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154 Tracheal resection
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that achieve disobliteration and the maintenance of a safe airway by the use of temporary and permanent stents. These
techniques are beyond the scope of this chapter. The longterm results of such therapy are less satisfactory than those
achieved by an operation and the opinion of an appropriate
surgical specialist should be sought before denying the
patient an operation.
PREOPERATIVE ASSESSMENT
The severity of airway narrowing can be assessed clinically, by
spirometry and lung function testing and by radiology. The
extent of disease, particularly its intramural and extramural
component, is aided by computed tomography (CT).
However, bronchoscopy remains the most critical evaluation,
and the use of the rigid bronchoscope under general anesthesia has the advantages of a wide field of view, temporary
breath holding, and the ability to take multiple large biopsies.
In the emergency situation its use can prove life saving, allowing measures to achieve rapid relief of critical stenosis. Using
the rigid bronchoscope the surgeon can accurately measure
the length of the trachea, the extent of the segment which
would require resection, and the relationship of its proximal
and distal margins from such key landmarks as the carina,
larynx, and any tracheostome. This is best done by marking
the bronchoscope with thin strips of adhesive applied at the
level of the upper incisors. The assessment of any dynamic,
malacic component is aided by examining the airway with the
patient coughing at the end of the evaluation.
Basic oncological principles apply when evaluating the
feasibility of airway reconstruction for malignant disease.
Distant metastases and extensive nodal disease should be
excluded. Mediastinoscopy may be of value but local, mediastinal extension does not carry the same import as when
evaluating lung cancer, as long as resection is deemed
feasible.
Patient fitness must be assessed carefully. A greater level of
fitness is necessary if a thoracic approach is needed, especially
if concurrent pulmonary resection is contemplated. It is less
of an issue if a cervical approach is judged suitable. Lung
function testing is not representative of the patient’s fitness in
the presence of severe airway obstruction! Psychological and
cerebral status may affect the patient’s ability to cooperate
with the physiotherapist in the postoperative period, and to
tolerate the neck flexion necessary to safeguard the anastomosis (see later).
Tracheal resection should not be undertaken as an emergency. Surgical disobliteration will allow measured evaluation, accurate staging of malignant disease, discontinuation
of steroid medication, and clearance of distal infection. The
patient can then be brought to elective surgery fully appraised
of the risks and benefits of surgery, and in the best physical
and psychological state. The surgeon can plan the surgery
carefully, ensure expert anesthetic support, and the availability of frozen section pathology services.
OPERATIONS
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Segmental resection of the trachea by a cervical
approach
Following induction of anesthesia it is helpful to repeat
1
the bronchoscopic assessment using a rigid bronchoscope. This will allow the anesthetist to assess the size of
endotracheal tube that can be negotiated through the strictured area. The surgeon can assess the location of the stricture
relative to the skin incision by inserting a narrow-bore needle
percutaneously into the lumen and viewing its relationship to
the stricture through the bronchoscope. Ventilation during
tracheal mobilization is safer if an endotracheal tube can be
placed across the stricture. If this is not possible the airway is
precarious and intermittent obstruction may be encountered.
A size 5.5 or 6.0 Fr. armored endotracheal tube can usually be
negotiated through the stricture into the distal, normal trachea. The patient is positioned supine, with the neck
extended by a sandbag under the shoulders and the head
secured in a ring.
Operations 155
1
2
A curved, collar incision is made, centred upon the
2
tracheostomy scar, or midway between the thyroid cartilage and the suprasternal notch, extending between the lateral
borders of the sternomastoid muscle on each side. The incision is deepened through platysma muscle using the
diathermy, dividing superficial veins. The sternomastoid
muscles are mobilized laterally from the suprasternal notch
to the level of the thyroid cartilage. The trachea is identified in
the midline and mobilized along its anterior aspect for the full
length of the incision. The strap muscles may be divided but
are usually reflected laterally. If necessary the isthmus of the
thyroid gland is divided between transfixion sutures.
156 Tracheal resection
Recurrent
laryngeal nerve
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One must now decide where to make the initial
3
incision into the trachea. It is usually preferable to make
the distal transection first as this allows one to speedily transfer ventilation to an endotracheal tube inserted into the distal
trachea, if this is thought to be necessary. However, if the
proximal margin of resection is easier to define one can easily
start at this point. The limits of the stricture may be apparent
from external examination of the trachea, but if this proves
difficult identification of this important point is aided by
temporarily withdrawing the endotracheal tube over a flexible bronchoscope. The light is visible through the tracheal
wall, and the precise point at which to make the first incision
can be identified by passing a fine gauge needle into the
lumen under endoscopic control. The trachea is mobilized
circumferentially at this level. Care must be taken to avoid the
recurrent laryngeal nerves. Some experts would favor dissection to identify these nerves. However the surrounding
inflammatory response can make this difficult and it is usually preferable to avoid damage to the nerves by keeping the
dissection close to the diseased tracheal wall. The contralateral nerve is at greater risk and extreme care is needed when
dissecting between the trachea and the esophagus around the
far side of the trachea.
The anterior wall of the trachea is incised with a pointed
blade and circumferential division undertaken using scissors.
Stay sutures of 2/0 monofilament are inserted into the anterior wall of the distal trachea to prevent retraction of the distal lumen. Ventilation is not interrupted, as the cuff of the
tube should lie distal to this level. A longitudinal incision is
then made along the anterior wall of the trachea, until the
normal lumen is identified at the other limit of resection.
3
Operations 157
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The endotracheal tube can be retracted anteriorly
4
whilst the whole circumference of the diseased segment
is mobilized. If this step is difficult or prolonged, the endotracheal tube should be withdrawn into the larynx. A suture into
its tip facilitates retrieval into the trachea. Ventilation is then
transferred to an endotracheal tube inserted into the distal
lumen across the operating field. A Bain’s circuit is less intrusive for connecting this tube to the ventilator. This distal
endotracheal tube is often in an unstable position and it is as
well to delegate an assistant to focus entirely upon maintaining satisfactory ventilation. Liaison with the anesthetist is
essential during this type of ventilation. Care is necessary to
keep close to the tracheal wall whilst undertaking this circumferential mobilization, avoiding damage to the esophagus and the recurrent nerves. Once the length of the tracheal
defect is known the surgeon should assess if further mobilization or release procedures are necessary to allow apposition of
the tracheal ends without tension (see later). Mobilization of
the distal airway should be limited to the anterior and posterior aspects of the trachea, preserving the lateral, vascular
tissues.
4a
4b
158 Left-sided pulmonary resections
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An end-to-end anastomosis is performed using
5
continuous monofilament material, such as 3/0 Prolene
on a 17 mm needle. The anastomosis is reinforced at each
quadrant with interrupted sutures of 2/0 Prolene which,
ideally, should pass through the cartilages of the trachea and
not penetrate the lumen of the trachea. The first interrupted
suture is placed at the near posterior cornu of the tracheal
cartilage. The continuous suture runs, over and over, through
the full thickness of the posterior tracheal wall to the opposite
cornu where the second stay suture is inserted. Each of the
stay sutures should be inserted just ahead of the running
suture to avoid damage to the continuous suture. Once the
posterior wall of the anastomosis has been completed the
sandbag beneath the shoulders is removed. Traction of
the two stay sutures approximates the ends of the trachea
and the continuous suture is drawn tight. The continuous
suture continues around the far wall of the trachea to the
anterior aspect of the anastomosis. A further stay suture is
inserted at this point. The standing suture at the near side of
the posterior wall is then used to run in an over-and-over full
thickness fashion around the nearside of the trachea to the
anterior wall. The fourth stay suture is inserted at the anterior
quadrant, ahead of the continuous suture. The continuous
suture is tied, and the four stay sutures are tied to complete
the anastomosis. If an endotracheal tube has been inserted
into the distal lumen, at some point during the anastomosis it
becomes intrusive. The translaryngeal tube is retrieved into
the trachea to continue ventilation, and the distal tube is
removed.
5
Postoperative problems with sputum clearance
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6
are uncommon but if this occurs there can be
great difficulty inserting a minitracheostomy tube. It
is best to insert such a tube, above or below the anastomosis, as a routine.
Operations 159
7
6
A corrugated drain is inserted and the strap
7
muscles are approximated in the midline.
The skin is closed with continuous subcuticular
suture. The chin is fixed to the presternal skin
using strong monofilament sutures with the
neck in moderate flexion.
160 Tracheal resection
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Resection of the cricoid cartilage
The proximal margin of resection may
8
be extended into the larynx if
necessary. The technique, described by
Pearson, allows resection of the anterior
and lateral aspects of the cricoid cartilage
with preservation of the recurrent laryngeal nerves. These are protected by dividing the cricoid cartilage obliquely, avoiding
the posterior plate and the cricothyroid
junction, the landmark at which the recurrent nerves enter the larynx.
The mucosa overlying the posterior
plate can be elevated and resected if, as is
often the case, it is fibrotic. The cartilage of
the posterior plate may also be partially
resected using fine rongeurs to enlarge the
lumen.
Recurrent
laryngeal
nerve
8
The anastomosis is performed as described above. The
9
continuous suture along the posterior part of the anastomosis passes through the membranous wall of the distal trachea and superiorly is limited to the mucosa of the larynx,
which is usually quite robust. Full thickness bites and the
reinforcing sutures at each quadrant are only inserted once
past the posterolateral angle on each side where the nerves
enter.
9
As with all airway anastomoses it is important to
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10
be necessary (see below). The subglottic area is narrow, and
edema associated with such a high anastomosis may involve
the larynx. In most such cases therefore the author prefers to
protect the upper airway by inserting a T-tube at the end of
the procedure, leaving the proximal limb extending above the
vocal cords. It is best to bring the T-tube through the trachea
above or below the anastomosis. A minitracheostomy tube is
thus unnecessary. A corrugated drain is led through a stab
incision and the chin is fixed in slight flexion.
avoid tension and a laryngeal release procedure may
Operations 161
Release procedures
It is important to limit circumferential mobilization of the
airway to the segment to be resected and a cuff at each end for
anastomosis. This minimizes ischemic injury that may result
in complete dehiscence or defects in the anastomosis leading
to the formation of granulation tissue, a process often attributed to tissue reaction to suture material. However, tension
10
on the anastomosis is equally undesirable. The early cadaveric
studies undertaken by Dr Grillo have shown the various
release procedures that can allow more extensive airway
resection to be undertaken without undue tension. However,
individual surgeons will have to judge from their own experience when tension on the anastomosis is excessive, requiring
a release procedure, and even when it is prudent to limit any
further resection and accept an incomplete resection.
162 Left-sided pulmonary resections
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When tension is considered excessive there are
11
several steps that can be taken that will sequentially
assist approximation of the anastomosis. First check that the
maximum flexion of the neck has been achieved. Freeing the
anterior wall of the proximal and distal segments will allow the
airway to slide a few millimeters without adding to the
ischemic injury. Mobilizing the posterior wall is more effective but also more hazardous. Grillo has emphasized the
importance of preserving the lateral vascular pedicles,
although this seems less imperative given the good results of
slide tracheoplasty. When a thoracic approach has been used
one can provide release by mobilizing the pulmonary hilum
and freeing the pulmonary ligament. Additional length is
achieved by incising the pericardial attachments of the
pulmonary vessels. When carinal resection has been under-
Digastric
muscle
taken a Barclay reconstruction (see later) may be necessary.
When a cervical approach is used a laryngeal release can be
added, the method now preferred being the supralaryngeal
release described by Dr Montgomery. A second, circumferential skin incision is made over the hyoid bone. Its anterior
surface is cleared of platysma and the attachment of stylohyoid
divided. The three thin, muscular attachments to the superior
surface of the hyoid, mylohyoid, geniohyoid, and genioglossus, are divided, exposing the pre-epiglottic space. The
lesser cornu is divided, freeing the pharyngeal muscles
attached to it and releasing the sling of digastric. Heavy
scissors are used to divide the body of the hyoid bone from the
greater cornu on each side, immediately anterior to the sling
of the digastric muscle, allowing the central portion to slide
inferiorly.
Severed ends of the
mylohyoid, geniohyoid
and genioglossus muscles
11
Line of transection of
the greater cornu
Operations 163
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If a laryngeal release is judged to be necessary when
undertaking a thoracic approach to the trachea or carina
it is logistically easier to perform this step prior to
thoracotomy.
The mediastinal pleura is
12
chea, the azygos vein is divided and
its ends transfixed, the hilum of the
right lung is circumnavigated, freeing the hilar structures and dividing the pulmonary ligament.
Lymph nodes around the affected
segment of the airway will be
resected, and in malignant cases
more extensive nodal evaluation is
required. During this maneuver
bronchial and mediastinal vessels
will be encountered. Whilst one
should divide as few as possible, it
is important to accurately define
the anatomy and the extent of
disease.
incised over the lower tra-
Resection of the lower trachea
A right thoracotomy through the fourth interspace or the bed
of the fifth rib provides access to the intrathoracic trachea, the
main carina, the whole of the right bronchial tree, and the left
main bronchus to its lobar division. If the airway will accommodate a double-lumen endobronchial tube, this facilitates
dissection prior to airway division.
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