Abruzzini procedure: transsternal bronchial closure for left bronchopleural fistula post-pneumonectomy

Bronchopleural fistula (BPF) is a rare but severe complication following pneumonectomy, associated with high morbidity and mortality, particularly when pleural contamination occurs. Several predisposing factors have been described, including preoperative corticosteroid use, right-sided pneumonectomy, neoadjuvant therapy, diabetes mellitus, and the presence of a long bronchial stump. Preventive strategies such as bronchial stump reinforcement have been widely employed, though the optimal technique and material remain controversial. Therapeutic options range from minimally invasive approaches, including endobronchial closure with cauterization or biological glue, to complex surgical procedures such as intrathoracic muscle transposition, thoracostomy, and thoracoplasty. In cases where conventional reclosure of the stump is hindered by infection or adhesions, the transsternal transpericardial approach described by Abruzzini in 1961 offers an alternative that avoids direct manipulation of the infected pleural cavity. This technique enables safe exposure of the mediastinal structures through a full median sternotomy, allowing direct closure of the bronchial stump. The present study provides a descriptive account and educational video of the Abruzzini technique, based on a real clinical case. The patient, a 72-year-old male with silicosis and endobronchial aspergilloma, underwent left pneumonectomy with radical mediastinal lymphadenectomy. Postoperative evolution was complicated by stump dehiscence and recurrent BPF, despite previous surgical attempts with manual suturing and thymic flap reinforcement. Definitive management was achieved through the transsternal transpericardial approach, involving careful mediastinal dissection, protection of major vascular structures, and closure of the bronchial stump with stapling under bronchoscopic guidance. This report emphasizes the technical nuances of the procedure, including the impact of mediastinal shift in left pneumonectomy, the risks of vascular injury, and the necessity of meticulous preoperative imaging. Differences between left- and right-sided fistulas are also highlighted, underscoring the importance of individualized surgical planning. BPF remains one of the most challenging post-pneumonectomy complications, with mortality exceeding 50% in uncontrolled cases. Although rarely performed, the Abruzzini technique remains a valuable tool in selected scenarios, with reported success rates above 80%. By documenting this surgical approach through video demonstration, the present work aims to enhance thoracic surgery training, preserve classical techniques, and promote safer management of complex BPF.