Ann Thorac Surg 1996;61:1819-1821
© 1996 The Society of Thoracic Surgeons
Case Report
Left Thoracotomy for Distal Tracheal Repair
Ray H. Chen, MD,
David A. Ott, MD
Department of Cardiovascular and Thoracic Surgery, Texas Heart Institute, Houston, Texas
Accepted for publication December 2, 1995.
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Abstract
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When consulted emergently by another surgeon in the operating room, we accomplished repair of a major laceration of the posterior wall of the distal trachea with associated avulsion of the left upper-lobe bronchus via the existing left thoracotomy exposure in a 7-year-old girl. Mobilization of the descending aorta anteriorly provided adequate exposure of the tracheal injury.
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Introduction
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Distal tracheal injuries are usually approached through a right thoracotomy, so that the left-sided aortic arch is not in the way during tracheal exposure and repair. When distal tracheal trauma is associated with a left bronchial injury or hemorrhage from the left side of the chest, a bilateral thoracotomy is the usual approach to this potentially life-threatening condition. Recently, we used a left thoracotomy alone to repair a laceration of the distal trachea and avulsion of the left upper-lobe bronchus.
A 7-year-old girl was riding a horse in the presence of her father when the animal became startled, reared up, and then fell in such a manner that the child was temporarily pinned beneath it. The girl did not lose consciousness, but her lips were cyanotic, and no respiratory movements were seen. Her father immediately performed mouth-to-mouth resuscitation, and the patient's respirations resumed. She was taken to a local hospital, where she was found to have a closed fracture of the left humerus and a large left-sided pneumothorax with subcutaneous emphysema of the left side of the face and neck. The fracture was splinted, and the subcutaneous emphysema resolved after a chest tube was inserted. Because she continued to experience dyspnea and persistent air leakage, she was transferred to a pediatric hospital 4 hours after the accident.
Upon admission, the patient underwent repeat chest roentgenography, which showed a worsening of the pneumothorax, although the chest tube was satisfactorily positioned. The upper portion of the collapsed left lung revealed a severe contusion pattern. The patient was taken immediately to the operating room. Bronchoscopy through the uncuffed endotracheal tube disclosed ``submucosal emphysema'' of the distal trachea and a small amount of blood in the left main bronchus. A left thoracotomy was performed, and a small but continuous flow of air was found to come from the aortopulmonary window. Opening of the tissue plane revealed a massive air leak, which came from a distal tracheal laceration.
Finger occlusion of the leak temporarily provided adequate ventilation, and an intraoperative consultation was requested with our cardiothoracic service. Because of the presence of an uncuffed endotracheal tube, however, the air leak became difficult to control at the aortopulmonary window and ventilation of the patient was compromised. Repair could not be accomplished through the aortopulmonary window because of inadequate exposure. To resolve this problem, we divided three upper intercostal vessels and urgently mobilized the left subclavian artery, distal aortic arch, and descending aorta (Fig 1
). Elevation of the aorta revealed a 4-cm laceration of the membranous portion of the distal trachea. The laceration extended to the take-off site of the right main bronchus. The left upper-lobe bronchus was completely avulsed and severely contused, and the left upper lobe was hemorrhagic and solidified in appearance and consistency. The tracheal laceration was repaired with interrupted 4-0 polypropylene sutures, and a left upper lobectomy was then performed.
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Fig 1. . Mobilization of the left subclavian artery, distal aortic arch, and descending aorta exposed a 4-cm laceration in the membranous portion of the trachea.
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Postoperatively, respirator ventilation was continued for 3 weeks because of bilateral pulmonary infiltrates. Hyperalimentation was started on the third postoperative day and was continued for 3 weeks because of chylothorax, which resolved spontaneously. On the 30th postoperative day, the patient was discharged from the hospital, in excellent condition, with a healing left humeral fracture.
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Comment
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In 1955, Björk [1] described a left-sided bronchotracheal anastomosis for treating tuberculous stenosis. Although he used the prone position, his procedure is identical to ours in both basic concept and anatomic relationships. More recently, a left thoracotomy approach has been used for treating left main bronchial carcinoma and for carinoplasty involving neoplasms and tuberculosis [2–7]. Division of three to five upper intercostal arteries has not resulted in paraplegia [1–7].
Although the carina and the first 3 cm of the distal trachea can be exposed from the aortopulmonary window [5, 7], the upper end of the distal trachea can be adequately and securely approached only by anterior mobilization of the distal aortic arch and the descending aorta [1, 7]. The intrathoracic trachea can be easily exposed more than 5 cm above the bifurcation (see Fig 1
). A Wilson tube or a double-lumen tube should be used initially, as it can provide one-lung ventilation, prevent aspiration into the right lung, and allow unhurried dissection and repair, thereby enhancing the safety of the operation. Use of either of these tubes may also allow adequate exposure, thereby eliminating the need to divide the intercostal vessels [8].
Right thoracotomy remains the incision of choice for treating an isolated distal tracheal injury. In our case, however, the existing exposure was through a left thoracotomy and the urgency of uncontrollable air leakage made it impractical to perform a second, right thoracotomy. By using the existing left thoracotomy incision rather than a bilateral one, we were readily able to repair the trachea, and we also gained direct access to the other bronchopulmonary injuries. This approach proved life-saving in this case and is worthy of consideration for elective exposure of the distal trachea or for emergent repair of combined distal tracheal and left bronchopulmonary injuries.
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Footnotes
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Address reprint requests to Dr Ott, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.
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References
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- Björk VO. Left-sided bronchotracheal anastomosis. J Thorac Surg 1955;30:492–8.
- Smith RA, Nigam BK. Resection of proximal left main bronchus carcinoma. Thorax 1979;34:616–20.[Abstract/Free Full Text]
- Perelman M, Koroleva N. Surgery of the trachea. World J Surg 1980;4:583–91.[Medline]
- Grillo HC. Carinal reconstruction. Ann Thorac Surg 1982;34:356–73.[Abstract/Free Full Text]
- Salzer GM, Muller LC, Kroesen G. Resection of tracheal bifurcation through a left thoracotomy. Eur J Cardiothorac Surg 1987;1:125–8.[Abstract/Free Full Text]
- Kulka F. Successful resection of the tracheal bifurcation through a left thoracotomy [Letter]. Eur J Cardiothorac Surg 1988;2:133.[Free Full Text]
- Maeda M, Nakamoto K, Tsubota N, et al. Operative approaches for left-sided carinoplasty. Ann Thorac Surg 1993;56:441–6.[Abstract/Free Full Text]
- Newton JR Jr, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272–80.[Abstract/Free Full Text]
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Abstract
Introduction
