Resection

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In the cervicomediastinal field, the anterior bony plaque is removed (Figure 34-2B). This commences by dissecting circumferentially beneath the clavicle, on either side, at a point approximately 4 cm from the medial end of the bones, with care taken to avoid injury to the subclavian vein. A Gigli saw is passed beneath the bone, and with pressure on the bone to prevent binding of the saw, both clavicles are divided. The intercostal muscles are carefully separated from the lateral margins of the sternum and the second costal cartilages are divided. The divided sternal segments are elevated on either side from the underlying mediastinal tissues. After dissecting beneath the first cartilages, these are divided and, keeping dissection close to the junction of clavicles and sternum, the segments of bony plaque on each side are resected (Figure 34-2C).

Tactics for removal of the specimen depend upon what structures are involved. In general, lateral dissections are completed, exposing the medial margins of the carotid arteries and jugular veins. The dissection extends posteriorly toward either the esophagus, if it will remain, or to the anterior surface of the vertebral bodies, if laryngotracheoesophagectomy is necessary. Handling of the thyroid gland and strap muscles has been discussed.

The trachea is dissected circumferentially at the level of proposed division, taking care not to destroy blood supply to the distal trachea. Lateral traction sutures of 2-0 Vicryl are placed on either side through the full thickness of the tracheal wall, one ring below the anticipated level of division, and the trachea is then divided. Intubation is carried out across the operative field with a flexible armored tube. The distal margin is examined by frozen section. The proximal end of the trachea is retracted with Allis forceps to elevate the esophagus. If anterior exenteration only is being done, resection is carried upward on the preesophageal plane to remove the specimen en bloc. Localized invasion of the esophageal wall may be excised, either with muscularis alone or full thickness, as indicated. If the upper esophagus only is to be removed with the specimen, dissection is carried distally into the mediastinum, as far as is desired, before esophageal transection and closure. If the colon is to be used for replacement of the esophagus, there is no reason for a total esophagectomy. The entire specimen, including the trachea and esophagus, is elevated from the prevertebral fascia and dissected to its cervical attachments (see Figure 8-9 in Chapter 8, "Secondary Tracheal Neoplasms"). If the stomach is used for reconstruction, the entire esophagus is resected by completing the dissection transhiatally from below, facilitated by Pinotti's maneuver of dividing the diaphragm from the hiatus forward to the sternum.

Proximally, the hyoid bone and epiglottis are usually removed with the larynx. A residual epiglottis can interfere with swallowing. Muscles attaching to the superior margin of the hyoid bone are divided, as described for the laryngeal release procedure (see Figure 24-19 in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection"). The posterior cornua of the hyoid bone may be divided and

Hyoid Bone

figure 34-2 Exposure of the operative field and exploration. A, The upper skin flap has been elevated to the hyoid bone. Cervical exploration is completed first to determine operability in that region. The lower flap is then elevated to below the sternal angle. The pectoralis muscles are reflected as shown. B, The sternum is divided vertically through the manubrium and across the second interspace, allowing full exploration of the mediastinal trachea and extent of involvement. For succeeding steps, the sternocleidomastoid muscles are divided from the clavicles and medial heads from the sternum. C, The plaque of sternum, which was divided for exploration, is removed with the medial heads of the clavicles and the first two costal cartilages on either side. The already divided sternum facilitates removal of bony segments.

left in place. The lateral musculature of the larynx is divided and the pharynx entered just above the epiglottis and on either side above the hyoid bone. Sutures are placed to mark the mucosa—in the anterior midline, laterally, and, finally, posteriorly above the cricopharyngeus (Figure 34-3A). The proximal extent of tumor sometimes may be visualized directly through the opened pharynx.

A substernal tunnel must be made wide enough to permit passage of the esophageal substitute and omentum. In making the tunnel, it is better to keep the hand to the left of the midline over the heart. This helps to avoid herniation of the colon into the right chest and possibly redundance of the colon bypass later. It also minimizes the occurrence of a right pneumothorax during dissection.

Once it is clear that the operation can proceed, a second team commences the abdominal portion of the procedure. The omentum is mobilized from the transverse colon, preserving all of its components, since it will be transferred into the neck. If the colon is to be used for reconstruction, the omentum is usually pedicled on the right gastroepiploic artery in order to reach the pharyngeal level (see Chapter 42, "The Omentum in Airway Surgery and Tracheal Reconstruction after Irradiation"). If the stomach is used for reconstruction of the esophagus, the omentum remains attached to the greater curvature and will be transferred upward with the stomach. The abdominal team is charged with providing an adequate length of omentum and an adequate segment of well-vascularized gut for reconstruction of the esophagus. Even figure 34-3 Reconstruction of the gastrointestinal tract and fashioning of mediastinal tracheostomy. A, The operative field after resection of the larynx, trachea, thyroid gland, tumor, and involved lower-most pharynx and upper esophagus. Contents of the neck between the carotid sheaths down to the prevertebral fascia have been removed en bloc. The lateral traction sutures in the distal residual trachea are shown. Intubation is done across the operative field. For a very short tracheal stump, the innominate artery is electively divided and sutured closed following appropriate pre-operative studies and with electroencephalogram monitoring. Four sutures are placed in the pharyngeal end for alignment ofanastomosis.

figure 34-3 (continued) B, Reconstruction beginning with the left colonic segment anastomosed widely to the pharynx. The curve of the colon is such that anastomosis is usually made end-to-side, although end-to-end is occasionally possible. The stomach is used frequently Either is advanced substernally. C, The omentum has been advanced substernally and arranged to cover pharyngogastric or colonic anastomosis, to protect sutured ends of the innominate artery or that artery in continuity, and is also sutured to the emerging stump of trachea one ring below transection. The tracheal stump is passed through an aperture made in the omentum. Traction sutures are in place for ease of manipulating the tracheal stump. See the text for description of advancement of the omentum.

figure 34-3 (continued) B, Reconstruction beginning with the left colonic segment anastomosed widely to the pharynx. The curve of the colon is such that anastomosis is usually made end-to-side, although end-to-end is occasionally possible. The stomach is used frequently Either is advanced substernally. C, The omentum has been advanced substernally and arranged to cover pharyngogastric or colonic anastomosis, to protect sutured ends of the innominate artery or that artery in continuity, and is also sutured to the emerging stump of trachea one ring below transection. The tracheal stump is passed through an aperture made in the omentum. Traction sutures are in place for ease of manipulating the tracheal stump. See the text for description of advancement of the omentum.

where the entire esophagus is removed transhiatally, I prefer to advance the esophageal replacement sub-sternally. It is a shorter route for the colon and, in the case of the stomach, permits the bulky omentum to be advanced easily with the stomach.

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