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Eur Arch OtorhinolaryngolDOI 10.1007/s00405-014-2981-y

LAryngOLOgy

Surgical treatment of non‑malignant laryngotracheal stenosis

Romaldas Rubikas · Ieva Matukaityte · Julius Jonas Jelisiejevas · Mindaugas Rackauskas

received: 8 november 2013 / Accepted: 21 February 2014 © Springer-Verlag Berlin Heidelberg 2014

mobilization of the mediastinal trachea, which allows for carrying out the anastomosis with minimal tension. Early internal abnormalities of the anastomosis predict its restenosis.

Keywords Larynx · Trachea · Stenosis · resection · Anastomosis · Video mediastinoscopy · restenosis

Introduction

The anatomical and functional interrelations between the subglottic part of the larynx and the trachea are close; thus, pathologies of these organs are usually discussed together [1, 2]. non-malignant (post-intubation/tracheostomy, trau-matic, idiopathic) subglottic laryngeal and tracheal steno-sis remains the most common indication for single-staged surgical intervention (cricotracheal or tracheal resection followed by primary end-to-end thyrotracheal, cricotra-cheal, or tracheotracheal anastomosis). The classic princi-ples and methods of laryngotracheal and tracheobronchial surgery were elaborated by F.g. Pearson, H. grillo, M.I. Perelman, and many other surgeons from various countries [3]. However, progress in this field of surgery has never stopped, and new ideas, modern methods, and medical equipment are continuously being introduced into clinical practice [4–7].

Surgical management of non-malignant subglottic laryngeal and tracheal stenosis is a complex problem that could not be covered in a single study; thus, we focused on the evaluation of the applicability and technical aspects of non-standard technical approaches (e.g., video medias-tinoscopy) and causes of postoperative complications—particularly, early internal abnormalities of the anastomosis leading to its restenosis.

Abstract The objectives of this study were the follow-ing: (1) to analyze the results of surgical treatment of non-malignant subglottic laryngeal and tracheal steno-sis, (2) to evaluate the feasibility and technical aspects of the video mediastinoscopy for the mobilization of the mediastinal trachea, (3) to evaluate the influence of the early internal condition of the anastomosis on the devel-opment of restenosis. From 1996 up to 2013, 75 patients aged 11–78 years underwent surgery for post-intubation/tracheostomy (71 patients), post-traumatic (3 patients), and idiopathic (1 patient) subglottic laryngeal and tra-cheal stenosis. Twenty-three (30.7 %) patients with sub-glottic laryngeal and upper tracheal stenosis underwent cricotracheal resection and thyrotracheal anastomosis (group A), while 52 (69.3 %) patients with tracheal ste-nosis underwent tracheal resection and cricotracheal or tracheotracheal anastomosis (group B). The length of the resected segment in patients of groups A and B was 28–55 (42 ± 11) mm and 18–65 (36 ± 14) mm, respec-tively, (p = 0.22). Perioperative complications within 30 days occurred in eight (34.8 %) patients of group A, and in six (11.5 %) patients of group B (p = 0.04). There was one intraoperative and one postoperative death on the third day due to heart failure. The excellent results were achieved in 63 (86.3 %), satisfactory in 8 (11.0 %), and unsatisfactory in 2 (2.7 %) patients. The incidence rate of perioperative complications is related to the location of the stenosis and the type of the resection and anastomosis. Video mediastinoscopy simplifies the

r. rubikas (*) · I. Matukaityte · J. J. Jelisiejevas · M. rackauskas Clinic of Cardiac, Thoracic and Vascular Surgery, Lithuanian Health Sciences University , Eivenių 2, 5009 Kaunas, Lithuaniae-mail: romaldasr@email.lt

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Materials and methods

Patients

Our institution is a university hospital, which often admits patients with complex neck and chest pathologies, includ-ing laryngotracheal stenosis.

A detailed retrospective analysis was completed involv-ing 75 patients who underwent single-staged surgical inter-vention for non-malignant subglottic laryngeal and upper tracheal (group A) and tracheal (group B) stenosis from July 1996 to January 2013. There were 56 males and 19 females, with age range 11–78 years. All these operations were performed by one of the authors of this study (r.r.) together with his young colleagues.

The most common cause of stenosis was prolonged endotracheal intubation following head and/or chest trauma or illnesses leading to respiratory failure (Table 1). In 26 (34.7 %) cases, tracheostomy was undertaken. Prior to surgery, 11 of these patients were decannulated, while 15 patients still had tracheostomy tubes in place. There were three (4.0 %) cases of tracheal stenosis with concomitant tracheo-esophageal fistula. Twenty-nine (39.6 %) patients had various residual functional and mental disorders caused by head and/or blunt chest trauma.

Preoperative evaluation

All patients underwent thorough clinical examination fol-lowed by flexible tracheobronchoscopy (FTB), neck and chest computed tomography (CT). Since 2005, modern hel-ical CT display modes (virtual bronchoscopy and multipla-nar reformatting) have been obtained. The airways of the patients with tracheostomy tubes in place were examined using a flexible bronchoscope through the nose or mouth and a stoma in the neck. We recorded the distance from

vocal cords up to the lesion, the internal diameter and the length of the stenotic segment, and the length of planned resection segment [8].

Patients demonstrating clinical symptoms of tracheo-esophageal fistula underwent flexible esophagogastroscopy and water-soluble contrast swallow X-ray examination.

Surgical techniques

In general, we adopted the classic principles and methods of laryngotracheal surgery [2, 3, 9]. The plan of the surgi-cal intervention was made on the basis of preoperatively obtained clinical data, FTB and CT findings. Surgical tech-niques were applied with respect to the location and the extent of the stenotic lesion as follows: (1) subglottic laryn-geal and upper tracheal stenosis—cricotracheal resection—thyrotracheal anastomosis (group A), (2) tracheal steno-sis—tracheal resection—cricotracheal or tracheotracheal anastomosis (group B).

All patients were operated on under general anesthe-sia. Orotracheal intubation was attempted, trying to move a small-caliber endotracheal tube through the stenotic seg-ment. However, in 17 (22.7 %) cases, this maneuver failed, and thus the distal end of the orotracheal tube was left above the stenosis. In patients with tracheostomy, lung ven-tilation was started via the tracheostomy tube.

Most commonly, a transverse cervical incision was used. The tracheostomy stoma was excised when present. Longitudinal sternotomy was undertaken in one case of combined pathology including myasthenia gravis (radi-cal thymectomy was done) and tracheal stenosis, and in three other patients with long (6–6.5 cm) tracheal stenosis. right-sided posterolateral thoracotomy was performed in one patient operated on due to the stenosis of mediastinal trachea.

Video mediastinoscopy in laryngotracheal surgery

Since 2003, we use a video mediastinoscope to mobilize mediastinal trachea [10–12]. Video-assisted control pro-vides a safe dissection of the antero-lateral (cartilaginous) wall of the mediastinal trachea up to its bifurcation and even main bronchi, if required. Surgical approach used in laryngotracheal surgery provides a good access to the mediastinum with a video mediastinoscope as well. When dissecting pretracheal fascia below the thyroid gland, care should be taken to apply ligation on the inferior thyroid vein to avoid bleeding, which causes additional difficul-ties when performing video-assisted mediastinoscopy. The pretracheal space just above and posteriorly to the innominate artery is entered and slightly widened with a blunt instrument and/or the surgeon’s index finger. This ensures a safe insertion of the video mediastinoscope

Table 1 Etiology of stenoses

a Including 26 patients with tracheostomyb Including 17 patients with associated thoracic, abdominal, and other injuries

Causes number of patients

Endotracheal intubation 71a

Brain trauma 44b

Blunt chest trauma 12

respiratory failure 8

Intoxication 5

Myasthenia gravis 1

Hemorrhagic stroke 1

Blunt neck trauma 3

Idiopathic 1

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along the anterior surface of the trachea. Before the begin-ning of further dissection, the tracheal rings should be clearly seen on the screen of the monitor. An experienced operator has no difficulties identifying the surrounding anatomical structures (the upper cava vein on the right side, aortic branches on the left side; and paratracheal and tracheobronchial lymph nodes). The instruments for dis-section and/or bleeding control are introduced through the internal lumen of the video mediastinoscope. As a dissect-ing instrument, a suction catheter with a small metal ring on the tip for electrocoagulation is used. Small bleeding vessels could be easily coagulated by touching the cath-eter’s electrocautery ring under video control. Vascular clips using special instruments could be applied as well. In most cases of laryngotracheal resection and anasto-mosis, it is enough to release the antero-lateral cartilagi-nous wall of the mediastinal trachea without accessing its bifurcation. To gain an extended tracheobronchial release, a firm fascial layer that usually covers the tracheal bifur-cation and the subcarinal space should be dissected. How-ever, at the right-sided tracheobronchial angle, the azygos vein is at a risk of injury. At the left-sided tracheobron-chial angle, care should be taken to avoid damage to the recurrent laryngeal nerve.

The anterior and lateral dissection of the lower part of the larynx and the circumferential tracheal dissection spar-ing the inferior laryngeal nerves extended over the scar and the malacic tissues. The trachea was exposed and transected just below the lesion. From this moment until the posterior part of the anastomosis was completed, the patients were kept on lung ventilation via a tube inserted into the distal part of the trachea. In cases of subglottic-tracheal steno-sis, the anterior and lateral portions of the cricoid cartilage were resected, leaving the posterior plate intact. The tra-cheal lesion was completely removed.

Until 2005, anastomosis was performed in a standard manner with interrupted sutures. During the recent years, we have used combined techniques including continuous and interrupted sutures. The posterior part of the anasto-mosis involving distal and proximal tracheal ends of the membranous wall or subglottic mucosa is performed with running 4-0 polydioxanone (PDS, Ethicon) sutures. The cartilaginous part of the anastomosis is carried out with interrupted 3-0 PDS or 3-0 polyglactin (Vicryl, Ethicon) sutures.

In patients with tracheal stenosis and concomitant tra-cheo-esophageal fistula, tracheal resection was performed in the manner described above. Subsequently, the esopha-geal fistula was closed with double-layer (mucosal and muscular) sutures and covered with vascularized muscular (m. sternocleidomastoideus or m. sternothyroideus) flap. The overlying trachea was anastomosed using the afore-mentioned technique.

At the end of the operation, two strong ligatures were placed through the patient’s chin and chest maintaining neck anteflexion for 7–8 days. As usual, patients were extu-bated in an intensive care unit as soon as they recovered spontaneous lung ventilation.

Assessment of the early condition of the anastomosis

Patients underwent FTB on the 6th or the 7th day after the operation to evaluate the internal condition of the anasto-mosis. At this time, the postoperative irritation and edema of the inner layer of the laryngeal and tracheal wall sub-side, making it possible to reveal internal abnormalities of the anastomosis (incomplete adaptation of the mucosa and/or suture dehiscence). To assess the internal condition of the anastomosis quantitatively, we developed an original scoring scale. The internal perimeter of the anastomosis is divided with two perpendicular lines into four equal sec-tors. Incomplete adaptation of the mucosa and suture dehis-cence in each of the sectors reduce the maximal score (10 points) by 1 and 2 points, respectively. In total, the early internal condition of the anastomosis was assessed as per-fect (10 points), satisfactory (9–8 points), or unsatisfactory (≤7 points).

A special assessment of the posterior part of the anas-tomosis was undertaken to compare the influence of con-tinuous (running) and interrupted sutures on the healing process.

Patients’ follow-up

Patients underwent clinical evaluation at 1, 3, and 6 months postoperatively, and subsequently—when indicated. FTB was undertaken in all patients in whom abnormalities in the early condition of the anastomosis were found. Bron-choscopic and/or surgical interventions were undertaken, if indicated.

At the end of the 6-month follow-up period, the out-comes were classified as follows: (1) excellent (free of symptoms), (2) satisfactory (mild and non-permanent symptoms), (3) unsatisfactory (postoperative complications requiring regular medical assistance).

Collection of data and statistical analysis

Personal details that might disclose the identity of patients were omitted. Permission from the local ethics committee for a retrospective study is not required in our country.

Perioperative events involved those occurring within 30 days. We recorded data concerning the patients’ age and gender, etiology and preoperative investigation, meth-ods of surgical treatment, and condition during the hospital stay, and 6-month follow-up. The variables are presented

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as number of cases and percentage, means with standard deviation, and range.

Statistical analysis was performed using SPSS software (version 15). A value of p < 0.05 was accepted as statisti-cally significant.

Results

Surgical aspects

Twenty-three (30.7 %) patients of group A underwent cri-cotracheal resection and thyrotracheal anastomosis. Tra-cheal resection with subsequent cricotracheal or tracheotra-cheal anastomosis was performed in 52 (69.3 %) patients of group B. The length of the resected cricotracheal segment was 28–55 (42 ± 11) mm, while the length of the resected tracheal segment—18–65 (36 ± 14) mm (p = 0.22).

Video mediastinoscopy during surgical intervention was used in 52 (69.3 %) cases. We never encountered any ana-tomical and/or technical difficulties when using this device. There were no technique-related complications. Compar-ing with the so-called “blind” (with the surgeon’s finger) approach, video-assisted mediastinoscopy provides a safer access to the tracheal bifurcation and even main bronchi. In all cases, this approach yielded a sufficient length of the mobilized mediastinal trachea, which allowed for carrying out the anastomosis with minimal tension.

The total duration of the surgical intervention using the standard and the modified (video mediastinoscopy and combined sutures for anastomosis) techniques was 155 ± 35 (range 115–200) min and 165 ± 25 (range 130–220) min, respectively (p = 0.50).

Perioperative events

Two (2.7 %) patients operated on for tracheal stenosis died: one during the operation, and one on the third postoperative

day; death in both cases was caused by heart failure, thus, the postoperative follow-up was continued in 73 (97.3 %) patients.

There were no cases of anastomotic suture dehiscence requiring urgent reoperation. The early internal condition of the anastomosis was assessed as excellent (10 points) in 62 (84.9 %), satisfactory (9–8 points) in 3 (4.1 %), and unsatisfactory (7–5 points) in 8 (11.0 %) out of 73 patients.

Incomplete adaptation of the mucosa along the posterior part of the anastomosis was detected in 8 (24.2 %) out of 33 patients in whom interrupted sutures were applied. The incidence rate of an incomplete adaptation of the mucosa following the application of continuous (running) sutures was 7.1 % (3 of 42 cases). However, the difference was not statistically significant (p = 0.08).

The total number of patients who developed one to three complications within 30 days following surgery in groups A and B was eight (34.8 %) and six (11.5 %), respectively, (p = 0.04). However, the incidence rate of individual com-plications did not differ significantly between the groups (Table 2).

Dysphonia and stridor seen just after the extubation of the patient were the earliest clinical signs indicating pos-sible vocal cord edema or lower laryngeal (recurrent) nerve palsy. All these patients underwent laryngoscopy before decision was made concerning the treatment options. For-tunately, tracheostomy was required only in one 54-year-old patient who sustained lesion of bilateral lower laryngeal nerves during surgically difficult cricotracheal resection and thyrotracheal anastomosis undertaken due to an idi-opathic subglottic stenosis.

Cervical wound infection in all cases was successfully cured with drainage and antibiotics. Two patients with anterior mediastinitis underwent cervical mediastinotomy, debridement, and drainage of the infected spaces. They both recovered without restenosis of the tracheotracheal anastomosis.

Table 2 Perioperative events

N total number of patients, n (%) number and percentage of patients with complicationsa Bronchoscopically assessed

Complications group A (N = 23) n (%) group B (N = 52) n (%) p

Wound infection 2 (8.7) 3 (5.8) 0.98

Anterior mediastinitis 1 (4.3) 1 (1.9) 0.77

recurrent nerve palsy

Bilateral 1 (4.3) – (0.0) 0.75

Unilateral 3 (13.1) 2 (3.8) 0.35

Unsatisfactory early condition of the anastomosisa

4 (17.4) 4 (7.7) 0.57

Pneumonia 2 (8.7) 2 (3.8) 0.74

Other 3 (13.1) 1 (5.8) 0.57

Intraoperative death 1 (4.3) – (0.0) 0.75

Postoperative death – (0.0) 1 (1.9) 0.69

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Events during the 6-month follow-up

restenosis developed in eight (11.0 %) patients in whom the internal condition of the anastomosis on the sixth or the seventh day after the operation was assessed at 6.43 ± 1.62 (5–8) points. Statistical analysis revealed that assessment less than 6.9 points predicts restenosis. Bronchoscopic interventions (dilation, elimination of free remnants of the suture material, and excision of granulations) were success-fully undertaken in six of eight patients with restenosis. They all are under continued follow-up. However, in two cases, repeated surgery was required. One patient under-went successful tracheal re-resection and end-to-end cri-cotracheal anastomosis. Another patient underwent trache-ostomy followed by a T-form tube insertion.

One patient who sustained a bilateral recurrent nerve lesion during the operation is still with the tracheostomy tube in place. Five patients with unilateral recurrent nerve palsy are living with minor symptoms.

In general, at the end of the 6-month follow-up, the post-operative results were classified as excellent in 63 (86.3 %), satisfactory in 8 (11.0 %), and unsatisfactory in 2 (2.7 %) patients.

Discussion

non-malignant (benign, non-tumoral) etiology and patho-genesis are the general features of post-intubation/tra-cheostomy, traumatic, and idiopathic stenosis involving subglottis and trachea, and thus problems arising towards surgical management of this pathology are often discussed together. Compared to the post-intubation/tracheostomy stenosis, traumatic and idiopathic lesion is a rare condition. The incidence rate of stenosis following prolonged tracheal intubation and/or tracheostomy has significantly decreased after modern tubes with low pressure and large volume cuffs were introduced into clinical practice. nevertheless, stenosis of this origin remains the most common indication for laryngotracheal surgery [13, 14].

The precise assessment of vocal cord function, the length of normal mucosa below the vocal fold, the loca-tion and vertical extent of the stenosis, inflammation and/or edema of airway mucosa, the patients’ functional condition, and co-morbidities are crucial steps of preoperative evalua-tion in each individual case. In clinically stable patients, it is recommended to delay the operation until regression of inflammation and stabilization of the scarring process are achieved. In general, appropriate indications and optimal timing of the surgery are the factors that significantly influ-ence on the outcomes [15].

Despite complexity and risk, a single-stage resec-tion of the stenotic segment with subsequent end-to-end

anastomosis provides success rates ranging from 74 to 97 % [16–19]. Our results (excellent in 86.3 %, and sat-isfactory in 11.0 % of cases) are consistent with those reported in the literature. On the basis of our experience, we would like to draw the readers’ attention to some impor-tant aspects inevitably arising in the laryngotracheal sur-gery. One of them is the creation of an anastomosis with minimal tension on the suture line. The suprahyoid (W.W. Montgomery method) or thyrohyoid (H.H. Dedo method) laryngeal release is commonly used to increase the possibil-ity of extended laryngotracheal resection. However, these techniques are complicated and risky because of swal-lowing problems arising during the postoperative period. Instead of the laryngeal release, we prefer the extended antero-lateral mobilization of the mediastinal trachea. As usually, surgeons perform this maneuver with fingers and/or standard instruments (the so-called “blind” method). At our clinic, mobilization of distal trachea has been modified by introducing video mediastinoscopy. There are no data in the literature concerning the use of video-assisted mediasti-noscopy in laryngotracheal surgery. The idea to use a video mediastinoscope (Storz, germany; Olympus, Japan) for antero-lateral dissection of the mediastinal trachea in lar-yngotracheal surgery arose when we became familiar with video-assisted mediastinoscopy in thoracic oncology. Thus, we transferred our skills and experience as well as the equipment from thoracic oncology to laryngotracheal sur-gery. Thoracic surgeons commonly use video mediastinos-copy for surgical staging of lung malignancies, when the involvement of mediastinal lymph nodes is suspected. First of all, this information helps to avoid unnecessary thora-cotomies [12]. This technique provides an excellent view of the operating field in the mediastinum, and ensures accu-rate bleeding control. We did not encounter any anatomical obstacles or technical difficulties when performing video mediastinoscopical antero-lateral dissection of the medias-tinal trachea up to the bifurcation or even the main bron-chi. In all cases, this technique yielded a sufficient length of the trachea, which allowed for carrying out the thyro-tracheal, cricotracheal or tracheotracheal anastomosis with minimal tension. no perioperative complications related to video mediastinoscopy in this series of our patients were observed. In experienced hands, video mediastinoscopic tracheal release is a safe procedure; however, the poten-tial for complications is apparent. Fortunately, most com-plications are minor, like pneumothorax or non-dangerous bleeding. Pneumothorax is treated with a standard drainage of the affected pleural space. Bleeding from small vessels is best handled with electrocautery, vascular clips, or by temporary packing with absorbable hemostatic material, i.e., Surgicel (Johnson & Johnson Medical, USA).

Major, catastrophic complications are extremely rare. They commonly include injuries to the great vessels, the

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trachea, or the esophagus. In cases of massive bleeding, immediate mediastinal packing temporarily controls this life-threatening complication, providing the time for urgent sternotomy or thoracotomy. Tracheobronchial lacerations involving air leakage are easily recognized during video-assisted mediastinoscopy. Most of these lacerations are small, and therefore could be successfully sealed by pack-ing with Surgicel. Oesophageal lacerations during video-assisted mediastinoscopy are casuistic events; however, they are often not recognized at the time of the procedure. Unfortunately, these dangerous complications are only revealed postoperatively when the patient develops acute perforating mediastinitis, confirmed by contrasting esoph-agography and computed tomography [10].

As we do not have our own data on suprahyoid or thyrohy-oid laryngeal releasing, we cannot compare it to video medi-astinoscopic approach. However, on the basis of our experi-ence (technical feasibility, any swallowing disturbances, and other perioperative mediastinoscopy related complications), we advocate the video mediastinoscopic tracheal release. Of course, in laryngotracheal surgery, we used our experience and skills gained in thoracic surgical oncology.

regarding the anastomosis technique, apart from the aforementioned avoidance of the excessive suture tension, meticulous adaptation of the proximal and distal ends of the airways is of great importance. Application of con-tinuous, instead of interrupted, sutures for the posterior (mucosal) part of the anastomosis does not require any extensive dissection of the mucosal layer to apply knots outside the lumen of the airways. In our series, a continu-ous (running) suture ensures a significantly better adapta-tion of the mucosa in the posterior part of the anastomosis.

Fortunately, in this series of our patients, there were no cases requiring urgent reoperation due to suture dehiscence. On the basis of our experience gained in the management of traumatic tracheobronchial injuries and the data from the lit-erature, we think that urgent reoperation should be indicated when the postoperative suture dehiscence is complicated by one or more of the following syndromes: (a) increasing air leakage, (b) acute mediastinitis, and (c) critical restenosis. Functionally stable patients without the above-mentioned complications should be treated non-surgically, including a bronchoscopic application of fibrin sealants [20].

Various etiologic and pathogenic aspects of postopera-tive complications following laryngotracheal surgery have been widely described [21, 22]. restenosis—which in most cases develops at the site of anastomosis—greatly reduces both the patient’s and the surgeon’s hopes for a fast relief of airways problems. We turned our attention to the influ-ence of the early internal condition of the anastomosis on its further healing process. Actually, the condition of the anastomosis is one of the most important criteria reflecting the quality of the surgical procedure. However, this factor

is rarely mentioned in the special literature. According to our experience, during 6–7 days after surgery postoperative irritation and/or edema of the inner layer of the laryngeal and tracheal wall subside enough to evaluate the internal condition of the anastomosis with flexible bronchoscope. Visual inspection performed by an experienced operator allowed for making an optimal decision concerning treat-ment options. Moreover, the quantitative assessment of the early internal condition using a scoring scale provides the quantification of the risk for restenosis.

A 6-month follow-up period seems to be enough to reveal postoperative complications, including restenosis. After that, an active observation and treatment should be continued in cases of satisfactory or unsatisfactory postop-erative outcomes. Sixty-three (86.3 %) of our patients with an uneventful postoperative course did not apply for any medical assistance due to airway problems after 6 months of follow-up. Hopefully, they are doing well. Our clinic is a referral center for laryngotracheal pathology, and thus all postoperative events are dealt with here.

The analysis of only one surgeon’s activity (of course, with the assistance of his young colleagues) in treating such a complicated pathology helps to avoid individual factors of diversity, which inevitably occur when the same type of operation is carried out by several surgeons. How-ever, in such cases, only the operating surgeon assumes all responsibility for the outcomes of the operations.

Conclusions

Our experience allows for concluding that the outcomes of surgical management of non-malignant subglottic-tracheal stenosis depend on the location of the stenosis, which determines the type of the resection and anastomosis. Post-operative complications are more common after cricotra-cheal resection with subsequent thyrotracheal anastomosis. Early internal abnormalities of the anastomosis predict its restenosis.

Video mediastinoscopy simplifies the mobilization of the mediastinal trachea, which allows for carrying out the anastomosis with minimal tension. We would like to encourage our colleagues to include this method in their professional armamentarium. Probably, during the period of the learning curve, cooperation with an experienced tho-racic surgeon would be advisable.

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