Tracheal Resection

Updated: Mar 08, 2018
  • Author: Dale K Mueller, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Overview

Background

Tracheal resection and primary reanastomosis for tracheal tumors and stenosis is a well-described procedure. [1, 2, 3, 4]  It is most commonly indicated for postintubation lesions but is also performed for malignancies, secondary tracheal tumors, and tracheoesophageal and tracheal innominate fistulas.

Approximately half of the trachea can be safely removed with a low incidence of anastomotic complications. [2, 3, 4, 5] Because of the lack of suitable replacement material for the trachea, various mobilization and release maneuvers have been demonstrated to increase the length of the tracheal resection by elevating the carina. These include hilar, suprahyoid, and suprathyroid laryngeal release [2, 6, 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 has been 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 the midline of the chest over the manubrium. [8] The use of tracheal retention sutures on the proximal and distal-lateral edges of the anastomotic line has also been suggested as an alternative to the traditional chin suture for reducing tension on the anastomosis. [9]

Thoracoscopic tracheal resections, though not common at present, have also been described. [10]

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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. [11, 12] Other indications include secondary tracheal tumors and tracheoesophageal and tracheal innominate fistulas. [13]  (See the images below.)

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).
This resected tracheal segment shows ulceration of This resected tracheal segment shows ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue.
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Contraindications

Contraindications for tracheal resection and reconstruction include the following:

  • Medical contraindications for such extensive surgery
  • Impaired pulmonary function - 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
  • Problematic anatomy - 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 - This is a relative contraindication and should be accompanied by some type of flap, including pleural, intercostal muscle, or omental wrapping [14]
  • Tracheal resection of over half the trachea [2, 3, 4]
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Technical Considerations

Anatomy

The trachea is nearly but not quite cylindrical and is 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 C6, and extends to the intervertebral disk between T4 and T5 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.

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