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Tracheal Resection

  • Author: Dale K Mueller, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
 
Updated: Sep 15, 2015
 

Overview

Tracheal resection and primary reanastomosis for tracheal tumors and stenosis is a well-described procedure.[1] Postintubation lesions are the most common indication for tracheal resection and reconstruction. Malignancies including predominantly squamous cell carcinoma and adenocystic carcinoma also remain an indication for resection.[2, 3] Other indications include secondary tracheal tumors, tracheoesophageal and tracheal innominate fisutlas.[4]

The images below depict resected tracheal segments.

This resected tracheal segment shows ulceration of This resected tracheal segment shows ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue.
This resected tracheal segment shows internal and This resected tracheal segment shows internal and external changes that were secondary to prolonged endotracheal intubation.
This photo shows a resected tracheal segment (same This photo shows a resected tracheal segment (same segment as in the previous image).

The trachea is nearly but not quite cylindrical, flattened posteriorly. In cross-section, it is D-shaped, with incomplete cartilaginous rings anteriorly and laterally, and a straight membranous wall posteriorly. The trachea measures about 11 cm in length and is chondromembranous. This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck, opposite the 6th cervical vertebra, to the intervertebral disc between T4-5 vertebrae in the thorax, where it divides at the carina into the right and left bronchi. For more information about the relevant anatomy, see Trachea Anatomy.

For cervical lesions, a horizontal neck incision is used, while occasionally accompanied by a median sternotomy or mini-sternotomy. Intrathoracic lesions can be addressed via a sternotomy, which is the author’s preference, or a right thoracotomy. Right tracheal sleeve pneumonectomies are done via a right thoracotomy, while left tracheal sleeve pneumonectomies are done via a combined approach or via a thoracosternotomy ("clamshell" incision), although some have abandoned this operation.

Approximately half of the trachea can be safely removed with a low incidence of anastomotic complications.[1] Because of the lack of suitable replacement material for the trachea,[5] various mobilization and release maneuvers have been demonstrated to increase the length of the tracheal resection by elevation of the carina. These include hilar,[1] suprahyoid,[6] and suprathyroid laryngeal release;[7] anterior and posterior digital tracheal dissection; and constant neck flexion.

Constant neck flexion by a suture between the skin of the point of the chin and midline of the chest over the manubrium is also widely considered paramount to successful tracheal resections. An orthosis has also been used as a more comfortable alternative to utilizing the traditional suture between the chin and midline of the chest over the manubrium.[8]

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Indications

Postintubation lesions are the most common indication for tracheal resection and reconstruction. Malignancies, including predominantly squamous cell carcinoma and adenocystic carcinoma, also remain an indication for resection. Other indications include secondary tracheal tumors, tracheoesophageal, and tracheal innominate fisutlas.[4]

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Contraindications

Contraindications include the following:

  • Medical contraindications to such extensive surgery.
  • A careful evaluation of pulmonary function, if lung resection is to be included, is mandatory and should include spirometry and possibly quantitative ventilation perfusion scans.
  • For a right carinal pneumonectomy (the most common carinal resection), the distance from the right distal tracheal margin to the proximal medial left mainstem should not exceed 4 cm in most cases. Resections that exceed this are likely to result in excessive anastomotic tension.
  • Prior irradiation is a relative contraindication and should be accompanied by some type of flap, including pleural, intercostals muscle, or omental wrapping. [9]
  • Tracheal resection of over half the trachea. [1]
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Anesthesia

Tracheal resections require general anesthesia. An arterial line and often central line are also useful for the procedure. Airway control is critical for tracheal resections, and intubation should not be taken for granted. If the lesion is critical, maintaining a sedated and breathing patient while passing an endotracheal tube past the stenosis can avert sudden respiratory arrest.

Ventilation while resecting the stenosis can be maintained via an endotracheal tube passed into the operative field. This is placed beyond the stenosis after the tracheal is transected. Additional options include JET ventilation or hyperventilation with periods of apnea. Rarely, extracorporeal membrane oxygenation (ECMO with cardiopulmonary bypass) needs to be established prior to or during intubation.[10] This modality can allow tracheal resection to occur prior to establishing an airway. Most patients are extubated in the operating room and monitored in the intensive care unit postoperatively.

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Equipment

Equipment needs include the following:

  • Operative table
  • Thoracotomy tray
  • Multiple sizes of endotracheal tubes
  • Ability to perform JET ventilation
  • Ability to place on ECMO
  • Rigid bronchoscope with dilators and laser for possible dilation prior to resection
  • Bean bag, pillows, and cushions to allow for positioning
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Positioning

Cervical resection and intrathoracic tracheal resection via sternotomy

The patient is placed in a supine position with a towel roll placed horizontally under the shoulders.

Intrathoracic tracheal resection and right tracheal sleeve pneumonectomy via right thoracotomy approach

The patient is placed in posterolateral thoracotomy position with the right chest at approximately 90 º off the horizontal. Appropriate cushions and a bean bag are used to aid this position and prevent injury.

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Technique

Cervical tracheal resection and intrathoracic tracheal resection via sternotomy

A neck incision, ministernotomy, or full sternotomy are performed as indicated by the level of tracheal stenosis. The strap muscles are retraced or incised for cervical stenosis, and the innominate artery, superior vena cava, innominate vein, and pulmonary artery are retracted for exposure to the distal trachea. Operative dissection is performed directly on the trachea and associated scar tissue to avoid injury to the lateral blood supply and recurrent laryngeal nerves.

Circumferential dissection of the trachea is confined to the area of stenosis, and no more than 1-2 cm of normal trachea above and below the stenosis. This method of detailed dissection preserves the lateral segmental blood supply of the trachea. Most cervical trachea disease can be approached through a low collar incision or a collar incision combined with an upper partial sternotomy. If a stoma is present, then it is usually incorporated into the collar incision; however, if it is higher than normal, then it can be excised and closed separately.

Subplatysmal flaps are elevated to the thyroid notch superiorly and the sternal notch inferiorly. The strap muscles are saved and retracted laterally or incised with electrocautery. The thyroid isthmus is divided and reflected laterally. Mobilization of the trachea is performed only on the anterior surface before resection from the cricoid to the carina.

The level of the stenosis is determined by extrinsic anatomical deformity of the trachea or by intraoperative bronchoscopy with transillumination of the trachea and inspection with a needle placed through the stenosis. Circumferential dissection is carried out directly at the stenosis to minimize injury to the nerves and maintain the segmental blood supply. The trachea is first divided below the stenosis in an area of normal trachea, and dissection is carried proximally to free up the esophagus posterior to the trachea.

The trachea is divided proximally, and, after the stenotic segment is removed, cross-field ventilation via the operative field is achieved in the distal trachea. Stay sutures are placed laterally 2 rings above and below the planned resected segment, and with neck flexion of the patient, assessment of the tension on the completed anastomosis is carried out. Cervical neck flexion and anterior mobilization to the carina will allow, in most cases, a tension-free anastomosis of the cervical trachea. If additional length is required, a suprahyoid laryngeal release can be performed by the Montgomery technique and neck flexion performed for approximately a week postoperatively.

Intrathoracic tracheal resection and right tracheal sleeve pneumonectomy

A standard right posterolateral thoracotomy is performed. The initial dissection is commenced by division of the azygous vein to expose the carina. The distal trachea and right and left mainstem bronchus are encircled. Initial conservative incision into the distal trachea is guided by flexible bronchoscopy through the oral endotracheal tube.

The technique for reconstructing the airway is the same regardless of the level. Traction sutures are placed in the midlateral position of the proximal and distal airway to be reconstructed. These sutures are used to assess the ability of the airway to be approximated. If excess anastomotic tension is thought to exist, release maneuvers may help reduce tension on the anastomosis. Division of the pulmonary ligament and hilar release accomplished by dividing the pericardium circumferentially around the hilum provide an additional centimeter or 2 of mobility to the distal airway.

Suprahyoid release may also be used but may not add much additional length for carinal resection procedures. Once the determination has been made that the airway can be reapproximated, individual anastomotic sutures (4-0 Vicryl) are placed circumferentially. All sutures are placed to allow the knots to be on the outside of the anastomosis. Once the back row of sutures is tied, the table neck is flexed, the operative field endotracheal tube is removed, and the oral endotracheal tube is advanced onto the left mainstem bronchus beyond the anastomosis.

The front row sutures should then be tied and the endotracheal tube withdrawn to the trachea proximal to the anastomosis. When all of the sutures have been tied, the anastomosis should be checked to see if it is airtight. The anesthesiologist ventilates the patient to 20, 30, and 40 cm of pressure. The operative field is submersed in saline to allow identification of any leaks. Any leaks should be repaired even to the point of taking the entire anastomosis apart and starting all over if the leak can't be repaired. Once the anastomosis has been secured, soft tissue coverage of the anastomosis is achieved by a pedicled flap of pericardial fat, pleura, or intercostal muscle. Inspection of the anastomosis with bronchoscopy is performed prior to extubation. Frozen section to confirm complete resection for tracheal tumors is also generally indicated.[9, 11, 12, 13, 4]

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Complications

Potential complications include the following: 

  • Bleeding
  • Infection
  • Airway edema
  • Pulmonary insufficiency
  • Anastomotic dehiscence
  • Anastomotic fistula
  • Tumor recurrence
  • Anastomotic stenosis
  • Anastomotic leak
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Contributor Information and Disclosures
Author

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

References
  1. Pearson FG. Thoracic Surgery. New York: Churchill Livingstone; 1995.

  2. Jiao W, Zhu D, Cheng Z, Zhao Y. Thoracoscopic tracheal resection and reconstruction for adenoid cystic carcinoma. Ann Thorac Surg. 2015 Jan. 99 (1):e15-7. [Medline].

  3. Piazza C, Del Bon F, Barbieri D, et al. Tracheal and Crico-Tracheal Resection and Anastomosis for Malignancies Involving the Thyroid Gland and the Airway. Ann Otol Rhinol Laryngol. 2015 Aug 20. [Medline].

  4. Grillo HC. Development of tracheal surgery: a historical review. Part 2: Treatment of tracheal diseases. Ann Thorac Surg. 2003 Mar. 75(3):1039-47. [Medline].

  5. Shields TW. General Thoracic Surgery. Baltimore: Williams & Wilkins; 1994. 482–3.

  6. Montgomery WW. The surgical management of supraglottic and subglottic stenosis. Ann Otol Rhinol Laryngol. 1968 Jun. 77(3):534-46. [Medline].

  7. Dedo HH, Fishman NH. Laryngeal release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol. 1969 Apr. 78(2):285-96. [Medline].

  8. Mueller DK, Becker J, Schell SK, Karamchandani KM, Munns JR, Jaquet B. An alternative method of neck flexion after tracheal resection. Ann Thorac Surg. 2004 Aug. 78(2):720-1. [Medline].

  9. Mathisen DJ. Carinal Resection. Available at http://www.ctsnet.org.

  10. Villanueva C, Milder D, Manganas C. Peripheral Cardiopulmonary Bypass under Local Anaesthesia for Tracheal Tumour Resection. Heart Lung Circ. 2015 Jul. 24 (7):e86-8. [Medline].

  11. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg. 1990. 49:69-77.

  12. Mueller DK, Becker J, Schell SK, Karamchandani KM, Munns JR, Jaquet B. An alternative method of neck flexion after tracheal resection. Ann Thorac Surg. 2004 Aug. 78(2):720-1. [Medline].

  13. Grillo HC. Development of tracheal surgery: a historical review. Part 1: Techniques of tracheal surgery. Ann Thorac Surg. 2003 Feb. 75(2):610-9. [Medline].

 
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This resected tracheal segment shows ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue.
This resected tracheal segment shows internal and external changes that were secondary to prolonged endotracheal intubation.
This photo shows a resected tracheal segment (same segment as in the previous image).
Tracheal resection part 1a. Video courtesy of Dr. Mueller
Tracheal resection part 1b. Video courtesy of Dr. Mueller
Tracheal resection part 1c. Video courtesy of Dr. Mueller
Tracheal resection part d. Video courtesy of Dr. Mueller
Tracheal resection part 2a. Video courtesy of Dr. Mueller
Tracheal resection part 2b. Video courtesy of Dr. Mueller
Tracheal resection part 2c. Video courtesy of Dr. Mueller
Tracheal resection part 2d. Video courtesy of Dr. Mueller
Tracheal resection part 3a. Video courtesy of Dr. Mueller
Tracheal resection part 3b. Video courtesy of Dr. Mueller
Tracheal resection part 3c. Video courtesy of Dr. Mueller
Tracheal resection part 3d. Video courtesy of Dr. Mueller
Tracheal resection part 4a. Video courtesy of Dr. Mueller
Tracheal resection part 4b. Video courtesy of Dr. Mueller
Tracheal resection part 4c. Video courtesy of Dr. Mueller
Tracheal resection part 4d. Video courtesy of Dr. Mueller
 
 
 
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