Repair and Healing of the Airway

An ancient concern that cast a shadow on tracheal surgery into the twentieth century was that cartilage healed poorly. Hippocrates had cautioned, "The most difficult fistulae are those which occur in the cartilaginous areas... ."18 In the second century ce, Aretaeus pronounced, "The lips of the wound do not coalesce, for they are both cartilaginous and not of a nature to unite."7 As late as 1990, Naef repeated that "tracheo-bronchial tissue, as compared to the stomach, intestine, or even skin, does not heal well. both the rigidity and the poor blood supply of the cartilaginous structure are definitely major handicaps."19

figure 1 Tracheostomy pictured by Nicolas Habicot in Question Chirurgicale. Par laquelle il est demonstré que le chirurgien doit assurément pratiquer l'operation de la bronchotomie. J. Corrozet, Paris, l620. A, The patient. B, The larynx. C, The wound or bronchotomy. D, The instrument for bronchotomy. E, The hollow cannula. F, The straps for fastening it on the neck. G, Plain smooth band to apply over the cannula to scatter the air stream. H, Needle to suture the wound when one removes the dressing to make the wound heal.

Nonetheless, examples of early attempts and sometimes success in bronchial and tracheal repairs after trauma are recorded. Indeed, The Rigveda, a book of Hindu medicine dating from between 2000 and 1000 bce, noted that the trachea can reunite "when the cervical cartilages are cut across, provided they are not entirely severed."9 Ambroise Paré described suture of tracheal lacerations in the mid-1500s in three patients, the first from a sword wound, and the latter two from knife wounds.20 The first patient survived despite a concomitant injury to the internal jugular vein. The second patient suffered division of both the trachea and esophagus and died. We do not know the outcome of the third patient. Brasavola observed recovery after a suicide attempt severed five tracheal rings.7

Eventually, cumulative clinical experience in the twentieth century established that the trachea healed firmly with suture repair after laceration or rupture.21-27 Jackson and colleagues demonstrated firm healing of experimental bronchial anastomosis in 1949.28 In 1950, Daniel and colleagues confirmed fibrous tissue repair of linear tracheal incisions in the laboratory, as did Rob and Bateman clinically in 1949.29,30 Quinby and Morse pointed out experimentally, for the first time in 1911, the importance of peribronchial tissue in bronchial closure.31 In 1942, Rienhoff and colleagues made fundamental observations that bronchial healing after pneumonectomy was accomplished by new connective tissue, which grew over the ends of the stump, rather than by mucosal healing alone.32

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