Difficult Establishment of One-Lung Ventilation Due to Preoperatively Undiagnosed Tracheal Bronchus and Collateral Respiratory Pathway in a Patient with Situs Inversus Totalis

Secure one-lung ventilation (OLV) must be guaranteed during thoracoscopic surgery, and special attention is required for patients with central airway anomalies. A 72-year-old man with situs inversus totalis was scheduled for pleural biopsy for diagnosis of the pleural effusion etiology. We experienced difficult right bronchial intubation using a left-sided double-lumen tube due to subglottic resistance caused by tracheal deviation. Six months later, partial resection of the left lower lung lobe was scheduled under the diagnosis of adenocarcinoma. This time, we chose combined use of a single-lumen tube and a bronchial blocker; however, due to a tracheal bronchus and collateral respiratory pathways, which were preoperatively undiagnosed and incidentally found during the surgery, we could not successfully establish OLV. Based on our experience with this patient, we emphasize the importance of careful assessment of the tracheobronchial tree in patients with central airway anomalies who undergo surgery requiring OLV.