Tracheal Resection Technique

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

Tracheal resection is depicted in the videos below.

A neck incision, ministernotomy, or full sternotomy is performed as indicated by the level of tracheal stenosis. The strap muscles are retracted or incised for cervical stenosis, and the innominate artery, superior vena cava (SVC), 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 along with 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 on the basis of the extrinsic anatomic deformity of the trachea or by means of 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 two 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 via the Montgomery technique and neck flexion performed for approximately 1 week postoperatively.

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

The technique for airway reconstruction 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 extent to which the airway can 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 1-2 cm 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 polyglactin) are placed circumferentially. All sutures are placed in such a way as 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 ET tube is removed, and the oral ET tube is advanced onto the left mainstem bronchus beyond the anastomosis.

The front row of sutures should then be tied and the ET tube withdrawn to the trachea proximal to the anastomosis. When all of the sutures have been tied, the anastomosis should be checked to confirm that 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 anastomotic leakage must be addressed—by repair if possible or, if repair proves impossible, by taking the entire anastomosis apart and starting all over.

Once the anastomosis has been secured, soft-tissue coverage of the anastomosis is achieved with a pedicled flap of pericardial fat, pleura, or intercostal muscle. Inspection of the anastomosis with bronchoscopy is performed before the patient is extubated. Frozen section to confirm complete resection for tracheal tumors is also generally indicated. ^{[16, 23, 24, 25, 15]}

Potential complications of tracheal resection and reconstruction include the following: 

• Bleeding
• Infection
• Airway edema
• Pulmonary insufficiency
• Anastomotic dehiscence
• Anastomotic fistula
• Tumor recurrence
• Anastomotic stenosis
• Anastomotic leakage

Hyperparic oxygen therapy (HBOT) has been suggested as a potentially useful adjunct in the management of anastomotic problems after airway surgery. ^[26]