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After resection of the specimen, and after examination of the proximal and distal ends of the remaining trachea to be certain that the tissue is of good enough quality to promise healing without stenosis, the ease of approximation is determined. The anesthetist or an assistant is asked to put the patient's neck in flexion with a hand beneath the occiput. The chin must approach the upper sternum. This should not be done by raising the headpiece of the operating table, as this tends to thrust the chin forward rather than to provide flexion of the neck. The surgeon and the surgical assistant grasp the upper and lower tracheal traction sutures on their respective sides and draw these together without excessive tension (Figure 24-13). The anesthesia tube on the field is usually removed transiently to clarify this observation. Since the patient is fully oxygenated, there is no urgency for continuous ventilation. Initially, I measured the tension required for approximation in the operating room, using spring tensiometers. This was mechanically difficult and proved to be unnecessary. It becomes clear to the experienced surgeon's judgment as to whether the tension required for approximation is appropriate. Excessive tension must be avoided. Initial assessment of the lesion and its length by radiology, by bronchoscopy, and finally (in a very few) by external exploration should eliminate most patients in whom tension would be excessive. In borderline cases, however, adjunc-tive measures such as laryngeal release are available. These methods are described later.

figure 24-13 A, Testing for ease of tracheal approximation after resection. B, The patient's head is tentatively elevated so that the chin approaches the chest wall. Forceful or extreme flexion is to be avoided. The surgeon and an assistant pull the tracheal ends together using the lateral traction sutures. Approximation must be feasible without excessive tension.

figure 24-13 A, Testing for ease of tracheal approximation after resection. B, The patient's head is tentatively elevated so that the chin approaches the chest wall. Forceful or extreme flexion is to be avoided. The surgeon and an assistant pull the tracheal ends together using the lateral traction sutures. Approximation must be feasible without excessive tension.

After demonstration that the ends do approximate without excessive tension, the patient's neck is again extended and anastomotic sutures are placed. After trials with various suture materials (including Mersilene, Tevdek, Prolene, and polydioxanone suture [PDS]), I settled on 4-0, absorbable but long lasting synthetic polyglycolic acid sutures (Vicryl, coated). 5-0 Vicryl is used in infants and small children. This material has provided the necessary strength, flexibility, ease of use, and duration, essentially without complications. Use of Vicryl has almost wholly eliminated suture line granulomas in tracheal anastomosis. Monofilament PDS has proven more difficult to use in comparison, and it has no practical advantages over Vicryl. A lesser degree of early histologic reaction to PDS, over that seen with Vicryl,3 seems to have no real importance with respect to final results, as we have demonstrated.4

Anastomosis is commenced with an initial suture posteriorly in the midline of the membranous wall, which passes from outside into the lumen, in either the upper or the lower segment of the trachea, and then

Tracheostomy Stay Suture Video

figure 24-14 Commencement of tracheal anastomosis. A, Lateral stay sutures are in place. The initial anastomotic suture is located in the posterior midline so that the knot will be extraluminal. A hemostat holds the suture and this in turn is clipped to the drapes laterally. B, The next suture is placed 4 mm lateral to the first. The previous suture is pulled out of the way with a Blalock hook so that the subsequent suture will be anterior to the first. Each is clipped to the drapes caudad to the previous suture.

figure 24-14 Commencement of tracheal anastomosis. A, Lateral stay sutures are in place. The initial anastomotic suture is located in the posterior midline so that the knot will be extraluminal. A hemostat holds the suture and this in turn is clipped to the drapes laterally. B, The next suture is placed 4 mm lateral to the first. The previous suture is pulled out of the way with a Blalock hook so that the subsequent suture will be anterior to the first. Each is clipped to the drapes caudad to the previous suture.

from inside to outside in the opposite segment (Figure 24-14A). The suture is clipped with a hemostat and this in turn is clipped to the drapes with a curved hemostat at the cephalad end of the field, but no higher than the level of the base of the patient's neck. Sutures clipped to head drapes will fall against one another and possibly become snarled when the neck is later placed in flexion. Each successive suture is placed anterior to the previous one in the tracheal wall, progressing laterally (Figure 24-145). Since the sutures will be tied in the reverse order from which they are placed, it is important that these be laid down precisely. In this way, they will not cross one another as they are successively tied (Figure 24-14C). Each is clipped to the drapes progressively from cephalad to caudad, with the most posterior suture being most cephalad. Placement of these sutures is facilitated if the surgical assistant uses a Blalock hook to pull the previous sutures out of the way as each succeeding suture is passed through the tracheal wall (see Figure 24-145). Sutures are placed approximately 4 mm apart and 3 to 4 mm distant from the cut edge of the trachea. No particular effort is made to pass around the rings; indeed, this should be avoided in small children, since the rings may be flexible enough so that they can be folded together and the anastomosis narrowed. Suturing thus progresses from the midline of the posterior wall of the trachea to a point just behind a midlateral traction suture (Figure 24-15A). The traction sutures should lie exactly in the midline laterally, so that superior and inferior traction sutures will correspond when the trachea is pulled together. A second group of sutures is placed from the posterior midline to the opposite lateral traction suture and clipped to that side of the table (Figure 24-155). I prefer to place each "set" of sutures from the corresponding side of the table. Traction sutures are aligned so that the upper ones stretch out in the superior end of the field and the lower ones in the inferior end of the field. Placement of anastomotic sutures is facilitated by the assistant's pull on the traction sutures in appropriate directions.

The balance of the sutures are now placed anteriorly between the two sets of traction sutures and clipped in a fan-like arrangement to the drapes over the lower anterior chest wall below the inferior por-

Tracheal Anastomosis
figure 24-14 (continued) Tracheal anastomosis. C, Each succeeding suture will follow this pattern, clipped to the drapes caudad to the prior suture but lying anterior to it.

figure 24-15 Placement of the three groups of anastomotic sutures. Dashed line: midline. A, Initial posterolateral group running from the posterior midline of the trachea to a lateral midline stay suture (arrow). B, Second posterolateral group similarly placed on the opposite side of the trachea. C, Anterior and anterolateral sutures are finally placed, runningfrom one lateral stay suture to the opposite lateral stay suture.

Saber TracheaSaber Trachea

tion of the incision (Figure 24-15C). I usually place bracketing sutures, one on either side, just anterior to the lateral traction sutures, and then fill in appropriately between them. Discrepancy in the size of the proximal and distal trachea can be corrected by eye, with proportional placement of sutures. The tracheal ends are never tailored with wedge resections to correct discrepancies in size, even in a marked "saber sheath" trachea. The endotracheal tube in the distal trachea may be periodically removed if it interferes with suture placement. Monitoring oxygen saturation helps to guide intermittent removal of the tube.

When all anastomotic sutures are placed, the endotracheal tube across the field is removed. The peroral proximal tube is drawn into the field and, if a guiding catheter has been placed, it is removed. The distal airway is carefully suctioned. The proximal endotracheal tube is then guided further down into the dis tal segment of the trachea using blunt forceps. It is important not to pass it too far distally, since when the neck is flexed the tube will be driven into the right main bronchus or against the carina, making approximation difficult. The anastomotic sutures should be pulled taut before advancing the proximal endotra-cheal tube, and the tube advanced with care to avoid looping a suture over the tube. If a suture is inadvertently tied over the tube, it may be impossible to extubate at the end of the operation without breaking the suture forcefully.

The inflatable bag beneath the patient's shoulders ("thyroid bag") is deflated, giving a measure of cervical flexion. With the surgeon and the surgical assistant on each side gently drawing together the 2-0 lateral Vicryl traction sutures, one against the other, the anesthetist or the anesthetist's assistant places the patient's neck in flexion. Folded blankets are placed beneath the occiput to hold the neck firmly in flexion. This directs the chin down toward the sternal notch, lowering the larynx. Flexion is never extreme or forced. The endotracheal tube is adjusted in case it has slipped too far distally, and the cuff is inflated to provide a seal for ventilation. Lateral traction sutures are tied on either side to provide approximation without significant intussusception, using the double strands tied in a surgeon's knot. If due to pathology or anatomic discrepancy a degree of intussusception occurs, it is acceptable. Smooth healing will follow. The ends of these tied traction sutures are clipped with a larger clamp on either side.

The anterior anastomotic sutures are tied first. If the tracheal wall or cricoid cartilage is rigidified due to calcification, then the sutures may be tied more easily by approaching the midline from each side. This avoids initial excessive tension on the central suture. Sometimes, tentative approximation can be encouraged using a clamp-held "peanut" to push the ends together while initial tying is done. A more effective maneuver is for the assistant to pull the ends together by crossing the next suture beyond the one being tied by the surgeon. In cases where there is more discrepancy than desirable, I use one or more heavier sutures in the midline (3-0 or, on rare occasions, a 2-0 midline "keystone" suture). After each suture is tied with five knots, the excess suture is cut. This frees the field of dangling sutures.

On occasion, a considerable degree of calcification, particularly in the cricoid and sometimes in the trachea, resists placement of sutures. By taking a short hold on the anastomotic suture needle and driving it in at a right angle, a spot is often found where the needle will penetrate. If this is not possible, then I use either a more rugged needle (a hypodermic needle held in a hemostat) to force a channel for sutures, or occasionally a fine dental drill to produce a hole through which the suture needle can be passed.

After the anterior sutures are tied, a retractor is slipped in behind the lateral traction and posterior anas-tomotic sutures on one side (but in front of the thyroid isthmic traction suture). The assistant gently retracts the tied lateral tracheal traction suture of that side, and the surgeon continues to tie the lateral and posterior groups of anastomotic sutures, beginning with the one just behind the traction suture and progressing toward the posterior midline. The long ends of each suture are cut after the knot has been tied. The most posterior sutures may have to be tied by palpation rather than by direct vision. Each knot is carefully set to eliminate slack. After completing the first set of lateral sutures, the surgeon goes to the other side of the table and repeats the process on the remaining posterolateral sutures. The anastomosis is now complete (Figure 24-16). To test the integrity of a high tracheal anastomosis, the cuff on the endotracheal tube is deflated, the wound is flooded with saline, and the anesthetist transiently produces 30 cm of water pressure by continuous forced ventilation. Air is heard passing out through the larynx and pharynx. If there is a leak, air bubbles will appear in the saline. Usually, there is not. A low anastomosis is tested with similar ventilatory pressure, but the inflated cuff lies above the anastomosis. Since it is contaminated, the wound is thoroughly irrigated.

Posterior anastomotic sutures could be placed and tied prior to placing the anterior sutures. This, however, creates difficulty in patients who undergo lengthy resections of the proximal trachea, especially when close to the larynx. The cervical flexion that is required to bring the patient's trachea together allows only poor access for placing anterior sutures, if the posterior sutures are tied first. Although the described figure 24-16 Completion of anastomosis. A, Diagram to indicate how left posterolateral sutures lie, with the most anterior of the group being in front of the previous suture. For clarity, the right posterolateral as well as the stay sutures are omitted. A few anterolateral sutures are also shown. See text for the order of placement. B, The finished anastomosis. The heavy lateral stay sutures are tied first, taking tension off the anastomotic sutures. Only the left-sided stay suture is visible. Sutures have been tied in the order described in the text: anterior sutures first, followed by each posterolateral group, from lateral to medial.

Trachea Not Midline

system of placing all sutures prior to final anastomosis may seem to be complex at first, it becomes easy with consistent use. Its dependability is gratifying. I use this same method for carinal and for bronchial sleeve anastomoses and find it equally satisfactory in all cases.

The thyroid isthmus is frequently reapproximated over a high tracheal anastomosis. If for any reason a further seal is desired over an upper tracheal anastomosis, the strap muscles may be sutured above and below the anastomosis to trachea and in the midline to provide additional buttressing. A second layer is not routinely necessary, except intrapleurally. The use of a muscle pedicle to protect the brachiocephalic artery from the anastomosis has already been noted. The divided upper sternum is sutured with heavy sternal wires, using two or three sutures. Suction drains, which are placed through small stab wounds lateral to each end of the collar incision, lie in the substernal and pretracheal spaces. Strap muscles are sutured in the midline. The platysma is closed and the skin sutured with subcuticular stitches.

After the incision has been closed, the drapes over the neck and head are removed. Often, it is noted at this point that the patient's head and neck are not actually in as marked a flexion as was thought. A heavy "guardian" suture (no. 2) is placed to prevent excessive extension of the neck in the immediate postoperative period. This suture passes transversely through a generous bite of skin in the submental crease and then through the presternal skin (Figure 24-17). Where there is a midline vertical incision, I use two sutures from the chin to either side of the presternal incision. These sutures should be fixed in skin that has not been dissected up from the chest wall. Obviously, it is important to warn the patient and the patient's family about these sutures in advance! The guardian sutures remain for 6 or 7 days following operation. It must be emphasized that the purpose of the guardian suture is to prevent inadvertent hyperextension postoperatively, as during sleep. Extreme approximation of the chin to chest is to be avoided. Permanent quadriplegia has been reported after extreme positioning intra- and postoperatively, possibly analogous to similar disasters related to prolonged extreme cervical flexion during certain neurosurgical procedures.5 Extreme extension of the neck intraoperatively is also to be avoided. The origin of this disastrous complication is not clear but it may be due to vascular deprivation of the spinal cord. I have not personally encountered this disaster.

Since the patient has been carried on spontaneous or assisted ventilation without paralyzing agents, extubation can usually be carried out as the patient awakens. The airway should be satisfactory. Rarely, laryngeal edema may cause transient difficulty, particularly in procedures that involve the larynx itself. In these cases, a small endotracheal tube may be left in position for a few days, preferably without a cuff or with a deflated cuff. Tracheostomy is to be avoided initially, particularly in cases of lengthy resection. A tracheostomy could lie close to the anastomosis and produce a real risk of injury that could cause restenosis. Tracheostomy is never performed through a fresh anastomosis. If anastomosis of the trachea has been done properly, internal stenting, as with a T tube or endotracheal tube, is not required. Further management of a patient with persistent postoperative airway obstruction is discussed in Chapter 20, "Postoperative Management," Chapter 21, "Complications of Tracheal Reconstruction," and Chapter 25,"Laryn-gotracheal Reconstruction."

figure 24-17 The "guardian" chin stitch from the submental crease to presternal skin. The stitch is to prevent hyperextension postoperatively and not to effect extreme hyperflexion.

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