Cutaneous Tube Reconstruction of the Trachea

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Prior to recognizing the extent of tracheal resection, which is made feasible by cervical flexion, anatomic mobilization, and other maneuvers, a "trough" method for staged reconstruction of the cervical trachea was developed, using cervical skin and underlying platysma. The specific technique described was just one of several such procedures described by various surgeons. Patency was assured here by implantation of several polypropylene rings (see Figure 32-3) in laddered fashion between the dermis and the platysma, carefully avoiding epithelial communication and its consequences of probable infection.2,3 The technique offered the possibility of transferring a segment of cervical trachea into the mediastinum, with its lateral blood supply intact, in order to effect safe intrathoracic anastomosis where complete anatomic tracheal reconstruction seemed to be impossible. The gap in the cervical trachea was then to be filled with the cutaneous conduit in a later procedure. The procedure is detailed here largely for historic reasons. It must not be considered as a substitute for the now-standard reconstructive techniques described in earlier chapters.

At initial operation (Figure 32-8), a very low cervical collar incision is made, which later becomes the inferior margin of a horizontal bipedicled full-thickness flap of lower cervical skin and platysma that will ultimately form the cutaneous conduit (see Figure 32-8A). The tracheal resection is performed through this incision, if necessary with a vertical inferior extension over part or all of the sternum. The thyroid isthmus is divided and the thyroid dissected free from the trachea. The cervical tracheal segment is divided between first and second cartilaginous rings and is dissected anteriorly and posteriorly, carefully sparing the blood supply pedicles on both sides. The recurrent laryngeal nerves are very carefully preserved.

The precise location of the initial incision must be selected with consideration of the parallel incision to be made later at the lower edge of the beard line, to form the upper margin of the skin flap (see Figure 32-8A).

A bipedicled flap is elevated beneath the platysma, long enough to provide slack for infolding the flap into a trough to form the tracheal replacement (see Figures 32-8B,C). Blood supply arising from both lateral bases of the flap is adequate. Through short carefully placed incisions, a series of perforated polypropylene rings is introduced between the undersurface of the dermis and the platysma, using specially-made needles (Figure 32-9) that emerge through other short incisions at a point equidistant from the midline of the neck from the line of incisions made for introduction of the needles (see Figure 32-8B). The rings are drawn through the flap until a suture fixing the ring to the hub of the needle is seen and cut. Long sutures are attached to the last perforation of the free ends of the rings, and these are used to adjust the rings precisely in their subcutaneous location. If there is excess length of plastic ring, it is cut off with heavy, straight scissors and the corners trimmed. The mini-incisions for ring introduction on either side are closed with

Horizontal Neck Incision

figure 32-8 Staged reconstruction of the cervical trachea by construction of a cutaneous-platysmal tube. A, Two long horizontal parallel cervical incisions demarcate the vertical length of the tracheal replacement. In a male, the upper incision is placed just below the beard line. A bipedicled flap of skin with underlying platysma is elevated, with blood supply at both ends. The lower incision is the primary incision for cervical tracheal exploration, mobilization, resection, and devolvement, as is necessary. B, Perforated polypropylene rings of open circular form (see Figure 32-3) are introduced in separate channels between the undersurface of dermis and the platysma, using specially-made needles, and introduced and exited through lines of cutaneous nicks (as shown) far enough apart to provide tissue for a major part of the trough's circumference. The needle entry and exit points are sutured.

C, Anastomosis is made to a residual tracheal ring proximally, or to the cricoid, using individual 4-0 Vicryl sutures, and to the trachea distally.

D, In the midline superiorly and inferiorly, the infolded skin flap may not easily meet and the borders of the superior and inferior horizontal incisional edges may serve to complete the closure of the tracheal tissues. The horizontal incisions are closed lateral to the completed trough. Reproduced with permission from Grillo HC.2

figure 32-9 Special needles for subdermal introduction of polypropylene rings. An end of a ring is transiently sutured into the hub of the needle.

sutures, burying the rings completely in mesenchymal tissue. If the rings are left too long, they may erode to the skin surfaces, allowing infection to occur and forcing removal of the infected ring.

The inserted rings serve to shape the trough as part of a circular tube (see Figure 32-8C). Anastomosis is performed with 4-0 Vicryl between the upper and lower margins of the flap forming the cutaneous trough, to the remaining ring of trachea superiorly and to the tracheal end presenting inferiorly (see Figure 32-8C). Anteriorly, some of the tracheal margin may be sutured to the cutaneous margins of the flaps above and below, completing circumferential closure (Figure 32-8D).

During a healing interval, any hairs noted in the central portion of the bipedicled flap of skin are depilated by electrolysis. This is necessary in some male patients. Approximately 2 months are allowed for firm healing and acquisition of parasitic blood supply by the tissues of the trough.

At a second stage, an incision is circumscribed about the stoma that has been created, placed just far enough from the aperture to provide sufficient skin and platysma to infold for precise closure of the tube (Figure 32-10A). The platysma is elevated with the skin (Figure 32-105). Only enough dissection of this

figure 32-10 Second-stage completion of cutaneous tracheal replacement. This is performed several months after complete healing to allow time for the trough to acquire a posterior blood supply. A, The vertical stoma is circumscribed as shown (dashed line), more generously laterally to provide tissue for construction of the anterior wall of the tracheal reconstruction. B, Placement of additional segments of polypropylene rings anteriorly may be necessary, since a full-length ring can erode the skin by pressure against the anterior skin tube margins in the interval between the stages. These additional segments are also placed between the dermis and platysma. In turning these flaps, care is taken not to risk losing the posterior parasitic blood supply acquired after the first stage. C, The inverted skin incision is closed with a subcuticular absorbable suture. The platysma is next closed over the prosthetic rings. Reproduced with permission from Grillo HC.2

figure 32-10 Second-stage completion of cutaneous tracheal replacement. This is performed several months after complete healing to allow time for the trough to acquire a posterior blood supply. A, The vertical stoma is circumscribed as shown (dashed line), more generously laterally to provide tissue for construction of the anterior wall of the tracheal reconstruction. B, Placement of additional segments of polypropylene rings anteriorly may be necessary, since a full-length ring can erode the skin by pressure against the anterior skin tube margins in the interval between the stages. These additional segments are also placed between the dermis and platysma. In turning these flaps, care is taken not to risk losing the posterior parasitic blood supply acquired after the first stage. C, The inverted skin incision is closed with a subcuticular absorbable suture. The platysma is next closed over the prosthetic rings. Reproduced with permission from Grillo HC.2

central circular flap necessary to allow tension-free closure is done, in order to preserve the secondary blood supply of the final cutaneous flap, which enters posteriorly only. The tube is closed to itself with a fine subcuticular running suture (Figure 32-10C).

The tips of the plastic rings may sometimes be sutured together in the midline. More often, short additional segments of polypropylene rings must be added, between the undersurface of the dermis and platysma, after elevating the flap circumferentially (see Figures 32-105,C). On occasion, sufficient stability is evident without either joining the previously placed rings or adding segments anteriorly.

The inverted skin edge is closed with a fine running subcuticular absorbable suture (see Figure 32-10C). The platysma of the flap is next closed to itself over added rings with interrupted fine sutures (Figure 32-11A).

With cutaneous undermining and use of relaxing incisions laterally on both sides of the neck, the skin and platysma on either side of the incisional defect can be closed in layers in the midline. The gaps that present where relaxing incisions were made are grafted with split-thickness skin grafts, well away from the area of tracheal reconstruction (Figure 32-115). The "surgical embryology" of the replacement segment is diagrammed in Figure 32-12.

Patients clear sputum through a cutaneous tracheal reconstruction with vigorous cough. The absence of cilia does not seem to be a major problem. A patient with procedure completed is shown in Figure 32-13.

Relatively few of these procedures were done and the operation described is largely of historic interest. The reasons for infrequent use are 1) mobilization techniques now available for tracheal resection rarely require such added length; 2) the complexity of reconstruction and the multiple stages needed caused excessive complications, delays, and led to failure to complete the tubes in some patients; 3) for benign figure 32-11 Completion of the cutaneous tube. A, Closure. The upper horizontal incision is reopened right and left. Considerable undermining is done subplatysmally on both sides and to a lesser extent superiorly. Relaxing incisions are placed as shown, obliquely over the midlateral clavicles to allow the midline skin and platysma to close without excessive tension. B, Split-thickness skin grafts serve to surface the relaxing "gussets," where the graft overlies no essential structure. Reproduced with permission from Grillo HC.2

figure 32-12 Surgical embryology of the splinted cutaneous tracheal reconstruction. Cross-sectional diagrams. A, At the first stage, a segment of polypropylene ring (solid black line) is introduced between the dermis and platysma, creating a trough. The skin, including dermis, is stippled. The platysma (lined) underlies the dermis. At Stage 2, a circumferential incision (dashed line) allows circumferential elevation of the cutaneous platysmal flaps. B, The tube is completed by turning the anterolateral flaps and inserting additional segments of supporting rings, as shown in the drawing. Skin and platysma are closed over the reconstruction. Reproduced with permission from Grillo HC.2

disease, a T tube is a simpler, safer, yet generally satisfactory solution for managing a nonreconstructible trachea; and 4) huge tumors often also involve the larynx, and reconstruction is pointless if a functional larynx is not salvageable. In such cases, mediastinal tracheostomy may be in order.

FiGuRE 32-13 A completed cutaneous tube reconstruction in a patient who had extensive obstruction and invasion of the trachea by recurrent papillary carcinoma of the thyroid.

Although the operation is not advised, for the reasons given, and has largely been abandoned, it found use in a very few patients to provide continuity where this was demanded and seemed appropriate, and where no other reconstructive possibility was dependably available. In my longest follow-up, a cutaneous tube of this construction functioned well for 30 years. Its original indication was to restore a trachea following catastrophic failure of inauspicious tracheal resection for a supracarinal granular cell tumor performed elsewhere. Invasive papillary thyroid carcinoma required resection of the tube after 30 years. Tissue remodelling then permitted successful primary anastomosis.

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