The patient can often be cared for without cardiopulmonary bypass. However, there is no direct contraindication to bypass for this procedure. If it is elected, extrathoracic cannulation is usually easiest and should only be necessary for the duration of the procedure, since the airway will be secure at the completion of the repair. We have not used cardiopulmonary bypass for cases like this, but have used it in other patients to stabilize their respiratory situation while evaluation was proceeding.
Often, the most difficult aspect is securing the airway prior to operation. Under endoscopic guidance, we have introduced custom-made bifurcated endotracheal tubes into the respective mainstem bronchi in order to secure the airway and avoid cardiopulmonary bypass. Because of the small size of the tubes, it is sometimes difficult to keep them in place and to secure them. We have used a tracheostomy incision high up in the airway, with a catheter looped around the endotracheal tube, in order to secure it anteriorly and maintain ventilation (Figure 33-10A).
After the airway is secure, the operative approach can be planned. In patients who have a normal length of trachea, a combination of a right cervical incision and right thoracotomy provides the necessary exposure. In those with a foreshortened trachea, a cervical incision with perhaps a minor extension into the sternum is all that is necessary.
After the common tracheoesophagus is exposed, we prefer to make an incision on the right side along the junction between the tracheal cartilages and the wall of the esophagus (see Figures 33-10A,B). At this point, the endotracheal tube can be fitted into its best position under direct vision. The incision is started at the midpoint of the trachea and carried down to the distal extent of the cleft. One then needs to fashion a second incision on the wall of the esophagus, which will then be brought around posteriorly to create the "trachealis muscle" in the airway (Figures 33-11A,B). At the distal ends, the incision into the esophagus must be tailored in order to provide flaps of tissue to close the cleft into each mainstem bronchus (see Figures 33-10, 33-11). Care must be taken to avoid taking too much tissue, causing tracheobronchomalacia, which can be very problematic in the long-term. Usually, there is sufficient esophageal tissue so that esophageal narrowing has not been a long-term issue.
figure 33-10 Repair of type IV cleft with extension into both main bronchi (dotted line). A, A longitudinal incision is made in the right tracheoesophageal groove (dashed line) beginning at the midtrachea. At the distal extent, the esophageal incision is carried beneath the mainstem bronchus on the anterior esophageal wall to create a "U"flap. Note the loop in the tracheotomy, which holds the endotracheal tube anteriorly in the trachea. B, Cross-sectional diagram of the trachea and esophagus showing the location of the longitudinal incision.
We usually begin the repair distally in the mainstem bronchi, suturing the "esophageal muscle flap" to the cut edge along the tracheal cartilages (see Figures 33-11A,C). We have used 5-0 Vicryl or polydiox-anone sutures in either running or interrupted fashion. This gives an airtight closure and, starting distally, helps to prevent dislodgment of the endotracheal tube.
After the distal trachea and bronchi are closed, and before the repair is completed above, the bifurcated endotracheal tube is removed and a tracheostomy tube is placed under direct vision and connected to sterile ventilator tubing on the field. Alternatively, an orotracheal tube can be positioned just above the carina to maintain ventilation. We have preferred to use a custom-made "right-angled" tracheostomy tube. The patients often have concurrent tracheobronchomalacia and require positive pressure ventilation for some time after repair. The "right-angled" tube has shorter distance between the tube and the neck flanges that help prevent posterior pressure on the fresh suture lines.
Closure of the larynx and separation from the pharynx can be confusing, because the anatomy is seen from an unusual position on the right side. We have found that the best way to line up the structures is to open the pharynx laterally as a continuation of the incision between the tracheal cartilages and the esophagus below (Figure 33-12A). At the level of the arytenoid cartilages, an incision is made to separate
Esophageal flap (mucosal surface)
figure 33-11 A, Incision is continued in the left wall of the esophagus, 1 cm from the left tracheoesophageal groove, to create a flap for reconstruction of a membranous tracheal wall. Enough tissue is provided at the carinal region to allow closure of the bronchial clefts. A sufficiently broad flap is created to preserve the left recurrent laryngeal nerve, which travels in the left-sided tracheoesophageal groove. B, The point of division of the left-sided esophageal wall is indicated. Esophageal mucosa thus becomes the mucosa of the membranous wall of the trachea. C, The posterior tracheal wall is repaired, using interrupted sutures. A continuous suture is used to reconstruct the esophagus to the level of the inferior cornu of the thyroid cartilage. Care is taken to avoid redundant esophageal wall in repair of the trachea in order to prevent intraluminal prolapse.
Left side of esophagus
Right side of esophagus
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