Resection and Reconstruction

In preparation for distal tracheal transection, lateral traction sutures (2-0 Vicryl) are bilaterally placed, vertically in the midlateral tracheal wall, about one ring below the anticipated level of division (Figure 28-2). The sutures pass into the lumen and surround one ring. If a smaller bite of tissue is taken, the suture may subsequently tear out as traction is applied. The endotracheal tube cuff is deflated transiently while placing the sutures. The endotracheal tube is next withdrawn to a point above the lesion. The trachea is opened transversely, usually in an annulus on the side of the trachea away from the tumor base. A nerve hook is useful to expose the lumen through the partial transection, to see whether the level is distant enough from

Anterior Tracheal Reconstructions

figure 28-1 Exposure of the mid and lower trachea via right thoracotomy. A standard posterolateral incision is used. The pleura is incised over the lateral tracheal wall from the apex of the hemithorax to a point below the carina. The azygos is doubly ligated and divided. A segment of vein may be left attached to a tumor that seems to involve it. The phrenic nerve lies on the superior vena cava, which is contiguous with the trachea anteriorly. The esophagus is contiguous posteriorly. The extent of dissection is determined by the location and extent of the lesion. Some right lateral tracheoesophageal arterial branches are divided as trachea is dissected free. The right vagus nerve travels distally obliquely over the trachea to assume a paraesophageal course below the carina. Numerous branches are encountered to the trachea, carina, and esophagus (and to the cardiac plexus). Bronchial arteries, lymphatics, and lymph nodes are encountered at the carina. The superior bronchial artery crosses the esophagus to reach the carina and right main bronchus. Paratracheal lymph nodes and those at the right tracheobronchial angle are not shown, for clarity. The apical segmental ramus of the principal upper lobe arterial trunk is adjacent to the upper lobe bronchus. The left main bronchus is easily accessible in this exposure. The arch of aorta arcs over the left main bronchus, and the left recurrent laryngeal nerve loops up beneath the arch in just this location to assume a course in the groove between the left posterior tracheal wall and esophagus. The right recurrent nerve branches from the right vagus nerve high in the thorax to travel beneath the subclavian artery. The right vagus nerve is often divided to provide improved surgical access and to facilitate later tracheal reapproximation. LMB, RMB = left, right main bronchus; SVC = superior vena cava.

tumor. If not, the level is moved distally, replacing the traction sutures, if necessary. If the transection is to be close to the carina, lateral traction sutures are placed in the midlateral proximal walls of the right and left main bronchi.

The transected trachea is intubated across the operative field with a flexible armored tube. Usually, the tube is advanced into the left main bronchus to collapse the right lung, to provide optimal exposure during the remainder of dissection and anastomosis. Oxygen saturation is monitored throughout, and if saturation falls, the right pulmonary artery may be gently clamped to eliminate the shunt through the collapsed right lung. This is very rarely needed. The tube is held in place either by arranging the lateral traction sutures appropriately over the tube or by having a second assistant hold these sutures in one hand while steadying

figure 28-2 Resection of a tumor low in the trachea. The trachea has been divided distal to the tumor. Since it lies close to the carina, intubation across the operative field distally was made into the left main bronchus. This also collapses the right lung to give the best exposure. For this reason, the endotracheal tube is preferably placed in the bronchus rather than distal trachea, even if a greater length of distal trachea is available. The endotracheal tube is intermittently removed to simplify surgical maneuvers. A thin sliver of distal tracheal margin is taken for histologic frozen sections. To eliminate any possible question about the significance of positive findings, the specimen is preferably excised from the margin of trachea that is to remain. The part of the ring specimen that lies closest to tumor is marked with a fine suture.

figure 28-2 Resection of a tumor low in the trachea. The trachea has been divided distal to the tumor. Since it lies close to the carina, intubation across the operative field distally was made into the left main bronchus. This also collapses the right lung to give the best exposure. For this reason, the endotracheal tube is preferably placed in the bronchus rather than distal trachea, even if a greater length of distal trachea is available. The endotracheal tube is intermittently removed to simplify surgical maneuvers. A thin sliver of distal tracheal margin is taken for histologic frozen sections. To eliminate any possible question about the significance of positive findings, the specimen is preferably excised from the margin of trachea that is to remain. The part of the ring specimen that lies closest to tumor is marked with a fine suture.

the tube with long forceps. Since the endotracheal tube and connecting anesthesia tubing lie at a margin of the incision, they do not interfere with dissection. A tube may be sutured into place or inserted via broncho-tomy, but I prefer not to further injure the trachea or bronchus. Also, moving the endotracheal tube about, as dissection and reconstruction proceed, is helpful. High-frequency ventilation may be used with a catheter placed in the left main bronchus, or, if insufficient, with a bifid catheter into the right and left sides. With high-frequency ventilation, the right lung is not fully inflated and so it hardly impedes the surgical progress. The technique is a bit noisy, blows blood about, and, by itself, occasionally does not maintain satisfactory oxygenation. Since the method has not shown enough advantages, and because of our wholly satisfactory experience with cross-table ventilation, we use high-frequency systems only occasionally for augmentation or for special problems of carinal reconstruction, rather than by preference.

Division of the trachea distal to the tumor allows the specimen to be elevated, using Allis forceps, facilitating completion of dissection. Care must be taken not to injure the left recurrent laryngeal nerve as it lies on the aortic arch just beyond the left posterolateral tracheal wall. If a portion of esophageal wall is resected, repair of that structure is done as soon as the tracheal specimen is removed. Midlateral traction sutures are placed in the upper tracheal segment just prior to proximal division. After removal of tumor, horizontal slivers of tissue from proximal and distal ends of the remaining trachea, taken from the side closest to the tumor, are sampled for frozen sections (see Figure 28-2). If positive margins indicate the need for further resection, the surgeon must carefully judge the limit of tension to be accepted as being safe for the anastomosis. On occasion, a microscopically positive margin must be accepted as preferable to risking anastomotic dehiscence. Judgment of ease of approximation may be made by having the anesthesiologist flex the patient's neck (remembering the patient's orientation in the lateral thoracotomy position), while the surgeon and the surgeon's assistant each draw together the lateral traction sutures in proximal and distal tracheal segments on both sides of the trachea. It may be easily forgotten that cervical flexion (chin toward sternum) devolves the trachea into the mediastinum, even in the lateral thoracotomy position. If tension for approximation seems excessive, intrapericardial release may then be added, if not already performed. Limited blunt dissection over the anterior surface of the left main bronchus may also be helpful. The blood supply of the bronchi and carina must be respected (see Chapter 1, "Anatomy of the Trachea"). With tumors that are seen bronchoscopically to lie just above the carina, the surgeon must be prepared for the possibility that frozen sections will impel the need for carinal resection and reconstruction, a procedure of considerably greater complexity.

Reconstruction is performed in a manner almost identical to that described for the upper trachea (see Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection"). For anastomosis in adults, 4-0 coated Vicryl sutures are used, 5-0 in infants. I place all anastomotic sutures before tying any. The first suture placed, however, is the most "posterior" with respect to the operative field. Thus, in right thoracotomy, the suture actually lies in the left lateral tracheal wall, usually just anterior to the level of the left-sided lateral traction suture. The true anterolateral sutures (cartilaginous wall) are placed first, progressing anteriorly from that initial suture in the lateral wall (Figure 28-3). The sutures are clipped to the drapes on the anterior portion of the incision, almost as described for upper tracheal reconstruction, but instead ranging from caudad for the most "posterior" suture to cephalad for the last true anterior wall suture (cartilaginous wall), just in front of the right lateral wall traction suture. This reversal simply allows the successive sutures to be placed and to lie more easily. The surgeon's assistant exposes the trachea for placement of each successive suture, holding the previously placed sutures out of the way with the nerve hook. Tension on the trac-

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