Anterior Patch Tracheoplasty

The initial solution to the problem of long congenital tracheal stenosis, devised by Kimura and colleagues, was vertical incision of the entire length of the stenotic segment with insertion of a patch or "gusset" to widen the lumen.4,5 Costal cartilage or pericardium are principally used for the patch.4-8

Proponents of these techniques favor use of cardiopulmonary bypass, although the procedure could be performed without bypass in the absence of associated vascular anomalies.6-8 Approach is via complete

Tracheoplasty

figure 33-1 Examples of congenital tracheal stenosis short enough to be treated by resection and reconstruction. A, Three-month-old boy with a stenotic segment less than 'A of the length of his trachea. In addition, there was malacia present, which was best treated by resection. B, Followed from infancy with a noncritical stenosis, resection was done at the age of 23 years to improve exercise performance. With over 30% of his trachea involved, slide tracheoplasty would now be elected in infancy, but this length of resection was easily tolerated in a young adult. Reprinted with permission from Grillo HC et al.'2

figure 33-1 Examples of congenital tracheal stenosis short enough to be treated by resection and reconstruction. A, Three-month-old boy with a stenotic segment less than 'A of the length of his trachea. In addition, there was malacia present, which was best treated by resection. B, Followed from infancy with a noncritical stenosis, resection was done at the age of 23 years to improve exercise performance. With over 30% of his trachea involved, slide tracheoplasty would now be elected in infancy, but this length of resection was easily tolerated in a young adult. Reprinted with permission from Grillo HC et al.'2

median sternotomy. The thymic lobes are separated, the pericardium is opened, and the aortic arch retracted, permitting exposure of the lower trachea and carina (Figure 33-2). The entire trachea is visualized anteriorly. If partial cardiopulmonary bypass is to be used, cannulas are then placed in the atrium and aorta. If there is difficulty in identifying the proximal end of the stenosis, the patient is bronchoscoped and the point marked with a suture.

An anterior midline vertical incision is made in the trachea through the stenosis from its upper end to its lowermost point. This may be determined by direct inspection, as the incision is carried inferiorly. If pericardium is used for repair, a rectangular patch is outlined and excised from the readily available anterior pericardium.6,7 It is trimmed and sutured into the tracheal defect. Interrupted 5-0 Dexon sutures or continuous running 6-0 polydioxanone suture, which do not penetrate tracheal mucosa, have been recommended.6,7 Several partial thickness sutures are used to suspend a pericardial patch to mediastinal structures. Added sutures are placed to suspend the tracheal margins similarly. The innominate artery is suspended to the sternum in closing. I believe that the patch could be safely sutured with interrupted 4-0 or 5-0 Vicryl sutures passing through full thickness of the tracheal wall.

The patient remains intubated for a week or longer, as necessary, to permit the patch to stiffen so that the airway will not collapse. The upper and lower ends of the tracheoplasty are marked with hemoclips. The

Tracheoplasty

figure 33-2 Patch tracheoplasty. The vertical incision in trachea can be carried onto one or both main bronchi if stenosis extends that far. Running suture has been advised for pericardial repair. The patch, the trachea, and the brachiocephalic artery must also be suspended. Interrupted sutures are preferred for a cartilage patch, and care is taken to fashion it so that it does not prolapse into the lumen of the trachea. Both techniques require postoperative endotracheal tube splinting.

repair is examined with a flexible pediatric bronchoscope and an endotracheal tube is positioned so that its tip lies just distal to the lower end of the pericardial patch. The integrity of the tracheoplasty is checked under saline. In reports of this technique, second-layer buttressing has not been thought necessary. Granulation tissue formation, which requires repetitive bronchoscopic removal, occurs frequently.9 Contraction of the pericardial patch and complete epithelization both appear to occur in the long run. Tracheal growth has been adequate in follow-up.

Other native or preserved tissues have been used for augmentation of the trachea, but Kimura and colleagues' original use of cartilage has been successfully employed.4,5,8 Cartilage is harvested from the costal margin through the lower part of the sternotomy incision. After the length and shape of the tracheal defect is determined, the cartilage graft is carefully shaped, preserving perichondrium. The cartilage is precisely sutured into the defect with perichondrium facing the lumen, using interrupted sutures. Seven to 10 days of intubation and ventilation are followed by bronchoscopy to determine adequacy and stability of the repair

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