A Penrose drain is passed around the trachea where circumferential dissection has been done just below the lower end of the stenosis. The anesthetist is asked to deflate the cuff on the endotracheal tube, and two sutures of 2-0 Vicryl are placed vertically in the midlateral line of the distal trachea on either side, through the full thickness of the tracheal wall, usually encircling one ring (Figure 24-9). These are placed at a point that is estimated to lie one or two rings distal to what will be the line of tracheal division. This is not critical since the traction sutures may be easily replaced after tracheal division. Indeed, it is sometimes convenient to place the traction sutures after tracheal transection via the open lumen. In many cases, the border of the lesion is clearly visible from outside of the trachea. A tentative transverse incision is next made in the trachea, at the lower end of identifiable pathology. One can always remove more trachea, but one cannot replace it. If there is more disease distally, then successive partial transverse incisions are made until a cartilaginous ring of acceptable quality is encountered. In many cases, some inflammation continues distally and, more frequently, is noted proximal to the stenotic lesion. Indeed, sometimes, no absolutely normal trachea or larynx will be found proximally. All severe diseases must be removed to avoid restenosis, but unneeded resection increases the risk of complications from anastomotic tension. Some fibrosis or inflammation can be accepted if healthy cartilage is visible on transection.

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