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Lung cancer involving the carina can be treated by surgery, but patients must be carefully selected before the operation. Because pneumonectomy is required in addition to carinal resection, patients must be able to withstand the procedure, and they must be told that the operative mortality is 2 to 4 times higher than what is expected after standard pneumonectomy. Patients who have mediastinal nodal disease documented preoperatively by mediastinoscopy should not have this operation. In general, it is possible to perform a safe operation if the surgeon adheres to the principles of healthy bronchial suturing and restricts airway resection to a maximum distance of 4 cm. Surgeons must always remember, however, that it is better and safer to accept a positive resection margin than to have to deal with a bronchopleural fistula caused by anastomotic separation. Finally, reported long-term survival rates of 25% to 40% justify the use of this procedure.