Transcervical Tracheal Sleeve Resection
With Suprahyoid and Infrahyoid Release
return to:Trachea Surgical Protocols
see also mediastinal anatomy: Case Example Mediastinal Tracheostomy with Anatomic Diagrams
A separate protocol addresses the issue of upper tracheal stenosis involving the subglottic area. This protocol is written to address the problem of isolated, circumferential tracheal stenosis. Tracheal stenoses, located between the sternal notch and cricoid, which have failed endoscopic management with laser ablation, dilation, and steroid injection are an indication for this procedure. The long-term utility of conservative measures for tracheal stenoses, which are circumferential and greater than 1 cm in length, is questionable. Stenoses up to 3.5 to 4.5 cm are amenable to transcervical resection and primary anastomosis utilizing only transcervical tracheal mobilization procedures. For longer stenoses or for patients in whom cervical extension for exposure and cervical flexion will present a problem, intrathoracic maneuvers (mobilization of right hilum, dissection of pulmonary artery/vein, left bronchus reimplant) to mobilize additional trachea may be required. Stenoses that extend greater than 1 to 2 cm below the sternal notch may require limited thoracotomy for adequate exposure, particularly in more elderly patients.
- Severe pulmonary dysfunction or other medical problems, which present a high likelihood of requiring a tracheostomy in the future, are relative contraindications to this procedure. Patients with laryngeal stenoses as a separate problem should have that problem addressed prior to attempting tracheal sleeve resection.
- An incompetent larynx due to sensory, anatomic, or motor disturbance is a relative contraindication depending on the severity of the disturbance.
- Tracheal stenoses involving the intrathoracic trachea or stenoses greater than 4 to 4.5 cm should be done in conjunction with the cardiothoracic surgery service.
- Obstruction due to immature granulation tissue or very thin webs should be dealt with using endoscopic procedures. This procedure is reserved for circumferential, mature scar tissue with a vertical dimension greater than 0.5 to 1 cm.
- Pertinent Anatomy
- The trachea is a fibromuscular tube supported by 18 to 22 incomplete cartilaginous rings. There are approximately 2 rings per cm. The average length of the adult trachea from cricoid to carina is 11 cm (9 to 15 cm). The length of trachea above the sternal notch is approximately 6 to 9 cm. For young adults, a gap of 3 cm can be readily closed between tracheal stumps.
- For increased mobilization, a variety of transcervical maneuvers may be used. The amount of mobilization obtained with these maneuvers varies substantially among published series. The amount of trachea that can safely be excised also varies substantially between patients. The most frequently reported tracheal mobilization maneuvers include:
- Extreme flexion of the neck (1 to 6 cm)
- Incising the annular ligaments between tracheal rings (1 to 2 cm)
- Suprahyoid or infrahyoid release of the upper laryngotracheal unit (2.5 to 5 cm)
- Blunt dissection and mobilization of the lower tracheal segment (0.5 to 1 cm). A combination of laryngeal release procedures, blunt mobilization of the lower tracheal segment, and neck flexion will yield about 4 to 6 cm of mobilization depending upon the patients age and range of neck motion.
- Define etiology of stenosis through detailed history. If there is no etiology present from history (eg, tracheostomy, endotracheal intubation, trauma, etc) a work-up to evaluate for potential autoimmune disorders should be undertaken.
- All patients should have a sagittal MRI scan of the trachea and larynx to define the location and length of the stenosis. This must be done in the sagittal plane.
- The patient should have a direct laryngoscopy and bronchoscopy to assist in defining the exact location of the lesion, to rule out laryngeal pathology, and to determine the tissue nature of the stenosis.
- Preoperatively all patients should have a video stroboscopy.
- During a portion of the case, the patient will be jet ventilated. The tube used for jet ventilation is a Cook endotracheal tube changer. Discuss the need for this with the anesthesia team, and discuss the sequence of the case as outlined below. The patient only needs to be jet ventilated for a short period of time during the suturing of the posterior trachea.
- Potential Complications
- Failure of the procedure to secure an adequate airway is the major potential complication, and all patients are at risk for requiring a permanent tracheostomy following the procedure. The degree of this risk depends on a variety of factors including age, anatomy of the stenosis, comorbid illnesses, and history of prior neck surgery.
- Patients with diabetes and comorbid conditions that frequently require a tracheostomy have a high failure rate for laryngotracheal reconstruction procedures, and this should be discussed with the patient.
- The potential for recurrent nerve injury, esophageal injury, and the likelihood of temporary difficulty swallowing postoperatively should be discussed with the patient.
- Patients should be advised that they will have sutures securing the chin to the chest for 2 weeks following the procedure.
- Room Setup
- See Endoscopy Room Setup
- Back table x 2
- Mayo x 2
- See Endoscopy Room Setup
- Instrumentation and Equipment
- Medications (specific to nursing)
- 1% lidocaine with 1:100,000 epinephrine
- 4% lidocaine solution, topical (draw up in syringe to secure Abbocath)
- Oxymetazoline HCL nasal spray, 0.05%
- FRED (fog reduction elimination device)
- Prep and Drape
- Standard prep, 10% providone iodine
- After the endoscopic portion of the procedure and intubation, the patient should be prepped from the mouth to below the nipples. The patient will need to be draped so that the anesthesiologist can reach the endotracheal tube easily to partially withdraw and reinsert it at critical times during the case. The anesthesiologist also needs easy access to the endotracheal tube, through which the jet ventilation tube will be placed.
- Head drape
- Square off neck with towels
- Towel, plastic (sticky drape) placed on chin to isolate mouth if endoscopy procedure
- Split sheet
- Standard prep, 10% providone iodine
- Drains and Dressings
- Varidyne vacuum suction drains, 10 mm x 2
- Fluffs x 3
- Vaseline gauze
- Tegaderm x 2
- Special Considerations
- This procedure is indicated for tracheal stenosis at or above sternal notch not greater than 3.5 to 4 cm length. For longer stenosis below sternal notch, a combined thoracic procedure is advisable.
- Anesthesia will use jet ventilation. May use a Cook pediatric (or adult if endotracheal tube is at least a 7.5 cm) airway exchange catheter for the jet ventilation through the endotracheal tube.
- Have bronchoscopy setup to start with selection of bronchoscopes (4, 5, 6, 7 and 8).
- May use Cryo-glue. See Recipe for cryoprecipitate tissue glue.
- Jet ventilation apparatus, Cook endotracheal tube changer. This is a long, relatively stiff hollow tube that will be passed through the partially withdrawn endotracheal tube during the jet ventilation component of the case. The size and rigidity of this tube are ideal for these cases.
- Room Setup
- The patient should be supine with arms tucked and head toward the anesthesiologist for the operative part of the case.
- After the airway is secured and the patient asleep, a very large shoulder role should be placed for maximal neck extension.
- Be sure that the jet ventilation apparatus is in the room and functioning before the patient is put to sleep. All of the laryngoscopes and bronchoscopes should be ready when the patient is brought into the room.
- The patient should receive a perioperative dose of antibiotics and 8 to 10 mg of Decadron IV before the start of the case.
- The patient is induced with mask anesthesia, breathing spontaneously, not paralyzed. A bronchoscope is introduced that will likely pass through the stenosis; have several sizes available. When the airway is secure, patient may be paralyzed. Determine the exact length of the stenosis and distance from vocal cords. Determine that procedure is possible.
- The patient is then intubated with the largest tube that will pass through the stenosis. This is done by the otolaryngologist, and the tube is placed so that the cuff is distal to the stenosis. The patient is placed is extreme neck extension and the neck is prepped and draped.
- Transverse collar incision from lateral border of sternocleidomastoid muscle to contralateral side at the level of the cricoid, subplatysmal flaps raised from above hyoid to below sternal notch. Divide straps in the midline, divide thyroid at isthmus, and bluntly dissect the thyroid lobes laterally away from the trachea. Do not attempt to find or dissect the recurrent laryngeal nerves. All tracheal dissection is done medial to them; attempts at localization will increase the chance that they will be injured.
- Separate the straps and identify upper border of thyroid cartilage from superior horn to superior horn. Be careful not to injure the superior laryngeal neurovascular bundle. Sharply incise the thyrohyoid membrane along the upper surface of the thyroid cartilage; extend this cut out to the superior horns. Pre-epiglottic fat should be visible at the depth of the incision. Using heavy Mayo scissors, transect both superior horns (this releases the lateral thyroid ligament to the hyoid and is a crucial maneuver). Identify digastric tendons. Using Bovie dissection, skeletonize the hyoid from lesser cornu to lesser cornu. This will also include division of the strap muscles in this area. Using bone cutters or heavy Mayo scissors, divide the hyoid just lateral to both lesser cornu and remove intervening segment.
- The suprahyoid and infrahyoid release is now complete. Skeletonize the cartilaginous trachea from the cricoid to as far into the chest as possible using finger and blunt dissection. Measuring from the middle of the thyroid cartilage, determine where the middle of the stenosis will be. Vertically incise 1 or 2 tracheal rings at that location so that the stenosis can be visualized through the tracheotomy. Adjust the endotracheal tube if needed so that the balloon is distal to the stenosis and working area. When the length of the stenosis and its location are visualized, incise the annular ligament below and above the stenosis. Try not to make these circumferential incisions through cartilage as this will potentially predispose to reformation of the stenosis.
- Using careful sharp dissection under loupe magnification, excise the stenotic segment of trachea. Be careful posteriorly that the esophagus is not injured. Oppose the ends of the sectioned trachea and determine that an anastomosis is possible; further release can be obtained with gentle upward traction on the distal trachea and further finger dissection. Place 2 2-0 silk sutures through the distal trachea 2 rings distal to the sectioned end and 2 rings above the anastomosis. These are stay/control sutures and are placed laterally 180° from each other. Alternatively, place 2-0 vicryl sutures rather than silk, leave the needles attached (protected) and use these same "traction sutures" as as "bolstering sutures" tied after placing through cartilage two rings away from the anastomosis.
- Prepare the jet ventilation apparatus and tube. Intermittently suction the distal trachea so that blood does not run into the lungs. Withdraw the endotracheal tube into the upper trachea and advance the Jet ventilation tube through the endotracheal tube into the distal trachea. At no time during the procedure is the endotracheal tube completely withdrawn. Be sure that air egress is possible during jet ventilation. Bring the patients neck out of flexion. Oppose the back wall of the trachea and begin the anastomosis with 4-0 vicryl sutures; do not struggle trying to place the knots extraluminally. If that is not easily done, place the knots intraluminally and cut the sutures short. It is helpful to place most of the back wall sutures before tying them.
- Once the majority of the back wall is done, replace the 2-0 silk sutures used for traction with 2-0 vicryl sutures. Once the anastomosis reaches the cartilaginous trachea, switch to 3-0 vicryl sutures. These are placed through the annular ligament 1 ring above and below the cut ends of the trachea. Across the anterior 180° of the trachea, place 3-0 vicryl sutures as before and several more 2-0 vicryl bolstering sutures, 2 rather than 1 ring from the anastomosis.
- At a point when visualization into the trachea is still possible, remove the jet ventilation tube and advance the endotracheal tube so that the balloon is below the anastomosis. Complete the anastomosis.
- Place 2 large suction drains along the lateral trachea and up into the suprahyoid area. Be sure that hemostasis is meticulous. Close the neck incision with a minimal number of subcutaneous 4-0 vicryl sutures and Steristrips.
- Bring the neck into maximum flexion. Place 2 0-prolene sutures around the mandible and deeply into the upper chest subcutaneous tissue to maintain the neck in maximum flexion.
- The patient should go to the ICU intubated. Plan to extubate the patient the following morning At extubation have headlights and tracheostomy tray out and ready for immediate use. Flexible scope is used after extubation to evaluate larynx. Perioperative antibiotics should continue for 48 hours, and the patient should get 3 more doses of Decadron every 8 hours after surgery. After this the patient begins a Medrol Dose-Pack of oral steroids or equivalent.
- Heavy cool mist at all times for 4 days. Begin clears and advance as tolerated on postoperative day 2. Prolene chest sutures to remain for 10 days. These patients may develop some granulation around the anastomotic site several weeks following surgery. This should be anticipated if there is any evidence of airway compromise following surgery. They should be readmitted, placed on antibiotics and steroids, and cool mist and bronchoscopy should be scheduled.
31780, Excision of stenosis and anastomosis cervical
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