Thoracoscopic tracheobronchial reconstruction using a suture-hiding workflow: perioperative and early airway outcomes of a 22-patient case series

Thoracoscopic airway reconstruction remains technically demanding because limited exposure and long suture strands can complicate needle handling, suture organization, and tension control. The suture-hiding technique (SHT) temporarily secures one needle-bearing end of a double-armed polypropylene suture within a cylindrical gauze, allowing staged, bidirectional, visibility-guided continuous suturing. We evaluated the technical feasibility and early clinical outcomes of this workflow. This single-center retrospective case series included 22 patients who underwent SHT-assisted thoracoscopic airway reconstruction between July 2020 and December 2025, comprising 20 sleeve lobectomies and 2 tracheal resections. SHT was used selectively according to airway anatomy, anticipated operative exposure, and surgeon judgment. All procedures were performed by one surgeon with prior experience in thoracoscopic sleeve resection and airway reconstruction. Outcomes included technical completion, perioperative and pathological results, airway reconstruction-related adverse events, and follow-up findings. All analyses were descriptive. All 22 planned SHT-assisted reconstructions were completed through biportal video-assisted thoracoscopic surgery without conversion to thoracotomy, use of an alternative reconstruction strategy, additional repair sutures, or residual air leak on intraoperative testing. R0 resection was achieved in all patients; 13 had received neoadjuvant therapy and 5 had pathologically positive lymph nodes. Median airway reconstruction time was 22.5 min (range, 17–33). Postoperative complications occurred in 6 patients (27.3%), all Clavien–Dindo grade I or II, with no reintervention or 30-day mortality. All patients underwent computed tomography and bronchoscopy at approximately 1 month, with no reconstruction-site finding requiring intervention. No airway reconstruction-related adverse event was recorded during a median follow-up of 12.5 months (range, 1–65). One distant recurrence occurred at 17 months, and all patients were alive at their last documented follow-up. This 22-patient series supports the technical feasibility of SHT-assisted thoracoscopic airway reconstruction in selected patients treated by an experienced thoracoscopic airway surgeon, with complete resection and satisfactory early airway outcomes. Its reproducibility and comparative value should be evaluated across surgeons and centers using procedure-matched comparators.