dimensional computed tomography reconstruction. T or T-Y tubes are specially fabricated in advance in accord with precise measurements derived from these examinations (see Chapter 39, "Tracheal T Tubes"). Tubes of at least two diameters (most often 12 and 14 mm) are made, to be certain of a fit at operation. The T sidearm must be at an appropriate height in the trachea and at a proper distance from the carina if a T-Y tube is used. The angles of bronchial take-off must be correct. Proximal and distal ends can be shortened. As described in Chapter 39, "Tracheal T Tubes," these cut ends are carefully sanded smooth.

The long anterior tracheal incision is closed over the tube. After 4 to 6 months, during which firm healing of the wall takes place in its new position, the stent is extracted, leaving a permanently enlarged lumen.

The trachea cannot be dilated with a rigid bronchoscope, so firm is the pathologic process. Subglot-tic intralaryngeal nodules seem to remain small, allowing a small endotracheal tube to be inserted at least sufficiently to provide a satisfactory initial airway for anesthesia. A laryngeal mask airway may be considered in an extreme case where intubation seems tenuous or impossible.

Approach is through a cervical incision, with dissection high enough to allow later division of sterno-hyoid muscles at the hyoid bone, and by complete vertical sternotomy. The thyroid isthmus is divided and reflected. The anterior surface of the trachea is dissected to the carina. Access to the lowermost trachea can be made, if necessary, by dividing the anterior and posterior pericardium between the superior vena cava and aorta beneath the brachiocephalic vessels and above the pulmonary artery (see Figure 23-7 in Chapter 23, "Surgical Approaches").

After opening the anterior midline of the trachea (see Figure 32-5A), a suitably-sized endotracheal tube is inserted across the operative field, either into the most distal trachea or into the left main bronchus, to continue ventilation. If urgency demanded, two small-bore tubes could be placed, one right and one left, using two anesthesia machines. This seems unlikely. A bifid high-frequency catheter is another option, but care needs to be taken that the nodularity in the bronchi does not hinder escape of gases around the catheters.

A previously prepared or selected extra-long silicone T tube (or more often, a T-Y tube) is trimmed and fitted exactly to the airway, extending from just above the cricoid (but not impinging on the conus elasticus below the glottis), either to the lowermost trachea or into main bronchi if there is serious bronchial involvement (see Figure 32-5B). Bronchial disease is common but is not uniformly present or necessarily severe.

Ventilation is continued by tucking the tip of a properly sized endotracheal tube into the proximal end of the T tube in the subglottic larynx and capping the sidearm. Alternatively, ventilation is carried out across the operative field via the T sidearm, using an endotracheal adapter and a light tracheostomy swivel connector. The proximal vertical arm of the T tube above the sidearm in this case is occluded with a small inflatable balloon with a small access catheter (eg, Pruitt catheter), which emerges through the T tube sidearm beside the endotracheal tube adapter. A Fogarty catheter can also be inserted translaryngoscopi-cally to occlude the proximal T tube.

The tracheal wall is so rigid that a small amount of tissue usually must be excised to allow space for emergence of the T tube sidearm. This tissue provides a specimen for histologic examination. In one patient, a few large nodules were removed from the opened trachea with a pituitary rongeur. The long linear tracheotomy is easily approximated with interrupted 4-0 Vicryl sutures, as the lateral walls hinge outward like a book's covers (see Figures 32-5C-E).

A sternohyoid muscle pedicle, inferiorly based, is turned caudad and sutured over the tracheal incision inferior to the T tube sidearm (see Figure 32-4C). Both sternohyoid muscles may be required for this length of incision. The sternothyroid muscles may be approximated to cover the upper tracheal incision superior to the T tube sidearm.

The splinting T or T-Y tube is left in place for 4 to 6 months, with usual T tube care. The silicone rubber tube is then extracted under general anesthesia, with a ventilating rigid bronchoscope positioned through the vocal cords just above the tube. The airway is carefully inspected with a Hopkins telescope. I prefer to leave a capped stomal cannula (Montgomery) in place to maintain a tracheostomy channel until it is certain that the patient continues to enjoy a good airway. After about a month, during which the patient has been able to tolerate the cannula capped, it is removed and the stoma allowed to heal. Periodic broncho-scopic follow-up is advised, at least for a number of years. Patients with TPO produce quite an amount of mucoid secretions, which continues after airway obstruction is relieved. They are better able to clear secretions, however, because effective cough is possible. Only 4 patients have been seen with sufficiently severe obstruction to require reconstruction. In 3 patients, the procedure was successful. In 2 patients, follow-up has been over a period of many years (see Figures 14-22E, 14-23C in Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions") and over 3 years in the third patient. The fourth patient, who had difficulty after extraction of the T tube, disappeared from follow-up. Although experience is limited, I believe that the operation can be recommended.

We encountered TPO in the main bronchi in 1 patient, severe enough to require bronchoplasty as well as tracheoplasty. Both main bronchi were incised and a previously prepared T-Y tube was inserted. Access to the entire left main bronchus was obtained by opening the pericardium anteriorly and then posteriorly lateral to the aorta, after division of the ligamentum arteriosum. The recurrent laryngeal nerve was carefully preserved. No difficulty was encountered in suturing the bronchi closed over a T-Y tube. Thymic lobes were used to cover bronchial suture lines. In a very rare case of tracheal TPO with only segmental tracheal involvement, limited tracheal resection and reconstruction has been done. References to stented tracheoplasty and to segmental resection for TPO are noted in Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions." Modified lateral slide tracheoplasty has also been employed in an instance of segmental narrowing, but T tube tracheoplasty as I have described seems a simpler solution.1

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