled early detection and safe repair of a subtle airway injury that otherwise may have been overlooked. Free adipose tissue reinforcement is a feasible option for managing DLT-related membranous thinning. This case highlights the risks of DLT-related airway injury and the safe management strategies achievable using RATS.