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114 Tracheostomy
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The incision is marked 2 cm above the sternal notch, or
1
halfway between the cricoid cartilage and the sternal
notch. A 2–4 cm horizontal incision is routinely used for
elective tracheostomy, while a vertical incision is preferred by
some for emergency airway access. When performed under
local anesthesia, the incision and deeper tissues are infiltrated
with 1% lidocaine with 1:100 000 epinephrine.
2
1
The incision is deepened in a horizontal orientation
2
through the subcutaneous tissue. Once the fascia overlying the strap muscles is encountered, the plane of dissection
shifts from horizontal to vertical. Using Army-Navy retractors, the subcutaneous fat is retracted laterally, exposing the
midline fascia overlying the strap muscles. The midline fascial
decussation is incised, and the superficial strap muscles (sternohyoid) are retracted laterally. The thinner sternothyroid
muscles are encountered next, separated vertically and are
retracted laterally.
By gently elevating the muscles off the trachea with a
hemostat, the Army-Navy retractors can be used to retract
both strap muscles laterally, exposing the thyroid isthmus,
pretracheal fascia, and inferior thyroid veins.
The veins overlying the trachea may be retracted later-
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3
ally; or if large and arborizing, they are ligated. Following
retraction or ligation of these veins, the pretracheal fascia is
incised vertically and swept off of the anterior trachea to
expose the tracheal rings. The isthmus of the thyroid may
vary from 5 mm to several centimeters in vertical dimension.
If the isthmus is not excessively bulky, it may be elevated from
the anterior tracheal wall and retracted superiorly.
However, when the isthmus is large and prevents exposure
of tracheal rings 2–4, it should be divided. Using a curved
mosquito hemostat, the isthmus is elevated off of the underlying tracheal cartilages. This maneuver frequently requires
dissection from both the superior and inferior aspect of the
isthmus. Care is taken not to perform lateral dissection in
order to avoid injury to the recurrent laryngeal nerves and the
inferior thyroid veins. Once the isthmus is mobilized, clamps
are placed on either side, and it is divided in the midline. The
cut edges of the isthmus are oversewn with a running 3-0
chromic suture.
Operation 115
3
4
Following division of the isthmus, the thyroid is easily
4
retracted laterally to expose the upper tracheal rings. To
insure proper placement of the tracheostomy opening, the
tracheal rings should be counted at least down to tracheal
ring 4. The trachea is entered most often between the second
and third tracheal rings or occasionally between rings 3 and 4.
Tracheostomy between rings 1 and 2 should be avoided due
to the concern for granulation tissue formation and subsequent subglottic stenosis. Conversely, a low tracheostomy
(inferior to ring 4) should be avoided whenever possible due
to the potential for erosion of the innominate artery. The vessel crosses the anterior tracheal wall and the anterior curve of
the tip of the tracheostomy tube may erode the walls of the
trachea and innominate artery creating a tracheo-innominate
fistula. Exsanguination is almost immediate, should this
complication occur.
Various types of tracheal incisions and flaps have been
advocated for the tracheotomy site. Some authors use an
inferiorly based Bjork flap. This flap is fashioned by dividing
tracheal rings 2 and 3 lateral to the midline. The inferiorly
based flap is then sutured to the inferior aspect of the neck
incision. In obese patients this flap when sutured to the lower
neck skin may facilitate replacement of the tracheostomy
tube should inadvertent decannulation occur. Potential
problems with the Bjork flap include weakening and telescoping of the anterior tracheal wall, granulation tissue formation,
and tracheal stenosis.
In most patients, a horizontal incision at the muscular
interspace between tracheal rings 2 and 3 will permit easy
access to the tracheal lumen and will avoid problems occasionally encountered with the Bjork flap.
116 Tracheostomy
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Before opening the airway, a cricoid hook is placed beneath
the lower edge of the cricoid, and upward traction elevates the
trachea into the surgical field as well as maintaining stability
of the trachea during insertion of the tracheostomy tube.
Selection of the appropriate tracheostomy tube should be
made prior to opening the trachea. In general, adult males
will require a larger tube than females due to the larger size of
their trachea. A cuffed tracheostomy tube is placed when ventilatory support is required, and the scrub nurse inflates the
tracheostomy tube cuff to insure its integrity prior to insertion. The anesthesiologist deflates the endotracheal tube cuff
before the airway is incised to prevent premature puncture of
the endotracheal tube balloon.
The tracheal incision is made with a knife blade rather than
After the horizontal tracheal incision is made, the open-
5
ing is enlarged with a tracheostomy dilator or a hemostat. Prior to inserting the tracheostomy tube, the anesthesiologist removes the tape from the endotracheal tube, and the
tip of the tube is retracted to just above the tracheostomy site.
When the opening in the trachea is adequate, the previously
lubricated tracheostomy tube is inserted with gentle pressure
until the lumen is entered.
with electrocautery. In the oxygen-rich environment, incising
the trachea with the electrocautery may ignite the drapes or
the endotracheal tube. Once the trachea is opened, the endotracheal tube cuff is reinflated while all material is made ready
for insertion of the tracheostomy tube. In some patients with
a thick neck and a deep tracheostomy wound, it is advisable
to place a stay suture from the inferior tracheostomy skin
incision around the third tracheal ring. The ends of the
sutures are tied with an air knot, left long, and taped to the
chest wall. Traction on this suture will permit replacement of
the tracheostomy tube in the event of a premature decannulation. All remaining air is removed from the tracheostomy
tube cuff, and the inner cannula is removed and replaced by
the obturator within the lumen of the tube.
Once the tube is inserted, the anesthesia circuit is completed,
the patient is ventilated and the CO2monitor confirms the
patient is being ventilated. The tracheal hook and the ArmyNavy retractors are removed, once ventilation is confirmed.
The tracheostomy tube flange is then secured to the anterior
neck skin with either 2-0 silk or 2-0 prolene stay sutures.
Tracheostomy ties may also be placed circumferentially
around the neck; however, sutures provide added security
against premature decannulation. The incision is not closed,
and packing or dressings are unnecessary.
5
POSTOPERATIVE CARE
Humidified oxygen or room air is administered to prevent
dryness and crusting of secretions within the tracheostomy
tube lumen which could lead to airway obstruction. The
inner cannula is removed and frequently cleaned of secretions and dried mucus. Tracheostomy care also includes
cleaning the wound with dilute hydrogen peroxide every 8
hours for the first 5 days to remove secretions and reduce
encrustation.
Further reading 117
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The initial tracheostomy tube change occurs on postoperative day 4 or 5. The wound tract is well formed by this time,
and creation of a false passage is unlikely. The new tracheostomy tube is secured by cotton twill tape placed circumferentially around the neck and tied securely to the flange of
the tracheostomy tube.
OUTCOME
Local infections following tracheostomy are generally
uncommon and prophylactic antibiotics are unnecessary. In
obese patients who have a thick subcutaneous adipose layer,
fat necrosis can occur which predisposes to wound infection.
Also patients with an active pulmonary infection are at
increased risk for infection. Redness of the surrounding skin
or purulence in the tracheostomy site may indicate infection.
Cultures are obtained, and therapeutic antibiotics administered. Other rare complications of tracheostomy include
intra- or postoperative hemorrhage, which is usually due to
bleeding from the thyroid isthmus or the pretracheal veins.
Packing the wound with oxidized cellulose will often control
postoperative bleeding; however, wound re-exploration may
be necessary for significant bleeding. Even rarer is life-threat-
ening hemorrhage from the innominate artery. This complication occurs when the tracheostomy site is low and the
patient is mechanically ventilated. Excursion of the tip of the
tracheostomy tube erodes the anterior tracheal wall and the
wall of the artery producing massive hemorrhage. Avoidance
of a low tracheostomy has greatly reduced the incidence of
this complication. Finally, overinflation of the tracheostomy
tube cuff may result in ischemic necrosis of a circumferential
segment of the tracheal wall. The use of a tracheostomy tube
with a high-volume low-pressure cuff and avoiding overinflation will prevent this significant complication.
FURTHER READING
Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ.
Tracheotomy complications: a retrospective study of 1130 cases.
Otolaryngology – Head & Neck Surgery 2000; 123: 495–500.
Gysin C, Dulguerov P, Guyot JP, Perneger TV, Abajo B, Chevrolet JC.
Percutaneous versus surgical tracheostomy: a double-blind
randomized trial. Annals of Surgery 1999; 230: 708–14.
Pryor JP, Reilly PM, Shapiro MB. Surgical airway management in the
intensive care unit. Critical Care Clinics 2000; 16: 473–88.
Walts PA, Murthy SC, DeCamp MM. Techniques of surgical
tracheostomy. Clinics in Chest Medicine 2003; 24: 413–22.
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Right-sided pulmonary resections
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RYOSUKE TSUCHIYA, MD
Chief, Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
14
HISTORY
Graham performed the first successful pneumonectomy for
lung cancer in 1933. Pulmonary resection was also applied to
patients with tuberculosis before effective drugs were developed. Lobectomy became the standard procedure as a radical
resection for lung cancer in the 1950s. Cahan described procedures of mediastinal and hilar lymph node dissection for
pneumonectomy and lobectomy in 1951 and 1960.
Bronchoplasty and vasculoplasty were introduced to lung
cancer surgery in the 1970s. Techniques for locally advanced
lung cancer invading great vessels and/or the heart were
described in the 1960s and were applied as clinical practice in
the 1980s. Limited resection, that is segmentectomy or partial
resection of the lung, were examined as potential operations
for lung cancer. However, the results of a randomized controlled trial revealed that local and/or regional recurrence
occurred more frequently in the limited resection group than
in the conventional lobectomy group and this translated into
a survival difference. VATS (video-assisted thoracic surgery)
lobectomy has been introduced as an option for early stage
lung cancer in recent years.
PRINCIPLES AND JUSTIFICATION
Right-sided pulmonary resections consist of pneumonectomy, lobectomy, segmentectomy, and partial (wedge) resection with or without broncho-vasculoplastic procedures.
These procedures are applied to lung malignancies, inflammatory lesions, and congenital anomalies. Most of the
inflammatory diseases can be controlled by medicine, and
lung cancer has become the most common disease for pul-
monary resection. Tracheal and bronchial plastic surgery is
applied to the right lung much more frequently than to the
left lung because of asymmetric anatomy of the tracheobronchial tree and the pulmonary artery. Combined resection of the superior vena cava is one of the characteristics of
right lung resection.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Extent of the lesion is the most important factor in deciding
what procedure to choose. Computerized tomography (CT)
provides good information concerning the extent of the
lesion, especially in the case of lung cancer. Lung cancer staging is defined by the primary tumor, nodal involvement, and
distant metastasis. Thoracic CT defines the primary tumor,
nodal involvement, intrapulmonary metastases, and pleural
involvement with or without effusion or pleural dissemination. Malignant effusion and intrapulmonary metastases prohibit curative resection of lung cancer. Those lesions should
be confirmed histologically or cytologically by a thoracoscopic approach. Upper mediastinal lymph node metastases
can be diagnosed histologically by mediastinoscopy when
thoracic CT shows increased size of those lymph nodes.
Upper airway obstruction causes obstructive pneumonia
or air trapping of the lung and disturbs intratracheal intubation. Therefore, obstruction of the airway should be released
by bronchoscopy before undertaking an intrathoracic procedure.
Smoking should be ceased at least 4 weeks before surgery to
decrease bronchial secretion and to reduce postoperative pulmonary complications.
120 Right-sided pulmonary resections
Right main pulmonary artery
Inferior pulmonary artery
Superior pulmonary vein
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ANESTHESIA
In cases of inflammation or lung cancer with airway obstruction, secretions from the lesion and/or obstructed bronchi
must be controlled during the operation. The face-down
position prevents secretions from flowing into the opposite
healthy lung. However, the face-down position limits the
operative procedure. Recently, surgery has been performed in
the lateral position under anesthesia, with a separate ventilation tube to suck up secretions during surgery.
Inhalation anesthesia stimulates the bronchial glands and
increases secretion. Instead of inhalation anesthesia, intravenous anesthesia with epidural anesthesia is used in wet
cases. Epidural anesthesia is usually continued until extraction of the chest tube after the operation.
Exposure of the hilum
OPERATION
Incision and exploration
Pneumonectomy and lobectomy may be performed through
a standard posterolateral thoracotomy. However, with recent
advances including the introduction of video-assisted thoracic surgery and the development of surgical instruments,
skin incisions have become shorter than those by conventional standard thoracotomy. Although some doctors recommend VATS lobectomy even for cases of lung cancer, open
thoracotomy is the most common procedure to perform
radical resection with systematic nodal dissection for lung
cancer.
Exposure of the hilum of the lung is the first step
1a,b
mediastinal pleura is opened from front to back beyond the
right main bronchus. The vagal nerve is taped to prevent
injury, but taping of the phrenic nerve is not always necessary. In the case of lung cancer located in the hilum, intrapericardial ligature of pulmonary vessels is required, and the
phrenic nerve should be taped to be preserved.
of pulmonary resection. The reflection of the
1
Pneumonectomy
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In cases of lung cancer involving the main bronchus, right
pulmonary artery, pulmonary veins, or left atrium, pneumonectomy would be chosen as a curative resection.
Bronchoplasty and/or vasculoplasty should be discussed
before a decision is made to perform a pneumonectomy.
Operation 121
DISSECTION OF THE PULMONARY LIGAMENT
In cases of lung cancer located in the lower or middle
2
lobe, lower mediastinal lymph node dissection is
required. After opening the pleura along with pulmonary ligament at the reflection, fatty tissue including lymph nodes is
divided from the esophagus and the vagus nerve until exposing the lower border of the inferior pulmonary vein. Pulling
the lower lobe and pushing the diaphragm are important
techniques for exposure.
2
122 Right-sided pulmonary resections
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SUBCARINAL LYMPH NODE DISSECTION
The subcarinal lymph node space is triangle-shaped and
3
connects with both hilar lymph nodes. Those lymph
nodes make a boomerang-shaped mass located to the back of
the right pulmonary artery, left atrium, and both pulmonary
veins. Therefore, early dissection of the subcarinal lymph
node improves the exposure and ligature of the inferior pulmonary vein.
Reflecting the esophagus from the subcarinal lymph
nodes is the first step. Retraction of the vagal nerve with a
tape makes finding the bronchial artery along the branch of
the vagal nerve easy. At the lateral thoracotomy, a branch of
the vagal nerve covers the bronchial artery because of the
outside location of the vagal nerve against the bronchial
artery. After cutting the branches of the vagal nerve and the
bronchial artery, the left hilar lymph nodes located along the
left main bronchus are dissected from the esophagus, vertebra, and thoracic aorta. The common wrapper covering the
hilar nodes and left main bronchus should be penetrated
along the border of lymph nodes and the bronchus. This
procedure of penetration between the main bronchus and
the lymph nodes should be done carefully because the
bronchial artery runs along the bronchus. The left hilar
lymph nodes are grasped and pulled by Allis forceps, and are
dissected from the pericardium until the tracheal bifurcation. Next, the right hilar lymph nodes are divided from the
right intermediate and right main bronchus and pericardium in a similar way to the left side. At the bifurcation,
the bronchial artery is ligated, and subcarinal lymph node
dissection is finished. The fibrous membrane dividing the
subcarinal region and the upper mediastinal region can be
observed after this dissection.
3
DIVISION OF THE INFERIOR PULMONARY VEIN
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The inferior pulmonary vein is exposed
4
after the inferior mediastinal and subcarinal
lymph node dissection. Because of the short
neck of the inferior pulmonary vein, further dissection of the vein is needed towards the inside
of the lower lobe of the lung. Adventitia of the
vein should be exposed to perform complete
lymph node dissection and to confirm the
reflection of the pericardium around the vein.
The vein will be divided by a stapler or after
double ligation with a transfixed suture.
Operation 123
4
If the incision line crosses the pericardium, an intraperi-
5
cardial procedure should be applied.
5
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