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36 Penetrating Trauma totheSubclavian Vessels
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b
Fig. 36.13 Endovascular treatment of a left subclavian artery false
aneurysm. (a) Initial angiogram demonstrating the false aneurysm. (b)
Completion angiogram showing exclusion of the false aneurysm after
catheter (via the 11cm 5F sheath) positioned in the proximal
subclavian artery or aortic arch. Alternatively, a single long
introducer sheath (9F, 100cm in length) can be used. It has
the advantage of only one femoral puncture providing stent
graft access and angiographic control of deployment, but in
very proximal injuries, achieving a stable position may be
difcult. Furthermore, contrast injection may be problematic
necessitating an even larger sheath and a cutdown might be
needed. The commercially available stent grafts include the
Hemobahn® endovascular prosthesis (W.L. Gore), the
Wallgraft® (Boston Scientic, Target Therapeutics, Fremont,
CA 94538 USA), and the Fluency® (Bard, Murray Hill, NJ,
USA). Sheaths are removed 60–90 min after intravenous
heparin and hemostasis is obtained with digital compression.
The patient is observed overnight and can be discharged the
next day, barring other injuries requiring continued hospitalization. No long-term anticoagulation or antiplatelet drugs
are prescribed. Figure36.13 depicts the successful endovascular management of a left subclavian artery false
aneurysm.
preoperative coil embolization of the participating vertebral artery to
prevent an endoleak
are usually self-limiting, as hypotension and soft tissue tamponade cause local thrombosis with healing over time.
Clinically, signicant subclavian vein injuries are the
result of a large open laceration of the skin and soft tissue
surrounding the vein with an equally large injury to the vein.
Under these circumstances, local tamponade is compromised
and massive external bleeding can occur. You can control this
by manual compression and/or the Foley catheter tamponade. Diagnostic imaging can then exclude arterial injuries
and the catheter should be left in place for 24–48h before
careful removal. If no bleeding recurs, you can suture the
wound and observe the patient for another 48h in the hospital before discharge. If bleeding recurs, the catheter should
be re-inated and exploration should be done. Fortunately,
this happens very seldom.
The other scenario is the patient bleeding actively from a
supraclavicular wound with an unknown vessel injury that
cannot be stabilized by Foley catheter tamponade. You
should take this unstable patient to the operating room with
manual compression of the wound and careful local exploration with a low threshold to do a midline sternotomy. The
color of the blood is usually not a good indication of the
36.4 Venous Injuries
source of the bleeding as in these patients, venous oxygen
saturation is high on 100% oxygen ventilation. If a venous
Clinically signicant subclavian vein injuries are an uncommon occurrence. Many penetrating neck and chest wounds
might involve the subclavian veins, but few will need treatment. The venous system has low pressure and these injuries
injury is diagnosed, careful handling of this injury is the key
to success. Proper exposure can at times be a nightmare
especially if the subclavian vein is damaged posterior to the
clavicle and if its conuence with the internal jugular vein to
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D. F. Du Toit
form the innominate vein is involved. A midline sternotomy
with supraclavicular extension is usually the exposure to
start with, but although time-consuming, resection of the
medial part of the clavicle with or without the corresponding
half of the manubrium can provide excellent exposure of the
subclavian vein. When handling the vein, manual compression with proximal and distal control is essential. The vein
should always be handled with great care as it tears easily
and a small injury can quickly become a massive problem if
grabbed with traumatic clamps. Soft straight vascular clamps
should be used to gently clamp the injured area. This will
achieve partial control and the vessel can be gently pulled up
by these clamps. A curved vascular clamp should now be
passed behind these clamps and the vessel is secured in a
horizontal fashion controlling the injury. The vein can now
be mobilized and repaired as needed. Extensive efforts to
properly repair the vein are not encouraged as ligation is a
safe alternative.
The subclavian vein injury can also present as a stable
arteriovenous stula which communicates with an adjacent
arterial injury. This can pose a great challenge as arterial and
venous bleeding and collaterals complicate surgery. This is
the ideal lesion to treat by endovascular techniques. A stent
graft should be used to treat the arterial injury while venous
patency is maintained.
Important Points
• In unstable, actively bleeding patients, try to control
bleeding by Foley catheter tamponade and stabilize
patients for preoperative imaging and evaluations for
endovascular treatment or planning of open surgery.
• Clinically signicant venous injuries usually present with
active bleeding and can be managed conservatively with
Foley catheter tamponade followed by angiography and
balloon deation after 48h if no arterial injury is detected.
• Unstable patients with uncontrollable hemorrhage should
always undergo open surgery. A controlled “peep” in the
neck wound might reveal a supercial bleeder or allow
vascular clamping of the injured vessel. A low threshold
for a midline sternotomy with extensions as needed
should be maintained.
• If at sternotomy, the subclavian vein is revealed to be the
source of bleeding and control is not possible via this
exposure, adding a medial claviculectomy might be of
great assistance.
• Stable subclavian artery injuries should all be considered
for endovascular management if no contraindications are
present.
• We do not advise division of the clavicle or the trapdoor
thoracotomy for arterial injuries.
• The friable elastic subclavian artery should be carefully
repaired with ne 60 polypropylene sutures. Primary
repair is preferable, but interposition vein grafting is often
needed. You should not hesitate to use reinforced PTFE if
the vein is too small or if the patient’s condition dictates
an expedient conclusion of the procedure.
• Connecting the supraclavicular exposure and the median
sternotomy entails the division of both heads of the sternocleidomastoid muscle and the strap muscles, taking
care not to damage the contents of the carotid sheath and
the phrenic nerve.
Suggested Reading
Demetriades D, Theodorou D, Cornwell E, etal. Evaluation of penetrat-
ing injuries of the neck: prospective study of 223 patients. World J
Surg. 1997;21:41–8.
Demetriades D, Chahwan S, Gomez H, etal. Penetrating injuries to the
subclavian and axillary vessels. J Am Coll Surg. 1999;188:290–5.
du Toit DF, Lambrechts AV, Stark H, etal. Long-term results of stent
graft treatment of subclavian artery injuries: management of choice
for stable patients? J Vasc Surg. 2008;47:739–43.
du Toit DF, Leith JG, Strauss DC, etal. Endovascular management
of traumatic cervicothoracic arteriovenous stula. Br J Surg.
2003;90:1516–21.
Eddy VA.Is routine arteriography mandatory for penetrating injuries to
zone 1 of the neck? J Trauma. 2000;48:208–14.
Layton KF, Kallmes DF, Cloft HJ, etal. Bovine aortic arch variant in
humans: clarication of a common misnomer. Am J Neuroradiol.
2006;27:1541–2.
Moore KL, Dalley AF. Neck. In: Clinically oriented anatomy.
Philadelphia: Lippincott Williams & Wilkins; 2005. p.211–65.
Robbs JV, Baker LW. Cardiovascular trauma. Curr Probl Surg.
1984;21(4):1–84.
Penetrating Trauma totheThoracic
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Oesophagus
EliasDegiannis, TugbaH.Yilmaz, andMartinMauser
37
Penetrating trauma to the thoracic oesophagus is a rare
injury. There are two reasons for that. The thoracic oesophagus is too deep for most stab wounds. Therefore, penetrating
trauma to the thoracic oesophagus, in the great majority of
cases, is secondary to gunshot injuries. It can involve the
heart and the mediastinal vessels, leading to a fatal outcome
in the pre-hospital setting.
37.1 Diagnostic Investigations
Start with a plain X-ray. Remember that the patient’s survival with this type of injury is directly related to the time
interval between injury and repair; therefore, have a high
index of suspicion so that you can come to an early diagnosis. Pleural effusions are present in a signicant number of
patients with oesophageal injury, and in their presence, you
should insert intercostal drains. Apart from pleural effusions,
a plain chest radiograph will quite frequently demonstrate
subcutaneous emphysema, pneumomediastinum, pneumothorax, and mediastinal air-uid levels. Investigate transmediastinal gunshot wounds with a CT scan if the patient is
physiologically stable. See the bullet tract and proceed to
further investigations if it is in close proximity to the oesophagus. A CT scan can also demonstrate mediastinal complications secondary to oesophageal perforation as
para-oesophageal air and mediastinal collections. Contrast
studies are very helpful. Start with a barium swallow since
E. Degiannis (*)
Department of Surgery, University of the Witwatersrand Medical
School, Johannesburg, Republic of South Africa
e-mail: degiannis@yebo.co.za
T. H. Yilmaz
Department of Surgery, Baskent University, Izmir, Turkey
e-mail: tugba.yilmaz@deu.edu.tr
M. Mauser
Department of Surgery, Chris Hani Baragwanath Academic
Hospital, University of the Witwatersrand Medical School,
Johannesburg, Republic of South Africa
barium is relatively inert and is better than Gastrogran in
showing hollow viscus leaks. Water-soluble contrast agents
like Gastrogran can cause severe pneumonitis if aspirated
and can miss small leaks. If the level of consciousness of the
patient is low but he still has a good gag reex, administer
the contrast carefully through a Foley catheter that you insert
high in the oesophagus and inate its balloon to prevent aspiration of the material. If your patient is intubated, you can
administer the contrast via a nasogastric tube positioned near
the suspected area. You can also conrm an oesophageal leak
by asking the patient to swallow methylene blue and see it
leaking from a previously inserted intercostal drain. Although
pathognomonic of the presence of oesophageal defect, it
cannot localise its exact site. If you still suspect oesophageal
injury in the presence of a normal swallow, proceed to exible oesophagoscopy. Oesophageal injuries are likely to be
missed if you do not properly inate the oesophagus so that
you can have a good look at the lumen with mucosal folds
completely attened. Impressive bubbling in an intercostal
drain bottle every time you inate the oesophagus during the
oesophagoscopy is a pathognomonic of an oesophageal leak.
37.2 Access toInjury
As mentioned, the prognosis of penetrating oesophageal
injuries has been shown to be directly related to the time
interval between injury and repair as morbidity and mortality
dramatically increase if it is more than 24h. It is advised in
many trauma books to approach the upper two-thirds of the
thoracic oesophagus via a right posterolateral thoracotomy,
and the distal third by a left posterolateral thoracotomy (for a
detailed description of this approach see Chap. 38
“Penetrating Trauma to the Thoracic Trachea and Main
Bronchi”). We agree with this, but we nd that the approach
to the oesophagus can be as effective via right anterolateral
thoracotomy, choosing the level of the incision according to
the site of the injury. In this case, if during the operation you
need to access the abdominal oesophagus or any other intra-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_37
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E. Degiannis et al.
abdominal structure, you can proceed with a laparotomy
without having to reposition the patient. It is desirable for the
anaesthetist to introduce a double-lumen tube, as this will
facilitate the operation, although, in cases of dire emergency,
the double- lumen tube can be omitted as its insertion can be
time- consuming. Use a small sandbag to elevate the patient’s
right side to 30° (this elevation can go up to 60° by tilting the
operating table) with the right arm abducted and suspended
by the anaesthetic screen cephalad to the surgical eld.
Prepare the neck, chest and abdomen in case you nd yourself in a situation where you must extend your surgery to
these anatomical areas, in which case you simply have to tilt
the operating table until the abdomen or the neck is parallel
to the oor. Make an incision along the intercostal space that
is appropriate for the expected level of the site of the injury,
from the sternum to the posterior axillary line in men. In
women, your incision should be at the inframammary fold,
and you should choose the space after elevation of the breast.
Incise the pectoral and the anterior serratus muscle at the
selected level. Use a high coagulation current and go very
slowly, ‘charcoaling’ the muscles. It is worth being patient
and going slowly than having a lot of oozing from the incision later on. Divide the intercostal muscles along the upper
border of the lower rib of the selected space. (Remember that
for counting the ribs, you should put your hand under the
elevated scapula. The highest palpable rib is usually the second rib.) Look for the internal mammary artery and ligate it
(although you can keep your incision laterally to it). Enter
the pleura carefully, making sure that you do not damage the
underlying lung (or if you damage it, you do not overdo it!),
and divide the cartilage of the rib at the cephalad of the incision after ligating its neuromuscular bundle. This cartilage
severance will make the wound incision bigger and the operating eld more accessible. If this is not done, you should be
very patient while opening the rib spreader in steps so that
you avoid fracture of the ribs. As mentioned above, intraoperative access to an oesophageal leak does not have the same
urgency as that of operating for thoracic bleeding, so breaking ribs is not acceptable as it can negatively inuence the
patient’s postoperative course. Look for the area of injury; if
this is not obvious, you can sometimes suspect the site of the
leak by a yellow discolouration under the posterior mediastinal pleura. If neither of the above two is present, divide transversely the mediastinal pleura where the oesophagus is
expected to be and expose it. Then divide the pleura longitudinally, proximally and distally to expose it at the surface of
the oesophagus until the site of the injury is detected.
Completely mobilise the oesophagus roughly 5 cm proximally and distally to the area of the injury. If you have never
had the experience of mobilising an oesophagus before, use
a pledget to create a groove at its lateral and medial aspects.
Then take a large Babcock and gently include as much of the
oesophageal “tube” as possible and elevate it from its bed.
You will see that there is tissue posteriorly that holds the
oesophagus in its bed. Take a large right-angled Lahey, penetrate this tissue and encircle the oesophagus with a ribbon.
By exerting traction with the ribbon, dissect and meticulously divide stepwise the tissue that holds the oesophagus in
its bed—remember that this includes the small arterial
branches that supply blood to the oesophagus. It is usually
easier to divide these branches between haemoclips.
If the azygos vein is in your way, divide the pleura super-
cially to the vein, then divide and transx it. As with every
septic wound, proceed with drainage of any collection,
washout of the area and debridement of the wound.
Remember that the majority of gunshot wounds are due to
low-energy bullets. Therefore, your debridement should be
limited. In the case of wounds in the oesophagus, it is common for the mucosa to retract and it is of paramount importance to detect the margin of the mucosa, even if you have to
increase the size of the muscle wound. The oesophageal
mucosa looks white and it is very important to include it in
your repair as it is the toughest layer of the oesophageal wall.
Inspect the circumference of the oesophagus at the site of the
injury to exclude additional injury.
37.3 Repair oftheInjury
37.3.1 Early Presentation withLimited
Damage
The management of injuries that present within 24h is different to those that present later, as the probability of wound
dehiscence following primary repair is low in the rst case
and signicant in the second. If the injury has been present
for less than 24h, washout, debridement, primary repair and
drainage sufce. There are many methods of primarily
repairing the oesophagus. We repair it with one layer of
interrupted horizontal mattress sutures. We choose a stitch
with high-tensile strength, not because we expect our sutures
to break, but because usually, they are quite thick and, therefore, less likely to cut through the oesophageal tissue while
approximating the tissue edges or when some tissue oedema
develops at the suture line. We use Nr 1 Vicryl making sure,
that with each bite we include, apart from the muscle layer,
approximately 4mm of the mucosa (Fig.37.1a). This method
of suturing results in everted suture lines. This does not make
any difference—remember that when using staplers, all margins are everted without that resulting in more complications
than in inverted suture lines. We tie the mattress sutures at
the end after all of them have been inserted in place, and we
do not cut the edges. Then we reinforce our suture line by
putting a 2.0 interrupted Vicryl stitch in the space between
two consecutive horizontal mattress sutures and then cut all
the stitch ends (Fig.37.1b).
a
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French) in the oesophageal lumen to convert the free perforation into a controlled stula. This can also apply in situations
when the injury is older than 24h and the repair is precarious, or the surgeon is not experienced with tackling an injury
in this anatomical area. If possible, approximate the edges of
the hole around the drain. Drain the pleural cavities with
separate tubes. Remove the T-tube after 5–6 weeks by
oesophagoscopy to avoid widening of the tract.
When the injury is present for more than 24h and there
are signs of a signicant infection, the primary repair may be
precarious. There is a variety of methods described for tackling this difcult problem; none of them are complicationfree. If it is possible to repair the defect, attempt to do it. It is
wise to buttress this repair. We prefer to mobilise the pleura,
b
which due to inammation is thickened, and wrap it ‘rmly’
around the repair, but not too tight so that the oesophagus is
obstructed (Fig.37.2a, b). The wrapping (buttressing) with
pericardium has also been described. We avoid it as in case
of failure of the oesophageal repair, the infection can spread
into the pericardial sac. If the oesophageal injury is close to
the hiatus, you can create a diaphragmatic ap and oversew
it on the oesophagus, covering the gap or re-enforcing the
suture line. The base of this ap should start 2cm from the
periphery of the hiatus and extend radially to about 6cm or
even longer if more length is needed to reach the defect site.
Fig. 37.1 (a) We repair the oesophagus in one layer of Vicryl 1 inter-
mitted horizontal mattress sutures. (b) We reinforce our suture line by
putting a 2.0 interrupted Vicryl stitch in the space between two consecutive horizontal mattress sutures and then cut all the stitch ends
Do a barium swallow on the seventh day after the repair.
If there is a small leak that presents itself as a small sinus, we
ignore it and start the patient on a liquid diet after another
7days.
Rotate the ap upwards from its base, towards the oesophagus, cover the repair or gap, and close the diaphragmatic
defect by interrupted sutures (Fig.37.3a, b).
There are cases where none of the repair methods or the
attempts to form a controlled stula are likely to be successful. In these cases, it is worth considering isolating the
injured area. Distal exclusion of the oesophagus is practised
on the basis that it controls the gastric secretions from being
reuxed to the area of the injury—use staplers and we make
sure that we avoid inclusion of the vagi.
37.3.2 Late Presentation or Extensive Damage
There are many methods, that attempt to tackle this difcult
situation. None of them have guaranteed satisfactory results.
The surgeon must be aware of all of them and decide which
or a combination of which is best in specic situations. It is
also important to mention at this point, that the nutrition of
the patient must be guaranteed in the presence of infection,
precarious repair or loss of continuity of the GI tract. That
could well mean the fashioning of a gastrostomy or a
jejunostomy.
If the gap is too large to approximate the edges of the
damaged oesophagus and/or the patient is physiologically
unstable, proceed to a “bailout” solution by proximal drainage of the oesophagus via an NG tube and insertion of an
intercostal drain near the oeophageal gap or a T-tube (22–24
The issue of proximal exclusion is more complex. It has
been suggested that this should be done by intrathoracic stapling above the site of the injury, coupled with the insertion
of an NG tube on low suction. This will act as a dead-end
oesophageal pouch, an undrained ‘sack’ that will be the
source of ongoing sepsis and aspiration, that can kill the
patient. Unfortunately, even though the NG tube will
decrease the chances of this happening, it is not always a
viable solution.
A suggested alternative is the fashioning of a loop cervical oesophagostomy. This has been disappointing in our
hands. We nd it difcult to mobilise the cervical oesophagus to obtain enough length to construct a tension-free loop
oesophagostomy. Usually over the next few days, the stoma
retracts to the extent that it almost closes. It is also very difcult to apply a drainage bag around the retracted stoma.
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Fig. 37.2 (a, b) We prefer to mobilise the pleura, which due to inammation is thickened, and wrap it ‘tightly’ around the repair in immediate
contact with the oesophagus but not very ‘tight’ so that it becomes obstructed
E. Degiannis et al.
Fig. 37.3 (a, b) Rotate the ap upwards from its base, towards the oesophagus, cover the repair or gap, and close the diaphragmatic defect by
interrupted sutures
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A better alternative is the construction of an endoesophagostomy: (a) a cervical-end-oesophagostomy or (b)
an oesophagostomy with a stoma cited subcutaneously in the
upper chest wall.
Mobilise the proximal to injury oesophagus and perform
an end-cervical oesophagostomy. To fashion this stoma,
make a left cervical incision at the anterior margin of the
sternocleidomastoid muscle. Incise the investing fascia along
its anterior border while retracting the muscle laterally.
Identify and divide the omohyoid muscle as it passes laterally deep to the sternomastoid muscle. Divide the rest of the
strap muscles, close to the clavicle, identify the carotid
sheath, and retract it laterally while simultaneously retracting the larynx medially. Visually identify the pharynx and its
continuation to the cervical oesophagus lying at the anterior
aspect of the cervical spine. Open with scissors the fascia
between the posterior aspect of the oesophagus and the vertebral column. The plane between those is avascular, so you
safely mobilise the posterior aspect of the oesophagus down
to the entrance of the thoracic cavity. The next step is to
mobilise the oesophagus from the trachea. Remember that
the oesophagus at that level deviates slightly to the left. It is
useful to rst divide the inferior thyroid artery and middle
thyroid vein. Identify the recurrent laryngeal nerve near the
groove of the oesophagus and the trachea, and preserve it
during the following manoeuvres. Retract the trachea slightly
upwards, and the oesophagus slightly downwards. Use your
scissors and, by cutting with its tip, open a plane between the
oesophagus and the posterior wall of the trachea. After this
plane has been ‘deepened’, you can use a right-angled Lahey
to complete the separation of the two viscera. Further distal
separation can now take place with a combination of blunt
and sharp dissection, always taking care of the recurrent
laryngeal nerve (Fig.37.4). At this point you can decide how
much length of oesophagus you need to perform a free tension cervical end oesophagostomy. Try to save as much
oesophagus as possible. Having a decent length of proximal
oesophagus for the construction of a cervical oesophagostomy will also later make reconstruction of the continuity of
the GI tract easier. If the proximal oesophageal stump is very
short, it will create difculty to anastomose and in certain
cases, you will be obliged to reconstruct the continuity of the
GI tract by making an anastomosis at the pharynx, with the
patient in most cases becoming physiologically crippled. We
prefer to position it at the anterior aspect of the chest via a
subcutaneous tunnel, instead of having the stoma in the neck.
This way the length of oesophagus preserved for later anastomosis will be much longer and also the application of a
stomal bag easier on the relatively at surface of the anterior
chest. However, if during the operation ischaemia of part of
the stump is detected, it should be resected—and if the
resulting length of the proximal oesophageal is not adequate,
do not hesitate to bring out the stoma through the cervical
incision.
Important Points
• Have a high index of suspicion in oesophageal injury.
• Liberal use of a CT scan of the chest and proceed to swallow, or oesophagoscopy if the CT scan shows track proximity to the oesophagus.
• Liberal drainage of the injury site.
• There is no “silver bullet” for managing extensive or late
presenting penetrating oesophageal injuries. It is important to be familiar with all suggested methods of operative
management.
Suggested Reading
Fig. 37.4 The cervical trachea has been encircled with red and the
cervical oesophagus with blue vessel loop. The recurrent laryngeal
nerve is seen running in the groove between the viscera
Degiannis E, Benn CA, Leandros E, Goosen J, Boffard K, Saadia
R.Transmediastinal gunshot injuries. Surgery. 2000;128(1):54–8.
Karmy-Jone RC, Wagner JW, Lewis JW Jr. Oesophageal injury. In:
Trunkey DD, Lews FR, editors. Current therapy of trauma. 4th ed.
St. Louis: Mosby; 1998.
Smakman N, Nicol AJ, Walther G, Brooks A, Navsaria PH, Zellweger
R.Factors affecting outcome in penetrating esophageal trauma. Br
J Surg. 2004;91:1513–9.
Penetrating Trauma totheMediastinal
Lo
(cardiac)
ior basal
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Trachea andMain Bronchi
EliasDegiannis, GeorgyIvakhov, andAlexanderSazhin
Penetrating injuries to the mediastinal trachea and the main
bronchi are fairly uncommon. They consist of a hole created by the path of a knife or bullet. When the assailant uses
a knife, the entrance point is usually at the lower neck. This
is not the case with gunshot wounds, where the entrance
point can be in a variety of sites and is related to a high
incidence of concomitant injuries to other mediastinal
structures.
As with all traumatic injuries, prompt diagnosis and rapid
repair provide the best outcome. If the presenting patient is
rendered by resuscitation in a physiologically stable condition, investigations should be undertaken as soon as possible,
thereby conrming the presence and site of injury, as well as
the possible presence of concomitant injuries, facilitating the
decision on the appropriate operative approach to the thoracic cavity/mediastinum.
Trachea
Carina
Right main
bronchus
Upper lobe
bronchus
wer part of
right main
bronchus
Middle lobe
bronchus
Lower lobe
bronchus
Medial basal
38
Apicoposterior
Anterior
Lingular
Apical
Anterior basal
Lateral basal
Poster
38.1 Anatomical Considerations
Fig. 38.1 Anatomy of trachea and bronchi
The trachea begins at the level of the intervertebral disc of
the sixth and seventh cervical vertebrae (C6–C7). Its length
is 10–12cm, half of which lies in the neck. The other half
consists of the mediastinal part of the trachea. It enters the
thoracic inlet in the midline in front of the oesophagus and
proceeds caudally and in a posterior direction. It occupies
the median plane except its lower end where the aortic arch
deects it to the right.
It bifurcates to the right and left main bronchus at the
carina which is at the level of the angle of Louis. In young
people, hyperextension of the neck can bring up half of the
E. Degiannis (*)
Department of Surgery, University of the Witwatersrand Medical
School, Johannesburg, Republic of South Africa
e-mail: degiannis@yebo.co.za
G. Ivakhov · A. Sazhin
Department of Surgery, Pirogov Russian State National Research
Medical University, Moscow, Russian Federation
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_38
mediastinal trachea into the neck. This is important from an
operative point of view since you can approach an isolated
injury of the upper mediastinal trachea via a low transverse
cervical incision, sometimes coupled with an upper
sternotomy.
The right main bronchus is larger than the left as it supplies the larger right lung. It is approximately 2.5cm long
and is more vertical than the left as the aortic arch deects it
to the right (Fig.38.1). The azygos vein arches above it from
behind on its way to drain into the superior vena cava. The
pulmonary artery lies rst below and then anterior to it
(Fig.38.2).
The left main bronchus is nearly 5cm long, narrower than
the right and passes downward and laterally below the aortic
arch and in front of the descending thoracic aorta and the
oesophagus. The pulmonary artery lies rst anteriorly and
then above the left main bronchus (Fig.38.2). Keep in mind,
327
328
Right pulmonar
s
ab
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Fig. 38.2 Anatomical
relations of the mediastinal
trachea and main bronchi
E. Degiannis et al.
Left common
carotid
Thyroid isthmu
Left subclavian
Brachiocephalic
brachiocephalic
artery
Right
vein
artery
Superior vena
cava
y
during a thoracotomy the left main bronchus is often not visible without incising the reection of the parietal and visceral pleura posteriorly, therefore fashioning a plane between
the posterior aspect of the left bronchus and the
oesophagus.
Structurally the trachea is tubular, supported by C-shaped
rings of hyaline cartilage with brous tissue in between. The
posterior wall of the trachea (where the C-shaped cartilage is
decient), is membranous consisting of brous tissue and a
sheet of smooth muscle, the trachealis. The ring at the bifurcation has a carina or keel that supports the “crotch” of the
trachea. The blood supply is segmental entering the trachea
from the two sides. The two main bronchi are similar in
structure to the trachea.
Left
brachiocephalic
vein
Aortic arch
Pulmonary
trunk
38.2 Establishing aDiagnosis
The clinical presentation depends on the severity and the site
of the injury. If the injury is conned to the mediastinum, it
usually presents with massive pneumo-mediastinum and
occasionally with pneumopericardium. On the other hand, if
the mediastinal pleura has been breached, there will be a
massive air leak into the pleural cavity resulting in extensive
pneumothorax, occasionally under tension. A massive
amount of “froth” in the bottle connected to the intercostal
drain should make you suspect a large tracheal/bronchial stula (Fig.38.3a, b).
Fig. 38.3 (a, b) Massive amount of froth in the bottle connected to the
intercostal drain, due to gunshot injury of the right main bronchus
Start the diagnostic evaluation of the patient with computed tomography (CT). In certain cases, a 3D reconstruction (3D tracheography) has been used to demonstrate the
injury in more detail and, in the case of conservative management (always in highly selected patients and under the
care of those with experience in these injuries) to follow-up
the healing process (Fig.38.4).
38 Penetrating Trauma totheMediastinal Trachea andMain Bronchi
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329
Fig. 38.4 Computed tomography with 3D reconstruction (3D tracheography) showing injury of anterior aspect of distal cervical trachea
due to gunshot. The patient was treated conservatively and followed up
Irrespective of the CT ndings, a bronchoscopy should be
undertaken to conrm the radiological diagnosis. This should
also be the case in all patients with signicant pneumopericardium or extensive pneumothorax refractory to its management by insertion of intercostal drain.
Nowadays, in most cases, bronchoscopy is performed
with a exible bronchoscope, which is easier to handle and
does not necessitate a general anaesthetic. This, apart from
visualization of the airway and conrmation of the diagnosis, allows intubating the patient by railroading an endotracheal tube, therefore safely establishing a denitive airway,
if the patient is not already intubated. Rigid bronchoscopy
offers the potential to provide ventilation during the
procedure.
38.3 Operative Strategy
The surgical approach to the injury is dictated by the fact
that the mediastinal trachea and main bronchi are situated
in the posterior mediastinum and that the aortic arch
with weekly intervals of CT 3D reconstructions. Left: the destruction of
cartilages distal to the vocal cords. Middle: healing process. Right:
complete healing of injury
deects the carina and to a larger effect the right main bronchus to the right of the midline. The best access to the posterior mediastinum is provided by a posterolateral
thoracotomy.
A right posterior-lateral thoracotomy at the fourth or fth
intercostal space is best for the repair of the trachea, the right
main bronchus and the proximal left main bronchus. Injuries
of the left main bronchus at a distance greater than 3cm from
the carina is best dealt with by a left posterolateral thoracotomy at the level of the fth intercostal space. In case of
complex or bilateral injuries, it is best to proceed, at least
initially, with a right posterolateral thoracotomy. This gives
access to most parts of the main intrathoracic airways and at
the same time, this facilitates dissection by avoiding the
heart and the aortic arch.
At this point it is important to repeat that hyperextension
of the neck in young people can bring up half of the intrathoracic trachea into the neck. This allows the possible repair of
an isolated upper thoracic tracheal injury via a low transverse
cervical incision coupled, in certain cases, with an upper
sternotomy (Fig.38.5).
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