Short segment tracheomalacia, which occasionally results from postintubation injury instead of stenosis, is best treated by segmental resection and primary anastomosis (see Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection"). Tracheomalacia in children is discussed in Chapter 6, "Congenital and Acquired Tracheal Lesions in Children."
Rarely, long segment or subtotal tracheomalacia has been encountered with no residual rings identifiable. In a very few patients in this category, the trachea has been approached anteriorly via cervicotomy and complete sternotomy. If the lower trachea cannot be exposed adequately from above behind the brachiocephalic vessels, inferior exposure is made anteriorly by dividing the anterior and posterior pericardium between the superior vena cava and aorta, beneath the brachiocephalic vessels (see Figure 23-7 in Chapter 23, "Surgical Approaches").
Three, four or more separate channels are bluntly dissected circumferentially around the malacic trachea one at a time, taking care to preserve tracheal blood supply between channels and to avoid injuring the trachea. Specially-made perforated polypropylene rings (Figure 32-3), discontinuous at one point, are passed through the channels, sometimes facilitated by a suture passed initially through a distal perforation in the ring (Figure 32-4A). The open side of the ring will ultimately lie anteriorly in the tracheal midline. Approximately three 4-0 Tevdek sutures are placed horizontally on each side of the trachea through adjacent perforations in the rings into tracheal tissue, with care to avoid the lumen. Account must be made of the spacing of perforations in the ring in placing these sutures, and also of the length of the ring circumference relative to the final tracheal circumference. Excessive ring length is removed with straight scissors.
figure 32-3 Polypropylene rings used on rare occasions for splinting of wholly malacic tracheal segments, where resection is not possible. These were originally devised for tracheal replacement with a tube of full-thickness cervical skin and underlying platysma. The perforations are for suture placement. The rings may be shortened as necessary. They are not routinely available.
figure 32-4 Use of polypropylene rings to support a completely malacic trachea. This procedure is not regularly employed. See text for alternative solutions. A, Each ring is passed through an individually dissected channel in order to preserve essential tracheal blood supply. A suture is placed in a terminal perforation of the ring to maintain control. Another is placed at the other end when the ring is pulled through the channel. Additional rings are placed as necessary about 2 cm apart, using as few rings as possible. Note the absence of cartilaginous rings in the malacic trachea. B, The polypropylene rings are shortened as necessary for the tracheal circumference. The anterior suture passes through the two end perforations at both ends of the ring, overlapping these in the anterior midline. Two additional sutures are placed lateral to these on either side, reaching as far posterior as possible without excessive dissection. Usually, all sutures in all rings are placed before any are tied. C, Sternohyoid muscles are pedicled as shown after detachment from the hyoid bone to cover the exposed rings anteriorly. Sutures fix the muscles to the trachea between the rings, and the muscles are sutured together in the midline. This serves to embed the rings for permanent support and also to protect against erosion of the brachiocephalic artery. D, Longitudinal section of the tracheal wall showing sternohyoid investment of polypropylene rings.
Sternohyoid muscle Polypropylene ring
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