Right upper lobectomy via selective right upper lobe isolation using a left-sided double-lumen tube placed in the right bronchus intermedius: a case report.

BACKGROUND: One-lung ventilation (OLV) using a left-sided double-lumen tube (DLT) in the left main bronchus is standard for right thoracic surgery. When the contralateral left lung is severely compromised, this approach forces OLV to rely on the dysfunctional lung and risks critical hypoxemia.

CASE PRESENTATION: An 84-year-old woman with a left diaphragmatic hernia causing approximately 70% compression and atelectasis of the left lung was scheduled for right upper lobectomy. Preoperative assessment indicated that standard DLT placement would necessitate complete right lung collapse, placing the patient at risk of life-threatening hypoxemia. A 32-Fr left-sided DLT was intentionally inserted into the right bronchus intermedius under fiberoptic bronchoscopy (FOB). The bronchial cuff was positioned at the orifice of the right upper lobe (RUL) bronchus to achieve selective occlusion. Ventilation was delivered through the tracheal lumen to the left lung and through the bronchial lumen to the right middle and lower lobes. The RUL collapsed completely. Intraoperative oxygenation remained stable, with SpO2 greater than 95%. The patient underwent an uneventful thoracoscopic right upper lobectomy, was extubated immediately after surgery, and was discharged on postoperative day 6.

CONCLUSIONS: Intentional placement of a left-sided DLT into the right bronchus intermedius is a feasible strategy for selective RUL isolation when standard OLV is contraindicated due to severe contralateral lung compromise. Preoperative computed tomography (CT)-based airway assessment and fiberoptic bronchoscopic guidance are recommended for safe implementation.