Suprasternal Region Part Incision

stoma is high, then the collar incision is placed at the elective level and the stoma separately excised as the superior flap is raised.

In anterior approaches, either cervical or cervicomediastinal laryngeal release, if necessary, may be performed best through a short transverse incision over the hyoid bone (Figure 23-4). The long U-shaped flaps favored by many otolaryngologists add nothing to the exposure and leave an unsightly scar, compared with two transverse "ladder" incisions. In a short-necked, older individual, with the larynx fixed at the suprasternal notch even despite cervical extension, a single collar incision carried a little further laterally on both sides may be elevated to provide access to the hyoid region for laryngeal release. The possibility of a high incision over the hyoid bone must be recalled when the field is draped.

On occasion, in order to preserve the skin of the upper chest below the sternal notch, I have used a long, U-shaped incision that ends laterally out on each clavicle, with the midpoint of the incision just above the level of the sternal angle (Figure 23-5A). This flap has also been used for cosmetic reasons, to move the incision below the neckline. When the superior flap is elevated, access to the entire trachea and lower larynx is easily obtained. In a rare case where it may be thought that the skin will have to be preserved in connection with a complex cutaneous reconstruction or for mediastinal tracheostomy, a similar approach may be used, if necessary in combination with a vertical sternotomy or a "J" incision, which provides access to the right thorax as well (see Figure 23-5A). Access to the entire neck and to the upper sternum as well is also provided through a long supraclavicular incision (Figure 23-5B). This is useful for initial dissection, where cervicomediastinal exenteration is a possibility (see Chapter 34, "Cervicomediastinal Exenteration and Mediastinal Tracheostomy").

Postintubation tracheoesophageal fistula is usually reparable through a collar incision, but it occasionally requires an upper sternal division. Urgent surgical management of a fistula into the brachiocephalic artery is expedited by a collar incision plus complete vertical sternotomy (see Figure 23-3A) or partial sternotomy angled into the right third interspace. These provide additional lateral exposure of the arteries.

Supraclavicular IncisionMediastinal Tracheostomy

figure 23-3 Extended tracheal resection. A, Complete sternotomy. The cervical incision is still needed for exposure of the upper trachea and larynx. Access to the lower trachea and carina is made possible. B, Incision permitting access to the entire trachea from the larynx to the carina. The cutaneous incision (dashed linej is submammary and the thoracic wall incision lies in the fourth interspace. The pec-toralis muscle is elevated with the cutaneous flap. C, Further variations in access. Either right or left hemithoraces may be exposed by lateral extensions into fourth interspaces, if sternotomy is inadequate.

Mediastinal Tracheostomy

figure 23-4 The incision for the suprahyoid laryngeal release lies over the hyoid bone. The skin flap between "laddered" incisions does not have to be dissected free, except as needed for exposure. This is preferable to a long "U" incision.

Submammary FlapApron Flap Tracheost

figure 23-5 Incisions for special circumstances. A, The "apron" flap preserves the site for possible mediastinal tracheostomy. It also cosmetically removes incision from the lower neck. The dashed line indicates the possible extension of the field for access to the lower trachea and carina. B, Supraclavicular incision, which allows for complete exploration of the neck and mediastinum (via upper sternotomy under the lower flap). For use where cervicomediastinal exenteration is likely.

A lengthy benign midtracheal lesion or a malignant lesion of midtrachea, which proves microscopically to be of greater length than anticipated, will not necessarily be most accessible through posterolateral thoraco-tomy, either for resection or for reconstruction. Several approaches are possible in this potentially difficult situation. The patient should be positioned so that possibilities for successively wider accesses are available. A supporting roll may be placed vertically beneath the chest of the supine patient, to the right of the midline, with the patient's arm abducted to a point where access to the right chest is available, as far as the anterior border of the latissimus dorsi muscle. A lateral tilt table permits levelling of the anterior chest wall so that the position during initial incision remains horizontal. Exploration may be commenced through a collar incision with upper sternal division. If further access is needed, a complete median sternotomy may be added (see Figure 23-3A) or an extension made into the right chest (see Figure 23-3B). The cutaneous incision angles out from the sternotomy beneath the mammary crease to the posterior axillary line, elevating the skin and pectoralis muscle so that the thorax is entered through the fourth interspace. It is also possible to "T" a full sternotomy to the right or left (see Figure 23-3C).

These approaches permit the use of mobilization maneuvers at both ends of the trachea, both of which may be required for reconstruction after removal of a lengthy midtracheal lesion. Laryngeal release may be done in the usual manner through an additional short transverse incision over the hyoid bone (see Figure 23-4). Mobilization of the right hilum by intrapericardial release can be accomplished either through the fourth interspace incision, or less easily through a full median sternotomy after opening the pleura. Median sternotomy does not easily permit transpleural left-sided intrapericardial release, since the required degree of traction on the heart is not well tolerated. A "T" into the fourth left interspace facilitates left hilar release (see Figure 23-3C). A preferable option for left hilar release via a complete sternotomy was devised by Dr. Cameron D. Wright at Massachusetts General Hospital. Through the open pericardium, with gentle retraction of the heart, a U-shaped incision is made in the pericardium, beneath and around the inferior pulmonary vein. The right-sided release is better accomplished transpleurally because intraperi-cardial access to the right inferior pulmonary vein is made difficult by the right atrium and vena cava. Bilateral intrapericardial release may also be accomplished via bilateral submammary thoracotomy, but access to the upper trachea is limited unless the sternum is also split vertically.

Complete median sternotomy allows entry into a quadrilateral space framed by the medial border of the superior vena cava, the medial border of the ascending aorta, the inferior margin of the brachiocephalic artery and, below, the right pulmonary artery. The pericardium is opened in the front and in the back, exposing the lower trachea and carina (Figure 23-6A,B). This approach was described by Abruzzini and amplified by Perelman and colleagues, who advised opening the pericardium anteriorly and posteriorly.3,4 Access is deep and restricted, making major dissection and complex carinal reconstruction difficult.

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