figure 27-3 Surgical management of erosion by tube at the stoma. A, Incision for exploration includes collar incision and sternotomy. Sternotomy should either be complete, as shown, or angle into the right third interspace. Either will provide the necessary exposure for arterial control. B, If a tube is still present in the stoma, it is replaced by an oral endotracheal tube. The artery is carefully dissected proximal and distal to the lesion and controlled with tourniquets or vascular clamps. Only then is the injured segment dissected from the trachea and stomal margin. The damage is resected. If ventilation will be needed postoperatively, then a new stoma is made proximally (dashed line) or an endotracheal tube is used. C, The proximal and distal arterial stumps are sutured closed. The arterial ends are carefully covered with well vascularized tissue, such as strap muscle or thymic lobes. If there is no other tracheal injury, the offending stoma is debrided and closed with a pedicled sternohyoid muscle flap. In this drawing, a new stoma has been placed at a conventional site. The cuff will preferably not rest directly against the old stomal closure.
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