Closure of Persistent Tracheal Stoma

A persistent tracheal stoma most often has epithelial union of tracheal mucosa and cutaneous epithelium. Usually, a patient has had a stoma for a long time, frequently with an extended period of ventilation. Not infrequently, the patient is older, debilitated, or has been chronically on steroids. If the stoma fails to close spontaneously within 6 months following decannulation, it should be closed electively. A stoma may be closed by drawing muscle over the aperture, but this may lead to granuloma formation. I, therefore, close persistent stomas of any size with an epithelized flap using the adjacent skin, which has healed to the margin of the stoma.2 Tracheal x-rays including fluoroscopy and bronchoscopy are advisable to rule out other lesions such as tracheomalacia, stenosis, or granuloma.

Tracheostomy Stoma

figure 22-4 (continued) D, After trimming excess skin from the margin of the flap, it is inverted and closed with running subcuticular 4-0 Dexon, presenting an epithelized surface to the tracheal lumen. E, The strap muscles are approximated in the midline, after which platysma and skin are sutured to close the transverse incision. A small drain is advisable for 24 hours.

figure 22-4 (continued) D, After trimming excess skin from the margin of the flap, it is inverted and closed with running subcuticular 4-0 Dexon, presenting an epithelized surface to the tracheal lumen. E, The strap muscles are approximated in the midline, after which platysma and skin are sutured to close the transverse incision. A small drain is advisable for 24 hours.

A sufficiently generous circular incision is made around the stoma to define the skin, which will be preserved and used for closure (Figure 22-4A). The circular incision is encompassed by a horizontal tapered ellipse and the cutaneous triangles on either side are excised. This will provide linear closure. The upper and lower skin flaps with platysma attached are elevated a few centimeters over the midline scar and trachea and over strap muscles laterally. The edge of the circle of skin is dissected up from its margins toward the center, taking care to leave an adequate breadth of circumferential attachment to the trachea (Figures 22-4B,C) where the parasitic blood supply of the flap originates. Excessive skin may be trimmed from the margin of the circular flap. The flap is inverted on itself using a subcuticular suture of absorbable material such as 4-0 Dexon (Figure 22-4D). The stoma is thus sealed with full thickness skin, with an epithelial surface presenting inside the lumen of the trachea. Granulomas do not form. The strap muscles are dissected from peristomal scar and elevated sufficiently so that they are easily approximated in the midline without tension. Normal tissue fullness is restored, eliminating the unsightly pit so often seen at a tracheostomy site (Figure 22-4E). The mobilized flap of skin and platysma are closed transversely in layers, the skin with a subcuticular suture to provide a cosmetic scar. A small drain for 24 hours is advisable. The single complication I encountered after this procedure was a hematoma in an undrained patient.

The method is not applicable where the stomal margin is still surrounded by granulation tissue. This closure may also be used during tracheal resections for another lesion such as an inferior stenosis, where stomal closure is desired. Otherwise, muscle flap closure is advisable, after debridement of marginal granulations.

References

1. Matthews HR, Hopkins RB. Treatment of sputum retention by minitracheostomy. Br J Surg 1984;71:147-50.

2. Lawson DW, Grillo HC. Closure of a persistent tracheal stoma. Surg Gynecol Obstet 1970;130:995-6.

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