Tsang, Goldstraw and colleagues proposed doubling the circumference of the stenotic trachea by dividing the stenotic segment horizontally at its midpoint, slitting the upper and lower stenotic segments respectively anteriorly and posteriorly, and sliding the two segments together.10 The trachea is thus effectively shortened by half of the length of the stenotic segment, which is usually an acceptable length of shortening. The circumference is doubled and the cross-sectional area of the trachea is quadrupled. Grillo adapted the technique with some modifications (Figure 33-3).11
The procedure is performed under ventilatory anesthesia in the absence of associated vascular or cardiac anomalies. It is preferable if a small bore endotracheal tube can be slipped through the stenosis, but it is possible with delicate dissection to perform the first part of the exposure with a tube positioned in the proximal airway above the stenosis (Figure 33-4). This is usually the case in infants and small children. It has been possible to expose the trachea sufficiently in these young patients through a collar incision alone. If additional exposure is required, the upper sternum or even the entire sternum may be divided. In most
figure 33-3 (continued) B, The right-angled corners at the midpoint tracheal division are trimmed above and below. A single traction suture is placed near the tip of the upper segment and two lateral sutures below the stenosis inferiorly, hence often at the tracheobronchial angles. Only absolutely necessary dissection is done, in order to conserve tracheal blood supply. Tracheal circumference will be doubled. C, After all anastomotic sutures have been placed and marshaled in orderly array, the segments are slid together, with the help of the stay sutures, and the anastomotic sutures are tied. D, An oblique suture line results, with quadrupling of the cross-sectional area, since the circumference of the trachea has been doubled. Reproduced with permission from Grillo HC.11
patients, the trachea can be exposed satisfactorily behind the aortic arch and brachiocephalic artery, but in some, the lower trachea is better seen by dividing the pericardium between the retracted vena cava and aorta. If a pulmonary artery sling is present, complete sternotomy becomes necessary. In this case, partial cardiopulmonary bypass is necessary for reimplantation of the left pulmonary artery, and it is then convenient to perform tracheoplasty also under bypass. All dissection prior to these steps is done under ventila-tory anesthesia to minimize bypass time.
The exact proximal end of the stenosis is identified with a bronchoscope, usually flexible. With transillumination of the trachea, at the point of stenosis, a fine needle is used to locate it precisely, marking the point with a fine suture. The lower end of the stenosis is generally evident. The trachea is divided transversely at the midpoint of stenosis after dissecting circumferentially only at this level (see Figure 33-3A). Ventilation is continued across the operative field, most easily after the lower stenotic segment has been incised vertically anteriorly. The endotracheal tube is usually passed into the proximal left main bronchus, which provides very adequate left lung ventilation (see Figure 33-45). It may be episodically removed for brief periods to facilitate suture placement and then easily replaced. Tsang and Goldstraw and their colleagues' original technique incised the upper segment anteriorly and lower segment posteriorly.101 prefer to open the lower segment anteriorly, allowing easy insertion of the endotracheal tube .11 The lateral attachments of the segment remain undissected to guarantee blood supply. The upper stenotic segment is dissected posteriorly, and to a lesser extent laterally, only until posterior vertical incision of the stenosis can be
figure 33-4 Management of ventilation during repair of long congenital stenosis, when cardiopulmonary bypass is not needed. A, Tightness of stenosis most often requires a small bore endotracheal tube (ET) to reside above the narrowing. B, After division of trachea, the distal segment is opened anteriorly and a second ET passed into the left main bronchus (LMB). Another small bore tube can be directed into the right if necessary, but it rarely is. C, After all sutures have been placed, the proximal ET is directed into the LMB and anastomosis performed. D, When the anastomosis is completed, the ET tube is retracted proximally to ventilate both lungs.
clearly performed. It is essential that the entire length of stenosis be incised. Inferiorly, this frequently requires that the tracheal incision reach the carina. At the point of intersection of the vertical incisions with the transverse tracheal division, the corners are trimmed conservatively to round the respective ends of the trachea for insertion at the apices of the vertical incisions during reconstruction (see Figure 33-3B). The originators of the technique dissected the entire stenotic segment circumferentially and noted no devascu-larization in a limited experience.10 I have preferred to conserve as much blood supply as possible. No devascularization problems have occurred in 8 patients aged 10 days to 19 years.12
Traction sutures help during suturing and in approximating the tracheal ends. In a low stenosis, I place one suture at each tracheobronchial angle, using 4-0 Vicryl in infants, and a single suture near the tip of the superior flap which lies anteriorly (see Figure 33-3B). Tentative approximation may be tested by drawing these sutures together while the patient's neck is gently flexed (see Figure 33-3C). Even with very long stenosis, approximation has been easily effected without clinically evident tension. In one patient who had undergone previous extensive mediastinal dissection, including anastomosis of a posterior pulmonary artery to superior vena cava, tracheal mobility was somewhat limited, but still feasible.12
Anastomosis is made with 4-0, 5-0, or 6-0 Vicryl sutures depending upon the patient's age and tracheal dimensions. I prefer interrupted sutures. The first is placed as a mattress suture from the apex of the "tongue" of the inferior tracheal segment to the top of the posterior vertical incision in the proximal segment. All sutures are placed so that the knots will lie outside of the tracheal lumen. Sutures are placed successively on both sides, working down from posterior to anterior. Attention is paid to even spacing about 3 mm apart. Sutures pass through the full thickness of the tracheal wall. Each suture is clipped with a hemo-stat and fastened serially to the drapes with a second hemostat. All anastomotic sutures are placed before any are tied. The endotracheal tube can be removed at intervals briefly for suture placement if necessary, since the patient is kept fully oxygenated. Once all sutures have been placed, an endotracheal tube is passed down from the proximal trachea into the left main bronchus (see Figure 33-4C). Generally, sutures are tied in reverse order of placement, commencing in anterior midline inferiorly and progressing up on either side to the apical posterior suture. The stay sutures and cervical flexion minimize tension during anastomosis. The endotracheal tube is retracted into the upper trachea, and the anastomosis checked for integrity under saline (see Figure 33-4D). The anastomosis is examined via endotracheal tube with a flexible pediatric bronchoscope. Stay sutures are removed (see Figure 33-3D).
The thymic lobes, divided in the midline during initial exposure, provide convenient tissue for a "second-layer" closure. Since the trachea has been reconstructed with tracheal tissue, an endotracheal tube is not necessary as a stent postoperatively. Most often, the endotracheal tube can be removed at the conclusion of the operation or the next day, if it is initially needed for suctioning. Guardian chin sutures to restrain hyperextension have been used. Drastic flexion is avoided. Laryngeal release has not been required in our experience.
Slide tracheoplasty may well be the procedure of choice for long congenital tracheal stenosis. The advantages are numerous. The trachea is repaired with native trachea, which is lined with normal tracheal epithelium and has firm cartilaginous structure. The trachea grows with the child.12 Intraoperative suspension and postoperative intubation for splinting, with many days of ventilation, are not required. Bypass is unnecessary except where there is a concomitant lesion such as a pulmonary artery sling that needs reimplantation. Because of the immediate approximation of epithelium to epithelium, granulation tissue formation is very rare and minimal, obviating the need for multiple therapeutic bronchoscopies postoperatively.
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