figure 25-3 (continued) C, The larynx and trachea are prepared for anastomosis. The bared inner surface of the cricoid will be covered by advancement of the posterior tracheal flap. The curved tracheal cartilage will repair the anterior cricoid gap. D, The reconstituted upper airway. For clarity, only two posterior mucosal sutures are shown. Their knots lie behind the mucosa. One "fixing" suture is also shown between the outer layer of the base of the membranous wall flap and the inferior margin of the posterior cricoid.

The balance of the anterior anastomotic sutures are placed next (Figure 25-4D). It is helpful to place an anterior midline suture initially, in order to simplify proportional placement of the lateral anterior sutures. Also, the midline suture may be of a size 3-0, or even 2-0, in order to facilitate approximation, when structures are rigid. The central suture often passes through the inferior margin of the thyroid cartilage in the midline. A catheter is passed upward, as previously described, and an appropriate endotracheal tube is slipped distally to replace the cross-field tube. The remaining "standard" anastomotic sutures are tied from lateral to anterior on each side. The order of anastomotic steps is summarized in Table 25-1.

Repair of laryngotracheal lesions is demanding and should not be undertaken until the surgeon has extensive and successful experience in tracheal resection and reconstruction as well as knowledge of laryn-geal anatomy. Results justify appropriate application of these methods, despite some variations in technique (see Chapter 9, "Tracheal and Bronchial Trauma," Chapter 11, "Postintubation Stenosis," and Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions").7,9,11,13 Pearson and colleagues alternatively curetted a groove in the inferior portion of the posterior cricoid plate.5 The distal trachea was transected horizontally and the two cartilaginous ends sutured together, imbricating the membranous wall. This narrowed opening was fitted into the groove created in the posterior laryn-geal cartilage. Pearson, together with Maddaus and colleagues, subsequently adopted the posterior flap for lesions extending far up on the posterior cricoid plate.13 Anastomoses were splinted postoperatively with a T tube. Their results have been good, as have been those by Couraud and colleagues using the same procedure, including postoperative stenting.7,13 As might be anticipated, however, results for laryngeal anastomoses generally do not wholly equal those obtained in the simpler reconstructions for tracheal stenosis.

figure 25-4 Laryngotracheal anastomosis after resection of circumferential stenosis, which involved the subglottic larynx. A, The base of the membranous wall flap is fixed to the inferior margin of the posterior cricoid plate with four sutures of nonabsorbable 4-0 material (such as Tevdek). These sutures do not penetrate the mucosa. Vicryl (2-0) stay sutures have been placed in the cricoid and trachea, located to correspond to each other when the larynx and trachea are drawn together. Scar and damaged mucosa have been excised from the posterior cricoid. The margin of remaining laryngeal mucosa is visible. B, Detail of suture placement. (a) Suture fixing base of the posterior flap to the inferior cricoid margin. (b) Posterior mucosal anasto-motic suture placed so that the knot will lie beneath the mucosa when tied.

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