CPT® Code 31766

1. Indications

The carinal reconstruction procedure is indicated for specific medical conditions that affect the integrity and function of the carina. These indications include:

• Malignancy - The presence of cancerous tumors that invade the carina, necessitating surgical intervention to remove the affected tissue and restore normal anatomy.
• Tumor invasion - Non-cancerous tumors that may cause obstruction or damage to the carina, requiring reconstruction to ensure proper airflow.
• Injury or defect - Traumatic injuries or congenital defects that compromise the structure of the carina, leading to the need for surgical repair.

2. Procedure

The carinal reconstruction procedure involves several critical steps to ensure successful repair and restoration of function. The steps include:

• Approach selection - The surgeon chooses either an anterior or posterior approach based on the specific clinical situation. The anterior approach utilizes a median sternotomy, while the posterior approach employs a right posterolateral thoracotomy.
• Exposure of the carina - For the anterior approach, the anterior pericardium is incised, and major blood vessels are retracted to provide access to the trachea and carina. In the posterior approach, the posterior mediastinal pleura is dissected up to the thoracic inlet, and the azygous vein is divided to facilitate access.
• Mobilization of surrounding structures - The esophagus is carefully dissected free from surrounding tissue and mobilized to allow adequate access to the carina. The vagus and laryngeal nerves are protected during this process to prevent damage.
• Separation of bronchial tubes - The right and left main bronchi are separated from the carina to prepare for the excision of any diseased or damaged tissue.
• Excision of affected tissue - Any diseased or damaged carinal tissue is excised, which may include a segment of the trachea above the carina, to ensure complete removal of compromised structures.
• Reconstruction of the carina - The carina is reconstructed by creating anastomosis sites for the main right and left bronchi. The left bronchus is typically anastomosed in an end-to-end fashion, while the right bronchus is anastomosed in an end-to-side fashion.
• Reinforcement of the repair - A muscle flap or other tissue flap or patch may be utilized to reinforce the repair, providing additional support to the reconstructed area.
• Closure of surgical incisions - Once the reconstruction is completed, the surgical incisions are meticulously closed to promote healing and minimize complications.

3. Post-Procedure

After the carinal reconstruction procedure, patients typically require careful monitoring and post-operative care to ensure proper recovery. This may include management of pain, monitoring for any signs of complications such as infection or respiratory distress, and ensuring that the anastomosis sites are healing appropriately. Patients may also need to undergo respiratory therapy to aid in recovery and improve lung function. Follow-up appointments are essential to assess the success of the reconstruction and to monitor for any potential long-term issues related to the surgery.