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between each of these four sutures to surround the stoma. The mucosa is accurately approximated to the skin (Figure 34-45).

Multiple flat suction drains are placed through lateral stab wounds to drain the neck, mediastinum, and subcutaneous spaces. The upper incision is closed using subcutaneous and subcuticular sutures or skin sutures. Usually, the upper incision can be closed without tension. Slight duskiness may be seen in the skin around the stoma at this time. It will almost invariably recover, provided there is no tension.

The lateral parts of the inferior flap incision may be sutured closed, but the central defect should be allowed to remain unstretched even if it seems possible to pull the gap together. This could place too much tension on the mobilized flap. The cutaneous gap overlies healthy lower anterior chest wall, well below the sternal defect. It is closed with a split-thickness skin graft (Figures 34-4C, 34-5).

If the vagus nerves are divided, pyloroplasty or pyloromyotomy is added. A feeding jejunostomy is placed. If colon bypass has been used and the stomach remains in the abdomen, a draining gastrostomy is also placed. If transhiatal esophagectomy has been done, a posterior mediastinal drain is brought out through the abdomen.

If the patient requires ventilation postoperatively, a flexible armored tube is placed in the trachea and carefully taped to the skin. Cuff pressure is minimal. The angle of a tracheostomy tube is inappropriate for a mediastinal tracheal stoma. Every effort should be made to discontinue ventilation as soon as possible, since the pressure from the cuff and the presence of the tube may interfere with healing of the proximal trachea. Humidity via a tracheotomy mask is necessary.

If a significant amount of anterior chest wall skin has necessarily been excised, as in the case of stom-al recurrence of laryngeal carcinoma, either rotational or island musculocutaneous flaps must be planned. These are individually designed for each patient. The mediastinal tracheostomy will emerge through the flap.

figure 34-5 Final result after resection of the larynx, trachea, esophagus, thyroid, plus left cervical node dissection in a 69-year-old man. The brachiocephalic artery was divided, the left colon was used for esophageal reconstruction, an omental pedicle was advanced, and mediastinal tracheostomy was then established. The tumor was an unusual squamous cell carcinoma of the thyroid, with negative lymph nodes. The defect from upper sternectomy, resection of clavicular heads, and the first two cartilages is visible, with the end tracheostomy to the right of the midline. The skin graft has contracted. The patient learned effective speech with an electrolarynx, and continued to serve as a moderator in town meetings. He died 3 years later from coronary artery disease, without recurrence of tumor.

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