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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
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Transtumoral Tracheostomy
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Fig. 4 Signicant airway deviation in a patient with a massive cervical desmoid tumor
Because the airway is compromised, the anesthesiologist must have instruments available to facilitate orotracheal intubation and may sometimes use bronchobroscopy (Fig.5) for adequate visualization of the airway and to minimize
local trauma with a risk of bleeding, which will make it even more difcult to
access [1, 5].
The well-known palliative procedure for anaplastic thyroid carcinoma is no longer a rarity in certain oncology centers where the patients are of low socioeconomic
status [2, 12, 13].
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Fig. 5 General anesthesia prior to tracheostomy, via intubation assisted by nasobroscopy
D.J.C. Silva et al.
Fig. 6 Lesions of cervical origin with tracheal compression
Transtumoral tracheostomy may be necessary in lesions originating from the
upper digestive tract and cervical lesions. The former are lesions of the larynx,
hypopharynx, and even the oropharynx. The latter are thyroid lesions (Fig. 6),
cervical metastasis of unknown primary tumor [1, 2]. Another signicant point,
which increases the difculty of the procedure, is radiation therapy, especially if
only recently completed [14].
Patient Approach
The patient being electively treated with a present neoplastic lesion and in whom
there is a risk of progression to transtumoral tracheostomy needs to be approached
in a precautionary way in order to convince them that performing the procedure
before obstructive symptoms occur (Fig.7) is the best option. The rationale for the
procedure and its potentially life-saving justication must be made explicit by the
Transtumoral Tracheostomy
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Fig. 7 Older patients with
large cervical masses with
an indication for
tracheostomy; older age
may be a factor in
resistance to acceptance of
a tracheostomy
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D.J.C. Silva et al.
surgeon. Certainly the ethical conduct of the professional, and formal documentation of it in the medical records, should not be neglected. Such time devoted to
verbal and documented clarication will undoubtedly be advantageous for the clinician in the future, both in relation to the patient’s family and in legal terms.
When there is still no cancer diagnosis, and depending on the family culture and
clarication, the justication for the procedure is more difcult. In these cases, it is
advisable to follow up with more regular consultations so that even without results
of an oncological diagnosis, knowledge of the evolution of the lesion itself provides
a sufcient and convincing argument for performing the tracheostomy before any
obstructive symptoms occur.
Surgical Technique
General anesthesia is performed by orotracheal intubation, and bronchobroscopy
often facilitates the procedure by reducing the risk of bleeding from airway trauma
and allowing better visualization of the lumen.
The patient is placed in dorsal decubitus with the use of a cushion under the shoulders and support under the head, allowing hyperextension of the neck. This maneuver exposes the trachea better, bringing it more anteriorly and showing more of its
length (Fig.8). The support helps to stabilize the head. The surgeon should position
the patient while the anesthetist raises his or her chin. The area to be demarcated will
have a upper limit of the mandible and a lower limit of the pectoral region [15].
A large horizontal incision (Fig.9) is performed, and then detachment of myocutaneous aps is performed in the upper and lower subplots (Fig.10).
The median raphe formed by the cervical fascia is incised vertically, and the
prethyroid muscles (hyoid sternum and thyroid sternum) are folded laterally
Fig. 8 Positioning of the patient on the surgical table in hyperextension and cranial xation, when
possible, are essential for the procedure
Transtumoral Tracheostomy
Fig. 9 A large cervical incision is important in transtumoral tracheostomy, even when there is
already an understanding of the tracheal topography
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Fig. 10 Lifting of the subplatysmal patch
(Fig.11). When it is not possible to fold these muscles because of tumor invasion,
they should be sectioned (Fig.12).
After removal of the prethyroid muscles, we reach the volume of the tumor mass
that is causing the compression and obstruction of the airway. The thyroid cartilage
is an important anatomical reference at this point, and the surgeon must be guided
by it in search of a viable tracheal area (Fig.13).
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Fig. 11 The sternohyoid and sternothyroid muscles are retracted laterally or sectioned if there is
a tumor invasion
D.J.C. Silva et al.
Fig. 12 (a) A large cervical incision is made for the safest possible approach to the already per-
formed transtumoral tracheostomy. (b) Section of the musculature
At this point the surgeon should evaluate the resectability of the lesion that is
anterior to the trachea. Whenever possible, it is important to remove the largest possible volume of the mass anteriorly for greater exposure of the airway, which should
maintain the permeability of the access route and facilitate the xation of the tracheostomy (Fig.14).
When it is not possible to remove the anterior mass volume (Fig.15), a tumor
incision must be made, thinning it with electrocautery, until a viable trachea is
achieved (Fig.16).
Transtumoral Tracheostomy
Fig. 13 During the procedure, with loss of the usual anatomy, in addition to the possibility of
preoperative examinations to locate the trachea site, palpation to identify structures such as the
carotid, cricoid, and thyroid cartilages is of great value
Fig. 14 Resection of as
much of the neoplasm as
possible, maintaining the
safety of the procedure,
with an emphasis on
diagnosis, treatment, and
improvement of the
surgical condition
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Once tumor debulking is performed, an inverted U-shaped incision (Bjork
technique) is performed and a tracheal ap is made of about one half to two thirds
the width of the trachea. The incision is performed in the intercartilaginous portion between the rst and second tracheal rings and extends inferiorly, promoting
the section of two rings. The xation of the tracheal aps is performed with nonabsorbable thread with stitches surrounding the tracheal ap and the skin of the
incised region, promoting xation of the tracheal orice to the skin [16, 17]
(Fig.17). Another possible technique is an H-shaped tracheal incision [18, 19, 20]
(Fig.18).
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Fig. 15 Putting the surgical procedure at risk (of bleeding, infection, and complications such as a
stula), the removal of a large volume of the mass anterior to the tracheal tract during transtumoral
tracheostomy is avoided
Fig. 16 Trachea with an
endotracheal tube
D.J.C. Silva et al.
Fig. 17 Fixation of the
tracheostoma on the skin
after resection of the
anterior wall of the trachea
Transtumoral Tracheostomy
Fig. 18 H-shaped incision in the trachea
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Cervical drainage may be required, depending on the debulking performed
(Fig.19), as well as cutaneous cannula xation to avoid the risk of dislocation of the
cannula outlet and exaggerated manipulation of the site (Fig.20).
It is not always possible to follow the predetermined surgical plan. Depending on
the degree of injury, destruction, and tracheal deviation, what happens depends on
the status of the airway. This is consistent with important points: the new tracheal
location (Fig.21) and the location of the obstruction, structures that may be in the
way, and the environment (the procedure site, anesthesia, and materials). The rst
two can be evidenced by physical examination when the patient has had a previous
medical appointment and the history of the neoplastic lesion is known, or by complementary examination. The third one will depend on the hospital structure available to the head and neck surgery at the moment to perform the procedure and the
surgeon should determine what he needs to do this procedure.
Technical Care
In addition to preparation of the patient and the family regarding the risk of the
procedure and the prognosis of each case, sufcient time should be allowed for suitable preparation of the setting in which the procedure will be performed. The information given to the anesthesia team and the surgical room team is important for
preparing the materials and avoiding distress and a sense of unpreparedness on the
part of the patient, which could cause desperation during the procedure if general
anesthesia is not feasible. Having surgical materials, a choice of cannulae, and
materials for difcult anesthesia in place is essential to avoid prolonging the
procedure.
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Fig. 19 Necessary cervical drainage after a large detachment, with signicant removal of the
lesion and risk of bleeding, reducing the chances of complication
Fig. 20 Secure xation of
the Portex cannula,
avoiding improper
manipulation and risk of
displacement of the
cannula
D.J.C. Silva et al.
In debulking, all removed material should be sent for histopathological study,
even with a previous diagnosis. If this is the rst approach to the patient, enough
material should be collected and sent for histopathological and immunohistochemical study to optimize the chance of a conclusive diagnosis and suitable treatment for
the patient.