Laryngotracheal Reconstruction Technique

Updated: Apr 08, 2016
  • Author: Brian Kip Reilly, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Technique

Approach Considerations

The goal of any LTR is to increase the size of the airway, decannulate a patient who is tracheostomy tube dependent, and preserve laryngeal function (ie, voice). The key components are the division of the narrowed segment and subsequent placement of anterior and/or posterior cartilage interposition graft to widen the airway lumen.

The difference in single-stage versus double-stage LTR refers to the number of steps involved in the reconstruction. In a single-stage LTR, the tracheostomy tube is removed during the reconstruction with the use of an endotracheal tube as a stent before extubation. If the patient is to undergo a double-stage operation, then the tracheostomy is deliberately maintained, and a stent is placed, which is then removed after healing of the graft.

By definition, in a double-stage LTR, the tracheostomy tube is kept in place at the conclusion of the procedure. If the procedure is successful, the patient is decannulated during a separate hospital admission, usually several weeks or months later. [7] The advantage of single-stage LTR is immediate decannulation or avoidance of tracheostomy altogether. The double-stage operation involves the use of prolonged stenting (Montgomery, Albouker, Cotton Stent), while the single-stage LTR requires prolonged endotracheal intubation and sedation.

See the image below.

Stent suture placement Stent suture placement

Most recommend double-stage LTR when complex multilevel stenosis, higher grade stenosis, significant neurologic deficits or lung disease, or anatomy that makes reintubation technically difficult is noted.

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Single-stage Laryngotracheal Reconstruction

A direct laryngoscopy and rigid bronchoscopy is repeated in all patients prior to performing open airway reconstruction. Once the appearance of the airway has been confirmed, the patient is intubated orotracheally in preparation for the LTR. The patient is carefully positioned supine with the neck extended. The incision is planned for a right-sided rib cartilage graft and a midline neck incision. These are injected with 1% lidocaine with 1:100,000 epinephrine. The skin is then prepped, and the patient is draped, keeping the donor site separate from the neck.

First, the rib cartilage graft is harvested. See the image below.

Chest and Neck incision Chest and Neck incision

A transverse incision is made through the skin into the subcutaneous tissue. The subcutaneous fat is then removed with electrocautery. The overlying musculature is then divided with electrocautery until the rib and its perichondrium are identified. Care is taken to preserve the perichondrium on the anterior surface of the rib. Incisions are made both superiorly and inferiorly with a No. 15 blade into the perichondrium of the rib near the bony cartilaginous junction. The underlying perichondrium is then elevated from the rib. A Doyen retractor is placed under the rib and superficial to the perichondrium. The rib is then divided at the bony cartilaginous junction.

Careful dissection is then performed to medially elevate the perichondrium from the undersurface of the rib to protect the underlying pleura. Once a 2-cm to 3-cm segment of cartilage is elevated, the cartilage graft is harvested. Hemostasis is achieved, and a leak test is performed. Any pleural defect identified should be immediately repaired. The wound is then closed in layers and a Penrose drain is left in place.

Attention is then turned to the neck, where a transverse skin incision is made in the midline through the subcutaneous fat and through the platysma. Subplatysmal flaps are then raised superiorly to the level of the hyoid and inferiorly to the sternal notch. The strap muscles are divided in the midline to expose the thyroid gland and the trachea. Additionally, the exposure is continued superiorly to the thyroid notch and the hyoid. The thyroid gland is divided in the midline to expose the entire airway from the thyroid notch to the approximately the sixth tracheal ring. Prolene retraction sutures are then placed through the cricoid cartilage on either side of the midline.

Either an RAE tube or armored endotracheal tube is prepared and a sterile circuit is placed onto the field to switch ventilation from an orotracheal tube from above to a distal endotracheal after the airway is opened. See the image below.

Armored Tube placed after removal of tracheostomy Armored Tube placed after removal of tracheostomy tube

Using a right-angle clamp and a Beaver blade, an anterior cricoid split is performed. The thyroid notch is used to maintain a midline incision. The extent of the incision depends on the site and extent of the airway pathology. Once the laryngofissure is performed, care is taken to assess the airway pathology and tailor the intervention. If posterior narrowing is seen, a posterior cricoid cartilage division may be performed. Prior to dividing the cartilage, it is injected with local with epinephrine (either 0.5% lidocaine with 1:200,000 or 1% lidocaine with 1:100,000 epinephrine). The No. 64 blade is then used to divide the posterior cricoid cartilage. A hemostat clamp is used to distract the cartilage to ensure that this division is complete.

Occasionally, the posterior division is extended superiorly into the interarytenoid region if posterior glottic stenosis is present.

The rib grafts are carved on a back table. The posterior graft is fashioned into a rectangle with a posterior flange. The width is approximately 5 mm with a 1 mm flange and the height is approximately 10 mm but this varies. The perichondrium is preserved on the luminal surface of the graft. After, the anterior cartilage graft is carved into a boat shape. See the image below.

Anterior Graft Placement Anterior Graft Placement

The length varies depending on the length of the anterior laryngofissure. See the image below.

Rib graft with preservation of perichondrium Rib graft with preservation of perichondrium

Again a flange is made and the ends are tapered to conform to the distracted airway.

Next, the posterior cartilage graft is placed by distracting the cricoid ring. The flange of the posterior cartilage graft and the natural recoil of the cricoid ring secure the graft into position. The airway is then examined from above with a telescope to confirm proper placement of the graft. Once this is done, the patient is then intubated nasotracheally with an appropriate sized nasotracheal tube. The end of nasotracheal tube is placed just distal to the anterior laryngofissure and the tube is secured.

Next, the anterior graft site is secured with 4-0 Prolene in a horizontal mattress suture technique. The sutures are placed submucosally on the intraluminal side of the trachea. The graft is then parachuted into position once all of the sutures have been placed. Saline is then instilled into the wound bed and a Valsalva is performed to check for an air leak. Ideally, the graft is placed in airtight fashion to minimize graft infection. The thyroid gland can be closed over the graft and the strap muscles are reapproximated in the midline. The wound is closed in layers over a Penrose dressing.

When a preexisting tracheostomy is in place, the surgeon must decide whether to perform a single-stage operation with decannulation or to keep the tracheostomy tube in place. In this operation, the patient’s stoma site is excised with the initial transverse skin incision. The airway is subsequently exposed in a similar fashion taking care to expose the airway distal to the tracheostoma. Then, the patient’s trachea is divided inferiorly to include the tracheostoma. A longer anterior cartilage graft is required to span the length of the anterior airway division. The anterior graft is then secured in a similar fashion and the patient’s incision is closed as above.

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Double-stage Technique

The double-stage technique involves slight modifications from the single-stage technique described above since the patient has a tracheostomy in place. Initial decisions are directed towards addressing the tracheostoma. In double-stage LTR, the tracheostomy is preserved, and typically a suprastomal stent is placed into the airway to support the cartilage grafts. In most cases, the incision and dissection avoids violation of the stoma site. If exuberant granulation tissue is present either at the skin or tracking into the trachea, revision of the tracheostoma at the same operation may be performed.

In double-stage LTR, once the posterior cartilage graft is positioned, a stent is used in the airway to provide framework for mucosal healing. Stents give support, protect against graft displacement, and help prevent scar tissue from causing contracture. The selection of which stent to use is by surgeon preference. Aboulker and cylindrical silastic stents are two of the more commonly used stents. The stent is sized to sit from a level inferior to the arytenoids, between the vocal cords, to just above the tracheostomy. The stent is anchored with a non-absorbable suture through the strap muscles and cricoid. It is tied into approximately 2 cm of knots and allowed to exit the neck at one side of the transverse skin incision. The stent is removed by cutting this suture during a separate procedure approximately 3-6 weeks after it is placed. Some patients may require longer stenting times.

At the conclusion of the double-stage LTR, patients should have a secure airway because of the existence of an undisturbed tracheostomy. All of those involved in the care of these patients must understand that a stent is in place suprastomally. If the patient is accidentally decannulated during this time, intubating the patient through the mouth is impossible without removing the stent.

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Cartilage Rib Graft

The mainstay graft material is cartilage from either the rib or the thyroid. Some surgeons prefer use of ear or thyroid cartilage because of less donor site morbidity.

The following surgical steps are performed for the rib cartilage removal:

  1. The right fifth rib is selected. An incision is made in the inframammary incision. In females, an estimated future breast crease is selected for women.
  2. Dissection is carried down onto the rib with Bovie cautery, carefully splitting the intercostals.
  3. The overlying periosteum is protected from thermal damage from Bovie cautery.
  4. A straight appearing nonbony portion of cartilaginous rib is then isolated.
  5. The undersurface of the rib is carefully dissected with a blunt instrument.
  6. The surgeon must harvest the desired length of rib base upon the length of the stenosis that needs to be repaired and whether anterior and posterior grafts must be placed.
  7. A pneumothorax must be avoided, and the surgeon must ensure that no defect is present in the pleura by irrigating the wound with saline. If a leak is present, the pleural defect is sutured. A leak is reassessed by applying positive pressure ventilation.
  8. A Penrose dressing is then placed.
  9. The intercostal muscles are reapproximated with suture.
  10. The skin is sutured closed.
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