Tracheotomy, closure of long-term tracheostomy and standard tracheal segmental resections

Abstract

Tracheotomy is a surgical procedure commonly employed to establish stable and long-term airway access. Iatrogenic airway injury post procedure may have serious consequences with limited treatment options. Tracheostoma or long standing tracheostomies require special closing techniques. Tracheotomies, tracheostomies, complications of these and treatment options, long standing tracheostomy closure techniques, and standard tracheal segmental resections are discussed.

Keywords: Tracheostomy; closure of tracheostomy; tracheal resections.

Figure 1

Trachea of an elderly kyphotic patient. The angle between sternum and trachea is almost 90 degrees.

Figure 2

Vertical tracheotomy over the 2nd and 3rd cartilages.

Figure 3

Flap tracheotomies are not recommended due to possible long-term complications.

Figure 4

Surgeon performs most of the procedure with one hand compressing the innominate artery and making the required dissections with the other hand until everything is under control.

Figure 5

Identification of the defect, closure or division but definitely exclusion from trachea is recommended. Some authors recommend to leave the fistoulous artery on the trachea by dividing the vessel from proximal and distal to the defect.

Figure 6

For the treatment of tracheoesophageal fistula resection of destructed trachea, primary closure of esophagus and muscle interposition are the mainstem of the treatment.

Figure 7

Dilatation of a stenosis is the first step of treatment in a patient. A tracheostomy or a reresection should not be performed if dilatation achieves success. Perforation of a trachea during dilatation may require an emergent operation.

Figure 8

Chest CT with three-dimensional reconstruction in the axial, coronal, and sagittal plans, the extent and location of tracheal injury may be mapped and assist with devising a treatment strategy.

Figure 9

Every millimeter is important in tracheal resections.

Figure 10

Operating room lights are turned off during bronchoscopy. So proper resection line could be planned. Remember “every mm is important”.

Figure 11

After the trachea is opened distally, a sterile ETT #8 is connected to the ventilatory tubing and handed off to the anesthesiologist. Oral ETT tube is pulled back, but still keeping in the limits of upper tracheal resection, a silk tie is attached to the distal hole of this tube.

Figure 12

Traction sutures may be used both at proximal and distal sites.