Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 678 - файл
.pdf
146
https://t.me/medicina_free
M. Zhang et al.
spread of tumour, as well as additional prognostic
features is challenging. Especially in adenoid
cystic carcinomas and invasive thyroid malignancy, MRI has been shown to provide additional
information regarding extent of invasion of the
tracheal wall. Despite these advantages, MRI has
not been specically been shown to confer any
signicant additional diagnostic benet.
10.7.1.4 Positron-Emission
Tomography (PET)
Fluorine 18-uorodeoxyglucose (FDG) positronemission tomography (PET) and fused PET/CT
images can be helpful in distinguishing between
malignant and benign tumours. Benign tumours
typically exhibit minimal or no standardised
uptake values (SUV), whereas malignant lesions
often demonstrate high SUVs. It can also be
helpful in establishing whether disease has
metastasised to regionally to lymph nodes, or to
distant sites. This modality can also help assess
response to adjuvant treatment and determine the
presence of residual or recurrent disease, with
follow-up PET scans typically performed at
8weeks post adjuvant radiotherapy.
10.7.1.5 Ultrasonography
Whilst not utilised to diagnose tracheal malignancies, the use of ultrasonography and ultrasonographically guided biopsies of lymph nodes
can be a useful adjunct in assessing progression
of disease.
nary function testing can be utilised to track
progress, with peak ows easily self- administered
to detect subtle early changes.
10.7.3 Endoscopic Evaluation
andBiopsy
Bronchoscopy and biopsy is the gold-standard
for diagnosing tracheal tumours and is a critical
step in the workup of these masses. Initial exible bronchoscopy can be performed to visualise
the lesion. In patients with non-obstructing distal
lesions, biopsies can be taken via the exible
bronchoscope. Despite both exible and rigid
bronchoscopy allowing for visualisation of the
trachea down to the level of the carina and biopsy,
the simplest way to evaluate tracheal lesions is
via microlaryngoscopy and a rigid endoscope
whilst the patient is either spontaneously breathing, or being oxygenated via jet ventilation or
THRIVE.Any lesions can then be biopsied, and
if necessary, the surgeon can debulk the tumour
with laser or coblation and/or perform airway
dilatations. Another advantage rigid bronchoscopy offers is the ability to apply pressure in the
event of bleeding from the tumour or biopsy
sites.
10.8 Management ofTracheal
Malignancy
10.7.2 Pulmonary Function Testing
Pulmonary function testing (PFTs) has a limited
role in the diagnosis of tracheal malignancies.
They can suggest upper airway obstruction with
attening of the inspiratory and/or expiratory
ow-volume loops. This can differentiate
between both proximal and distal airway disease
as well as intratracheal or extratracheal compression. The presence of these ndings does not
diagnose a tracheal tumour, and their absence
does not preclude one; further investigation with
imaging and endoscopy is required. Following
treatment of tracheal malignancies, serial pulmo-
The management of tracheal malignancies is
complex and necessitates multidisciplinary
approach with detailed input from surgeons
(ENT, Head and Neck, Thoracic), physicians
(respiratory and intensivists) and anaesthetics
for management of the shared airway, radiologists, pathologists, medical and radiation
oncologists. Given the scarcity of these
tumours, there are no randomised controlled
trials to suggest the most effective treatment
approach. Treatment regimens are based on
basic oncologic principles and contingent on
the surgical resectability of the tumour, with
adjuvant therapy determined by histopathological subtype and other high-risk factors includ-
10 Tracheal Surgery andTracheostomy
https://t.me/medicina_free
147
ing positive margins, perineural invasion,
lymphovascular invasion and extracaspsular
spread.
10.8.1 Endoscopic Assessment
andManagement
If examination under anaesthesia via microlaryngoscopy and rigid endoscopy has not been performed previously, it should be done immediately
prior to resection. This allows the surgeon to
comprehensively assess the lesion and airway,
plan the exact nature of the approach to the lesion
and precise location of incisions. Depending on
disease progression and patient suitability for
surgery, tracheal lesions may be debulked to
improve the airway with either coblation or laser,
avoiding a long-term tracheostomy whilst
enabling denitive, curative treatment via
radiotherapy.
10.8.2 Surgical Resection
Surgical resection is the core treatment modality
in tracheal malignancy, with tumour resectability
a key factor in long-term survival.
The three governing surgical principles in tra-
cheal surgery for malignancy are:
1. Ensuring all tumour is resected with adequate
margins to optimise outcomes.
2. Limiting lymph node dissection and excessive
tracheal mobilisation to preserve arterial supply, minimising risk of tracheal ischaemia,
necrosis and stenosis.
3. Achieving a tension-free anastomosis.
10.8.3 Airway Management during
Tracheal Surgery
The management of the airway during tracheal
surgery requires clear communication between a
surgical and anaesthetic team, with experience in
managing these complex cases. The initial establishment of an airway, followed by maintenance
of an airway after tracheal resection are the two
main challenges. Ideally, the airway is stabilised
prior to denitive surgical resection with debulking; however, it is not uncommon to have patients
in respiratory distress. In these cases, slow induction with inhalational gases, avoidance of paralysis and the maintenance of spontaneous
ventilation may be required. A tracheostomy is
generally only utilised in patients with proximal
tracheal lesions, as it may hinder subsequent tracheal anastomosis.
During resection, the nature of the lesion and
type of resection will dictate the manner in which
the airway is managed. For simple window resections, the endotracheal tube can often be left in
situ (or advanced beyond), with care taken to
avoid puncturing the cuff. Where segmental tracheal resection is required, ventilation via an on
table endotracheal tube needs to be planned (socalled ‘cross-eld’ ventilation). Generally, the
distal incision is made rst, with the distal tracheal stump intubated directly from the surgical
bed. This is done under apnoea. A silk suture can
be placed through Murphy’s Eye of the original
endotracheal tube to allow for easy retrieval at
the end of the procedure. The on table tube is
then secured and the orotracheal tube is left in the
larynx and out of the way of the resection. Once
the resection is complete, the posterior anastamotic sutures are placed. The existing endotracheal tube is then advanced beyond the
transection, allowing for the anterior anastamotic
sutures to be placed and the anastomosis to be
completed. Typically, all sutures are interrupted
with the knot placed on the external surface of the
trachea.
Depending on the location of the tumour,
other methods such as passing a small jet ventilation catheter into the distal airway, or for
more distal lesions, intubating the right and left
main bronchi directly are possible. Jet ventilation needs to be utilised with caution, as the
constant insufation of air can cause barotrauma due through progressive lung hyperination and increased ventilating pressures.
Cardiopulmonary bypass remains an option;
however, it comes with signicant thrombotic
risk and is rarely required.
148
https://t.me/medicina_free
M. Zhang et al.
10.8.4 Approach
Different incisions can be utilised to provide
access to allow for resection and reconstruction,
depending on the size and location of the primary
tumour. Upper and mid-tracheal lesions can be
accessed with a low cervical collar incision, with
the option of a further vertical limb or partial/full
median sternotomy providing access inferiorly.
For more distal tracheal lesions, access may be
gained through a right posterolateral thoracotomy through the fourth intercostal space. When
using a cervical incision, the patient is positioned
with the neck in a fully extended position with
the assistance of a shoulder roll. In a similar fashion to a tracheostomy, the subplatysmal plane is
developed and the trachea is exposed by separation of the strap muscles at the midline. Major
mediastinal vasculature, especially the innominate artery, need to be identied and protected.
Mobilisation of the trachea depends on the
extent of resection required and additional
procedures such as thyroidectomy and or lymph
node dissection. In general, the trachea should be
mobilised only on its anterior surface to the level
of the carina. At the point of resection, dissection
should remain close to the trachea to protect the
recurrent laryngeal nerves. Alternatively, these
can be fully dissected and formally identied
after removal of the thyroid gland and associated
lymphatic tissue. Should resection of the cricoid
cartilage be necessary, it is important to stay deep
to its external perichondrium in order to avoid the
recurrent laryngeal nerve at the level of Berry’s
Ligament and the criocothryoid joint, whilst preserving vascularity.
10.8.5 Extent ofResection
10.8.5.1 Tracheal Shave
This is the simplest method of tracheal excision,
typically performed in patients with thyroid cancer. A margin is shaved off the surface of the trachea, with postoperative radioactive iodine relied
upon to control and residual tumour should it be
present. Despite this method perhaps being simpler and initially effective, the tumour is more
predisposed to recur, especially if the trachea
shave demonstrated disease involvement.
10.8.5.2 Simple Segmental Tracheal
Resection
This is the most common type of tracheal resection, where a tracheal segment with disease/
tumour involvement is resected. Important anatomical structures and landmarks such as the thyroid isthmus, cricoid, trachea and innominate
artery are identied (Fig.10.1a). The trachea is
then mobilised on its anterior surface only to the
level of the carina, ensuring dissection remains
close to the trachea itself, and that superior mediastinal structures are avoided (Fig.10.1b). Based
on the extent of disease and accounting for margins, the superior and inferior limits of resection
are then identied (Fig. 10.1c). The trachea is
then mobilised circumferentially at the level of
the resection, along the trachea-oesophageal
groove; taking care to protect the recurrent laryngeal nerves bilaterally (Fig.10.1d).
After the excised segment is mobilised, the
inferior cut can be made. The endotracheal tube
is withdrawn slightly if required, allowing the
distal tracheal stump to be directly intubated via
the surgical bed with a exible, sterile endotracheal tube (Fig.10.1e, f). When the airway has
been established, the resection is completed with
the superior cut and division of the trachealis
muscle posteriorly.
Silk stay sutures are placed laterally around
the superior and inferior tracheal rings and are
brought together, allowing the surgeon to assess
the level of tension of the anastomosis
(Fig. 10.1h). Generally, a monolament suture
such as PDS is used, and the neck is placed in
exion to further reduce tension. The posterior
sutures are placed rst in a continuous manner,
with the knot of the suture on the external surface
of the trachea. The endotracheal tube may be
intermittently inserted and removed, balancing
the need for ventilation with repair of the posterior tracheal wall (Fig.10.1i). The anastomosis is
10 Tracheal Surgery andTracheostomy
https://t.me/medicina_free
149
completed anteriorly with the placement of interrupted sutures around the adjacent anterior tracheal rings (Fig.10.1j). Once the anastomosis is
almost complete, the original endotracheal tube
is pushed back down, distal to the anastomosis to
facilitate normal ventilation. A ‘reminder’ or
‘guardian’ chin-to-chest suture is placed to prevent hyperextension (Fig. 10.1k). The patient
should be extubated postoperatively.
10.8.5.3 Window Resection
andRepair
This type of resection most encountered during
thyroid surgery, where there is evidence of
tumour adherence to the tracheal wall. A horizontal cervical incision is made to expose the thyroid
isthmus, allowing the cricoid and trachea to be
identied (Fig.10.2a). The trachea is mobilised,
and the window to be excised is delineated
(Fig.10.2b). Care must be taken to avoid inadvertent injury to the recurrent laryngeal nerves.
The area is excised and the tracheal lumen is
entered (Fig. 10.2c). Following resection, there
are a number of methods by which the defect can
be addressed. Should the defect be mainly anterior, a tracheostomy tube can be inserted, and the
window can be allowed to heal via secondary
intention after decannulation.
For small non-circumferential defects, a local
ap is a simple option for immediate repair; with
the sternocleidomastoid located nearby
(Fig.10.2d). The sternocleidomastoid can either be
divided superior (Fig.10.2e) and rotated medially
to cover the defect (Fig.10.2f) or mobilised inferior
with the periosteum of the clavicle (Fig.10.2g) and
rotated medially to cover the defect (Fig.10.2h).
When suturing in the muscle, tension of the muscle
is required to prevent collapse of the muscle into
the trachea during inspiration.
10.8.5.4 Cricotracheal Resection
andThyrotracheal
Anastomosis
This method involves resection of the cricoid,
with subsequent thyrotracheal anastomosis
achieved in either a sliding or step-wise fashion.
Slide
The area to be resected is exposed, including the
thyroid isthmus, anterior arch of the cricoid cartilage and tracheal rings below (Fig.10.3a). The
thyroid isthmus is divided and the thyroid lobes
are dissected off the lateral tracheal walls with
care taken to avoid injury to the recurrent laryngeal nerves (Fig.10.3b).
The anterior arch of the cricoid is mobilised
from above and removed. The cricotracheal ligament laterally is also mobilised, staying deep/
inside the external perichondrium, protecting the
recurrent laryngeal nerves which run outside this
layer. The internal cricoid perichondrium is
mobilised posteriorly in continuity with the
trachealis muscle, allowing detachment of the
trachea from the remaining posterior cricoid lamina. The trachea can then be mobilised off the
oesophagus (Fig.10.3c).
The inferior cut is made, and the distal stump
of the trachea is directly intubated through the
surgical bed with a exible sterile endotracheal
tube. The oro-endotracheal tube is withdrawn to
facilitate this, but not removed as it will be
required after anastomosis (Fig.10.3d). The excision is completed with the superior cut, with care
taken to avoid inadvertent injury to the oesophagus posteriorly (Fig.10.3e).
Stay sutures are placed laterally, bringing the
segments together in a tension-free fashion. The
trachea inferiorly will telescope into the cricoid
and approximate the thyroid cartilage (Fig.10.3f).
The posterior wall is repaired rst by placing
sutures through the subglottic mucosa and part of
the posterior cricoid lamina using a monolament continuous suture (PDS).
The oro-endotracheal tube is retrieved back
into the distal airway, and the anterior wall of the
trachea is repaired with interrupted sutures placed
around the thyroid cartilage superiorly and tracheal ring inferiorly. Soft drains are placed, the
wound is closed in layers and a chin-to-chest
reminder suture preventing hyperextension is
placed. Extubation is preferred; however, a small
tracheostomy tube can be placed if there are airway concerns (Fig.10.3g).
150
https://t.me/medicina_free
M. Zhang et al.
ab c
de f
gh
jk
i
10 Tracheal Surgery andTracheostomy
https://t.me/medicina_free
151
Fig. 10.1 (a) The thyroid isthmus is exposed, with
important anatomical landmarks (cricoid, trachea and
innominate artery inferiorly) identied. (Key: red thyroid, green tumour, light blue endotracheal tube, grey
trachea, thin black lines recurrent laryngeal nerves). (b)
The trachea is mobilised bluntly on its anterior surface
only to the level of the carina, taking care to avoid injury
to superior mediastinal vascular contents. (Key: red thyroid, green tumour, light blue endotracheal tube, grey
trachea, thin black lines recurrent laryngeal nerves). (c)
The superior and inferior extent of resection are identied. (Key: red thyroid, green tumour, light blue endotracheal tube, grey trachea, thin black lines recurrent
laryngeal nerves, thick black line superior and inferior
margins of resection). (d) Circumferentially mobilise the
trachea at the level of resection, avoiding injury to the
oesophagus by separating the trachea-oesophageal
groove region. (Key: red trachea-oesophageal groove,
green tumour, light blue endotracheal tube, grey trachea,
thin black lines recurrent laryngeal nerves, thick black
line superior and inferior margins of resection). (e) The
trachea is entered via the inferior cut, the endotracheal
tube is withdrawn and the distal stump is intubated via a
separate endotracheal tube, through the operative eld.
(Key: red thyroid, green tumour, light blue endotracheal
tube, dark blue intubation of distal tracheal stump, grey
trachea, thin black lines recurrent laryngeal nerves, thick
black line superior and inferior margins of resection). (f)
The trachea is entered via the inferior cut, the endotracheal tube is withdrawn, and the distal stump is intubated
via a separate endotracheal tube, through the operative
eld. (Key: red thyroid, green tumour, light blue new
endotracheal tube, grey trachea, thin black lines recurrent
laryngeal nerves, thick black line superior and inferior
margins of resection). (g) The resection is completed by
making the superior cut and dividing the trachealis posteriorly. (Key: red thyroid, green tumour, light blue endotracheal tube, grey trachea, thin black lines recurrent
laryngeal nerves, orange defect). (h) Silk stay sutures are
placed laterally around the superior and inferior tracheal
rings and test bringing the segments together in a tensionfree manner. You may need to remove the shoulder roll
and place the neck in slight exion to reduce tension.
(Key: red thyroid, green tumour, light blue endotracheal
tube, grey trachea, thin black lines recurrent laryngeal
nerves, thick black line stay silk sutures, orange defect).
(i) Commence your repair by placing sutures posteriorly
rst. You might use a monolament (PDS) in a continuous manner. Utilise the stay sutures to bring the posterior
wall together to facilitate a tension-free repair.
Endotracheal tube may be intermittently inserted and
removed intermittently to facilitate oxygenation, or to
expose the posterior wall fully. (Key: red thyroid, green
tumour, light blue endotracheal tube, grey trachea, thin
black lines recurrent laryngeal nerves, thick black line
sutures, orange defect). (j) The anastomosis is completed
anteriorly by placing sutures around the adjacent tracheal
rings using interrupted sutures (PDS). (Key: red thyroid,
green tumour, light blue endotracheal tube, grey trachea,
thin black lines recurrent laryngeal nerves, thick black
line sutures, orange defect). (k) Once the repair is nearly
complete, push the endotracheal tube back down to facilitate normal ventilation. Insert soft drains to prevent subcutaneous emphysema and close the wound in layers.
Place a ‘reminder stitch’ between the mentum and the
sternum to prevent inadvertent hyperextension. Aim to
extubate the patient at the end of the procedure. (Key: red
thyroid, light blue endotracheal tube, grey trachea, thin
black lines recurrent laryngeal nerves, thick black line
sutures, orange defect)
Step-Wise
This technique is ideally suited to tumours
located at the level of the cricotracheal groove
and Berry’s Ligament, with sacrice of the recurrent laryngeal nerve potentially necessary. The
trachea is rst mobilised on its anterior surface to
the level of the carina (Fig.10.4a). The tumour is
then excised with sections of the cricoid cartilage
and adjacent tracheal rings. If possible, dissection should stay inside or deep to the external
perichondrium of the cricoid, protecting the
recurrent laryngeal nerves. (Fig.10.4b). A stepwise cut is fashioned in the distal trachea, with
the corresponding segment removed (Fig.10.4c).
The distal segment is advanced into the superior
resection margin, with stay sutures helpful in
bringing the segments together (Fig.10.4d). The
posterior wall is repaired rst, and then the anterior walls are brought together with interrupted
monolament sutures (PDS). The repair can be
completed while the endotracheal tube remains
in situ taking care to avoid injury to the cuff
(Fig.10.4e).
10.8.6 Principles ofAnastomosis
Following resection, the patient’s neck is restored
to a exed position to allow for anastomosis.
Depending on the segment excised, anastomoses
can be performed in an end-to-end, end-to-side or
sliding fashion utilising continuous sutures inter-
152
https://t.me/medicina_free
M. Zhang et al.
a
bc
de
gh
f
Fig. 10.2 (a) Expose trachea via a horizontal cervical inci-
sion. Identify cricoid above and trachea below the thyroid
isthmus. (Key: red thyroid, green tumour, light blue endotracheal tube, grey trachea, thin black lines recurrent laryngeal nerves). (b) The trachea is carefully mobilised, with
the window to be excised delineated. Care is taken to avoid
injury to the recurrent laryngeal nerve. (Key: red thyroid,
green tumour, light blue endotracheal tube, grey trachea,
thin black lines recurrent laryngeal nerves, thick black lines
window resection). (c) The area is excised, the tracheal
lumen is entered and tumour removed. (Key: red thyroid,
green tumour, light blue endotracheal tube, grey trachea,
thin black lines recurrent laryngeal nerves). (d) The adjacent sternocleidomastoid muscle is ideally located. (Key:
light red thyroid, dark red sternocleidomastoid, green
tumour, light blue endotracheal tube, grey trachea, thin
black lines recurrent laryngeal nerves, yellow clavicle, blue
periosteum of clavicle). (e) Option 1—The sternocleidomastoid muscle is partially divided superiorly, taking care
to avoid injury to the accessory nerve and underlying
carotid sheath. (Key: light red thyroid, dark red sternocleidomastoid, green tumour, light blue endotracheal tube, grey
trachea, thin black lines recurrent laryngeal nerves, yellow
clavicle, blue periosteum of clavicle). (f) Option 1—The
superior portion of the sternocleidomastoid is rotated into
the defect medially. This is sutured into the edge of the
defect ensuring adequate tension to avoid collapse into the
tracheal lumen during respiration. (Key: light red thyroid,
dark red sternocleidomastoid, green tumour, light blue
endotracheal tube, grey trachea, thin black lines recurrent
laryngeal nerves, yellow clavicle, blue periosteum of clavicle). (g) Option 2—The sternocleidomastoid muscle can be
mobilised inferiorly together with periosteum of the clavicle below. (Key: light red thyroid, dark red sternocleidomastoid, green tumour, light blue endotracheal tube, grey
trachea, thin black lines recurrent laryngeal nerves, yellow
clavicle, blue periosteum of clavicle). (h) Option 2—The
inferior mobilised muscle is rotated medially and sutured to
the edges of the tracheal defect, ensuring some degree of
tension in order to avoid collapse into the tracheal lumen.
(Key: light red thyroid, dark red sternocleidomastoid, green
tumour, light blue endotracheal tube, grey trachea, thin
black lines recurrent laryngeal nerves, yellow clavicle, blue
periosteum of clavicle)
10 Tracheal Surgery andTracheostomy
https://t.me/medicina_free
153
a
bcd
efg
Fig. 10.3 (a) Expose the area to resected which includes
the anterior arch of the cricoid cartilage and the tracheal
rings below. (Key: light red thyroid, green tumour, light
blue endotracheal tube, grey trachea, thin black lines
recurrent laryngeal nerves). (b) The thyroid isthmus is
divided, and the thyroid lobes are mobilised off the lateral
tracheal walls, taking care to avoid injury to the recurrent
laryngeal nerves. (Key: light red thyroid, green tumour,
light blue endotracheal tube, grey trachea, thin black lines
recurrent laryngeal nerves, thick black lines superior and
inferior limit of resection). (c) The anterior arch of the
cricoid is mobilised from above and removed. The cricotracheal ligament laterally is also mobilised, staying
deep/inside the external perichondrium, protecting the
recurrent laryngeal nerves which run outside this layer.
The internal cricoid perichondrium is mobilised posteriorly in continuity with the trachealis muscle, allowing
detachment of the trachea from the remaining posterior
cricoid lamina. The trachea can then be mobilised off the
oesophagus. (Key: light red thyroid, green tumour, light
blue endotracheal tube, grey trachea, thin black lines
recurrent laryngeal nerves, thick black lines superior and
inferior limit of resection). (d) The inferior cut is made,
and the distal stump of the trachea is directly intubated
through the surgical bed. The oro-endotracheal tube is
withdrawn to facilitate this, but not removed as it will be
required after anastomosis. A silk suture may be placed
through Murphy’s Eye in order to allow retrieval after
anastomosis. (Key: light red thyroid, green tumour, light
blue endotracheal tube, grey trachea, thin black lines
recurrent laryngeal nerves, thick black lines superior and
inferior limit of resection). (e) The resection is completed
following the superior excision, taking care to avoid
injury to the oesophagus posteriorly. (Key: light red thyroid, green tumour, light blue endotracheal tube, grey trachea, thin black lines recurrent laryngeal nerves, orange
defect). (f) Stay sutures are placed laterally, bringing the
segments together in a tension-free fashion. The trachea
inferiorly will telescope into the cricoid and approximate
the thyroid cartilage. The posterior wall is repaired rst by
placing sutures through the subglottic mucosa and part of
the posterior cricoid lamina using a monolament continuous suture (PDS). (Key: light red thyroid, green
tumour, light blue endotracheal tube, grey trachea, thin
black lines recurrent laryngeal nerves, thick black lines
sutures, orange defect). (g) The orotracheal tube is
brought back into the distal airway and the repair of the
anterior wall is completed using interrupted sutures placed
around the thyroid cartilage superiorly and the tracheal
ring inferiorly. Soft drains are placed and the wound is
closed in layers. A ‘reminder stitch’ preventing neck
hyperextension is placed. Extubation is preferable, but
placement of a small tracheostomy tube is appropriate
where there are airway concerns. (Key: light red thyroid,
light blue endotracheal tube, grey trachea, thin black lines
recurrent laryngeal nerves, thick black lines sutures,
orange defect)
154
https://t.me/medicina_free
M. Zhang et al.
ab
de
c
Fig. 10.4 (a) Mobilise the trachea on its anterior surface
only to the level of the carina. (Key: red thyroid, green
tumour, light blue endotracheal tube, grey trachea, thin
black lines recurrent laryngeal nerves, dotted thick black
line limit of resection). (b) The tumour is excised with
sections of the cricoid cartilage and adjacent tracheal
rings. If possible, dissection should stay within the external perichondrium of the cricoid cartilage to protect the
recurrent laryngeal nerves. Avoid injury to the oesophagus
posteriorly. (Key: red thyroid, green tumour, light blue
endotracheal tube, grey trachea, thin black lines recurrent
laryngeal nerves). (c) A step-wise cut is created and the
corresponding segment of the trachea is removed. (Key:
red thyroid, light blue endotracheal tube, grey trachea,
rupted or a combination of both, with the goal of
creating a tension-free join. If following the
required resection, there is still an unacceptable
tension on the potential anastomosis, release
manoeuvres can be performed to further mobilise
thin black lines recurrent laryngeal nerves, dotted thick
black line step-wise tracheal cut). (d) The distal segment
is mobilised into the superior resection margin. Stay
sutures laterally are helpful and bringing the segments
together. (Key: red thyroid, light blue endotracheal tube,
grey trachea, thin black lines recurrent laryngeal nerves).
(e) The posterior wall is repaired rst, and then the anterior walls are brought together with interrupted monolament sutures (PDS). The repair can be completed while
the endotracheal tube remains in situ taking care to avoid
injury to the cuff. (Key: red thyroid, light blue endotracheal tube, grey trachea, thin black lines recurrent laryngeal nerves, thick black lines sutures)
the trachea. Supra-laryngeal release procedures
allow further mobilisation of the tracheal inferiorly, with the suprahyoid and/or infrahyoid
release potentially generating an additional
1–2 cm of movement inferiorly each. Infra-
10 Tracheal Surgery andTracheostomy
https://t.me/medicina_free
155
laryngeal release procedures such as hilar release,
pretracheal dissection and incision of the annular
ligaments provide an additional 1–2cm of movement superiorly each. These manoeuvres are not
without their own challenges and complications– with supra-laryngeal release manoeuvres
placing the patient at a high risk of signicant
dysphagia, and infra-laryngeal release procedures requiring input from thoracic surgeons.
Following anastomosis, a local, regional, or
free ap can be utilised to ‘cover’ the anastomotic site, especially if there has been previous
irradiation. In the neck, the strap musculature or
a pedicled sternocleidomastoid muscle may be
used, whereas in the chest pericardial fat, pedicled chest wall muscle, or omental aps may be
used. A soft drain (such as an open penrose drain)
is placed at the anastomotic site to reduce subcutaneous emphysema and a chin-to-chest ‘guardian’ or ‘reminder’ suture (otherwise,
eponomyously known as the Grillo suture) is
often placed from the submental skin to the
sternal skin to hold the neck in exion for 7days,
preventing neck extension and rupture of the
anastomosis.
Following resection and anastomosis, it is
imperative that mechanical ventilation is avoided,
secretions are controlled, and prophylactic antibiotics are administered to prevent wound breakdown. If the patient requires re-intubation, a
small endotracheal tube should be placed under
rigid endoscopic vision ideally distal to the anastomotic junction. High ventilation pressures
should be avoided where possible.
Table 10.6 Comparison of early and late complications
following tracheal surgery
Early complications Late complications
Airway obstruction
(from oedema)
Bleeding Development of granulation
Infection Tracheomalacia
Anastomotic leak,
dehiscence or
rupture
Subcutaneous
emphysema
Dysphonia
(laryngeal oedema/
RLN injury)
Tracheal stenosis
tissue
Fistula (tracheoesophageal,
tracheo-inominate,
tracheopulmonary)
Dehiscence of anastomosis.
Dysphagia
bleeding, aspiration and anastomotic dehiscence
or rupture. With larger and recurrent resections,
or patients who are immunocompromised or have
previously received radiotherapy to the area,
there is an increased risk of anastomotic complication. Pulmonary complications such as retained
secretions, aspiration (especially after suprahyoid release manoeuvres or recurrent laryngeal
nerve injury) is also common and may require
management with antibiotics and swallow
rehabilitation.
Later complications can include stenosis of
the anastomotic junction requiring bronchoscopy
and dilatation, development of granulation tissue,
dysphagia, dehiscence of the anastomosis and stula to surrounding viscera or vessels. See Table
10.6 for a breakdown of early and late complica-
tions from tracheal surgery.
10.8.7 Risks andComplications
Tracheal surgery is complex, and as such it has
signicant intraoperative risk and postoperative
complications, which can be life-threatening in
nature through imminent loss of the airway.
Intraoperative risks include bleeding, damage to
surrounding vasculature, damage to nearby structures and injury to the recurrent laryngeal nerves.
Early complications can include airway
obstruction from postoperative oedema and
10.9 Non-Surgical andAdjuvant
Management
10.9.1 Radiotherapy
Radiotherapy can be utilised with curative intent
as an adjuvant following surgical resection in
patients with histopathologically aggressive disease. The presence of positive or close surgical
margins, perineural or lymphovascular invasion
indicates the use of adjuvant radiotherapy and
has been shown to increase median survival times
Соседние файлы в папке @xirurgi_2025