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 / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
56
A.S. da Fonte Neto et al.
2. The distance between the surgeon and the patient is much greater than when
using a surgical table, which increases the difculty of the procedure throughout
its course. In such cases, this difculty should be foreseen and a suitable table or
patient transportation to the operating room should be requested.
3. Lighting must be adequate, preferably providing white light and front focus.
4. The multidisciplinary support team is crucial at this time; the patient will require
sedation under the care of the ICU physician or anesthesiologist.
In other situations, the aforementioned positioning of the patient is not possible,
whether due to breathing difculties or due to facial or cervical trauma [17]. These
patients should be placed in the best possible position to optimize the breathing pattern, typically in a seated or lateral decubitus position. At that juncture, full anatomical
knowledge combined with rapid decision making will shape the outcome of the case.
After placing the patient in the optimal position and with the previous measures
ensured, tracheostomy should be performed when necessary [21, 26]. Properly attired
staff should perform antisepsis of the surgical eld. For this purpose, a 10% polyvinylpyrrolidone iodine-based solution, 2% or 4% chlorhexidine gluconate antiseptic
solution, or 0.5% alcohol solution should be used. The solution should be spread
evenly, from the chin region to the nipple, and from one shoulder to the other (Fig.5).
The excess is removed with a dry swab. Consensus has not been reached regarding the use of antibiotics [17, 21]. When an antibiotic is provided, the indication is
prophylaxis for specic skin pathogens; it should be administered between 30 and
60min prior to the procedure [26]. The placement of sterile elds is next, leaving an
adequate opening for the procedure (Fig.6).
This approach should be considered for most patients. In conscious patients, the
placement of elds in the mouth and nose area may lead to greater respiratory distress
and may cause psychomotor agitation. Placing a fenestrated drape in this area is advised;
thus, in such cases, the fashioning of a sterile eld with two openings is useful (Fig.7).
Spatial access to the patient’s bedside and bedside access for anesthesiologists
are crucial to provide assistance with the oxygen supply, ventilation, aspiration, or
perhaps positioning of the endotracheal tube when performing the tracheostomy.
Fig. 5 Delimitation of the
surgical eld using
chlorhexidine antiseptic
solution. The upper limit is
the chin area with lateral
extent to the shoulders and
the lower limit at nipple
height
Tracheostomy: Conventional Technique
Fig. 6 Positioning of the
sterile eld. Note the
positioning of the
fenestrated eld on the
face, which in conscious
patients decreases the
perception of suffocation
and facilitates patient
collaboration
57
Fig. 7 Detail of a
fenestrated drape on the
face, which is separated
from the surgical eld.
Consent for Publication
Notably, however, the technique previously described typically would not be followed during emergency tracheostomy because the primary goal would be to save
the patient’s life. An airway should be opened rapidly, whether by cricothyroidotomy or perhaps by establishing a tracheostomy, with the technique assuming secondary importance. Chevalier Jackson’s observation in the early twentieth century
58
A.S. da Fonte Neto et al.
in reference to execution of the emergency tracheostomy, which remains valid
today, was that surgery should be performed using two incisions: the rst in the skin
and pretracheal soft tissues and the second in the trachea, into which an endotracheal cannula is inserted. This sequence ensures the opening of the airway, with
blood loss evaluated subsequently [18].
Anesthesia
Intubated patients and those in an ICU should be sedated and eventually myorelaxed for mechanical ventilatory adaptation during the procedure [18, 20, 21].
Patients undergoing elective tracheostomy should be sedated judiciously, and
local anesthesia with 2% lidocaine with or without a vasoconstrictor should be used.
The use of an anesthetic with a vasoconstrictor may reduce bleeding during the
surgery [21, 26]; epinephrine in a 1/100,000 dilution should be administered in such
cases [20]. The local anesthetic must be introduced using a hypodermic needle
throughout the incisional area, followed by exchange to a large-bore needle and
subsequent anesthesia of the deep paratracheal planes (Figs.8, 9, 10, and 11).
Because the introduction of intratracheal anesthesia may cause a choking sensation, cough, and dyspnea, its use is inadvisable [2, 3].
The procedure is similar in patients undergoing emergency tracheostomy, in
whom positioning is the greatest difculty. Invariably, anesthesia is performed in
the usual manner.
In emergency tracheostomy, as previously discussed, procedural execution is
possible only within the constraints of the patient’s respiratory emergency.
Incision
The incision should be made between the following anatomical landmarks: the edge
of the cricoid cartilage superiorly, the sternal notch inferiorly, and the sternocleidomastoid muscles laterally [17, 19, 21, 23]. In some cases, because the trachea may
be displaced due to various causes, the space thus delineated by these anatomical
landmarks may not in fact correspond to the actual location of the trachea. When
Fig. 8 Skin inltration
with local anesthetic
throughout the incisional
area at the level of the
epidermis and dermis
Tracheostomy: Conventional Technique
Fig. 9 Deep median
inltration with local
anesthetic at the
prelaryngeal musculature
level
Fig. 10 Deep left
paratracheal inltration to
aid analgesia related to
lateral traction using
retractors
59
Fig. 11 Deep right
paratracheal inltration to
aid analgesia related to
lateral traction using
retractors
60
Tráquea
A.S. da Fonte Neto et al.
possible, the tracheal location should be identied using imaging to allow the planning of precise access (Figs.12 and 13).
In principle, the ideal skin incision should be tailored to a size sufcient for optimum tissue exposure during dissection and to ensure less intra- and postoperative
morbidity. The incision may be performed with a cold knife or an electrosurgical
knife (Figs.14, 15, 16, and 17).
Fig. 12 Anatomical
laryngotracheal
relationships. Laringe
larynx, Tráquea trachea
Laringe
Fig. 13 Cervical incision
options
Tracheostomy: Conventional Technique
Fig. 14 Horizontal skin
incision approximately
3–4cm in diameter at a
distance 1–2cm from the
sternal notch
Fig. 15 The skin is
opened using a cold scalpel
along a previously marked
line
61
Fig. 16 Subcutaneous dissection using an electrosurgical knife along a previously marked line
62
Fig. 17 Exposure of the
panniculus adiposus and
premuscular fascia deep
planes
A.S. da Fonte Neto et al.
The skin incision may be vertical or horizontal, each of which has advantages and
disadvantages. Ideally, the choice should therefore be based on the merits of each case.
The vertical incision is made on the midline in the space between the cricoid and the
sternal notch. Approximately 3–4cm in length, it permits tissue dissection on the midline with less risk of bleeding. Another advantage is that it allows vertical movement
together with the laryngotracheal complex, which is more physiological. However, lateral limits to the tracheal planes exist, making dissection difcult, particularly with displacement of the trachea, or perhaps restricting access when inadvertent bleeding occurs.
The horizontal incision should be made approximately 2cm above the sternal
notch, between the sternocleidomastoid muscles, and should be approximately
3–4cm in length. Because this incision is parallel to other neck skin cleavage lines,
its aesthetic result is far superior to that of a vertical incision. This incision is indicated when surgery in this region is undertaken—for example, laryngectomy or
thyroidectomy. As a more static incision, it may cause more discomfort, friction,
and resulting granulomas [2, 3, 11, 12, 23, 26].
The aforementioned incisions have strengths and weaknesses, limitations, and
inconveniences. Each incision type holds no technical superiority over the other.
The nal decision will depend on the constraints imposed by the patient, whether
according to anatomical considerations or morbidities. The choice should be made
based on the experience or training of a multidisciplinary team.
For patients with cervical hyperextension difculties, whether due to spinal deformity, trauma, or a short neck, a vertical incision appears to offer a larger eld of surgical exposure and reduced procedural morbidity. For patients who prioritize the aesthetic
result, those with long necks, or those with previous cervical lesions that obstruct
access, horizontal incisions appear to offer greater advantages and lower morbidity.
Because obtaining a patent airway is of paramount importance in an emergency
tracheostomy, the incision factor has lower priority. Notably, however, in such cases,
a need for combined incisions may exist—for example, cricothyroidotomy may be
required prior to tracheostomy.
Tracheostomy: Conventional Technique
63
In our routine practice, we have performed horizontal incisions in all reported
cases, elective and emergency. Generally, this incision type may be performed
quickly and offers low morbidity, a low complication rate, and early decannulation
without the need for any intervention to close the incision.
Dissection
After the skin incision, the dissection of the pretracheal tissue begins. The salient
factor at this stage is knowledge of the deep anatomy and its variations.
Initially, the top and bottom or lateral aps are pulled back, depending on whether
the incision is horizontal or vertical, respectively. This is accomplished using an
electrosurgical knife. Care should be taken to interrupt this step to cauterize or connect vessels when bleeding is encountered (Figs.18 and 19).
Fig. 18 Dissection of planes on the midline through the premuscular fascia
Fig. 19 Ligation of the prefascial vessels; fascial opening and cervical musculature on the
midline
64
A.S. da Fonte Neto et al.
The midline is then sought, due to the lower risk of bleeding. The opening is
made using the electrosurgical knife or Metzenbaum scissors. Then, with the aid of
curved dissecting and hemostatic forceps, inferior–lateral–superior movements are
performed to dissect the sternohyoid and sternothyroid muscles, displacing them
laterally using Farabeuf retractors [17, 19, 20, 21, 26] (Figs.20, 21, and 22).
At this stage, the thyroid gland is exposed, particularly its isthmus. The thyroid
gland is xed loosely to the laryngotracheal complex via its vascular communications, Berry’s ligament, and the pretracheal fascia. Thus, it is possible to carefully
dissect the inferior poles with curved hemostatic forceps and to suspend the gland
cranially, maintaining the eld using Farabeuf retractors [20, 26, 27] (Fig.23).
In some cases, whether due to a short neck, an enlarged thyroid gland, or an
ectopic gland, ligation of the isthmus may be necessary to gain wide access to the
trachea. This step follows next and demands caution to obtain adequate hemostasis
Fig. 20 Blunt dissection
using hemostatic forceps
from the midline with
inferior–superior–lateral
movements
Fig. 21 Separation of
cervical structures on the
midline after sequential
opening and placement of
retractors
Tracheostomy: Conventional Technique
Fig. 22 Prethyroid fascial
dissection and lateral
separation, exposing the
thyroid
Fig. 23 Superolateral
thyroid displacement,
which completely exposes
the trachea and avoids
bleeding
65
Fig. 24 Exposure of the pretracheal fascia, which provides complete exposure of the trachea