Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4652_Библиотеки_им_академика_М_И_Перельмана

Infant larynx is located at the levels of third to fourth cervical vertebra and it starts to descend by age of two to reach adult levels. e challenges in an infant larynx are based on its anatomy wherein up to ten tracheal rings lie in the neck in infants, it’s one-third the size of adult larynx and thyroid notch lie behind the hyoid bone. e technical diculties in performing a peadiatric tracheos­tomy is mainly due to the pliable cartilages of infant trachea which can make it dicult to identify from other tubular structures in the neck, thus increasing the possibility of injuring the major structures nearby like recurrent laryngeal nerve, esophagus etc. For peadiatric tracheostomies most palpable landmark is cricoid cartilage, unlike thyroid notch in adults. e location of tracheotomy in children for aspiration or prolonged ventilator support, is made at third or fourth tracheal rings. When indicated for incipient laryngotracheal stenosis (LTS) due to prolonged intubation, it must be at first tracheal ring to preserve as many normal tracheal rings distally as possible or low in the neck at sixth or seventh tracheal rings so as to spare sucient number of normal rings be­tween the stenosis and tracheostoma. e surgery is performed under general anesthesia with the airway secured where ever possible with an endotracheal tube or a rigid ventilating broncoscope. For cosmetic reasons a small hori­zontal incision is preferred which is then deepened through subcutaneous fat plane to strap muscles and bipolar diathermy used to cauterize small vessels in the surgical field. e anterior surface of trachea is exposed over 3 to 4 tracheal rings. e debate is still ongoing whether a vertical or horizontal tracheal inci­sion, with or without flap should be made. However the vertical incision seems safer and preferred during all the procedures done at our institute. However tracheal stay sutures are placed or either sides and secured to either sides of chest or an inferiorly based Bjork flap transecting a single tracheal ring maybe taken and sutured to the inferior edge of skin to facilitate reinsertion of the tracheostomy tube while it is being changed or during accidental extubation. In infants accidental dislodgement of the tracheostomy tube is something that one must be careful about and hence the immediate post tracheostomy period is important with the infant requiring utmost care if possible by sta trained to do so. e smallest tracheostomy tube that ensures specifically adapted gas exchange in relation to child’s age is selected. e postion of distal tip of tra­cheostomy tube, which should rest at least two to three rings above the carina, must be ensured hence the availability of appropriate sized tracheostomy tubes for infants is important. One ring Bjork flap is one of the ways to prevent anterior accidental subcutaneous dislodgement of the cannula.