Equipment
Equipment needs include the following:
-
Operating table
-
Thoracotomy tray
-
Endotracheal (ET) tubes in multiple sizes
-
Capacity to institute jet ventilation if needed
-
Ability to place the patient on extracorporeal membrane oxygenation (ECMO)
-
Rigid bronchoscope with dilators and laser for possible dilation before resection
-
Bean bag, pillows, and cushions to allow proper positioning
Patient Preparation
Anesthesia
Tracheal resections typically requires general anesthesia (though alternative approaches have also been employed [19, 20] ). An arterial line and, often, a 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 ET tube past the stenosis can avert sudden respiratory arrest.
Ventilation during resection of the stenosis can be maintained via an ET tube passed into the operative field. This is placed beyond the stenosis after the trachea is transected. Additional options include jet ventilation or hyperventilation with periods of apnea. Rarely, ECMO with cardiopulmonary bypass must be established before or during intubation. [21, 22] This modality can allow tracheal resection to be performed before an airway is established. Most patients are extubated in the operating room (OR) and monitored postoperatively in the intensive care unit (ICU).
Positioning
For 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.
For intrathoracic tracheal resection and right tracheal sleeve pneumonectomy via right thoracotomy, the patient is placed in a posterolateral thoracotomy position with the right chest at approximately 90º off the horizontal. Appropriate cushions and a bean bag are used to aid in positioning and to help prevent injury.
-
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
