Ann Thorac Surg 1997;64:1158-1160
© 1997 The Society of Thoracic Surgeons
Case Report
Onlay Patch Repair of Tracheobronchial Rupture
Raymond D. Crouch, MD,
Larry E. Nelson, DO,
Philip C. Hawley, MD,
Douglas A. Frank,
Ccp,
Thomas E. Williams, Jr, MD
Department of Surgery, Grant Medical Center, Columbus, Ohio
Accepted for publication May 2, 1997.
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Abstract
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Two cases are reported of tracheobronchial repair in which a posteriorly based intercostal muscle flap was incorporated into the membranous portion of the airway to increase the diameter of the reconstruction or to relieve tension in the suture lines. This technique permits repair of a small left main bronchus without compromise to the lumen and tension-free repair of the membranous trachea.
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Introduction
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Rupture of the trachea or bronchi from blunt trauma is an uncommon occurrence [1, 2]. We report two unusual cases, (1) a complex traumatic left main bronchial rupture successfully repaired with a pedicled intercostal muscle flap to reconstruct the membranous portion of the bronchus and (2) a case of traumatic rupture of the membranous trachea that was repaired using a similar pedicled flap.
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Case Reports
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Patient 1
A 55-year-old woman fell from her car and the front wheel ran over her. Shortly after admission her decreasing oxygenation and deteriorating mental status necessitated endotracheal intubation. Physical examination revealed hemodynamic stability, a left flail chest, mild abdominal tenderness, and no evidence of subcutaneous emphysema. The initial chest roentgenogram demonstrated pneumomediastinum with pneumopericardium, mild subcutaneous emphysema, bilateral pulmonary contusions, and no evidence of pneumothorax. Repeat chest roentgenograms on admission to the intensive care unit revealed a left pneumothorax. Tube thoracostomy was performed and yielded 50 mL of blood and a persistent air leak after reinflation of the left lung. Fiberoptic bronchoscopy revealed transection of the left main bronchus with approximately 1 cm distraction of the cartilaginous rings. Pulsations were obvious anterior to the tear. There was no evidence of tracheal or right bronchial injury.
The patient underwent a left posterolateral thoracotomy via the fifth intercostal space with a right double-lumen endotracheal tube in place. Exposure was facilitated by division of the ligamentum arteriosum and separation of the trachea and left main bronchus from the esophagus. A complex tear of the main bronchus was found with complete transection at its cartilaginous midportion and a linear tear in the midline of the membranous portion extending from the first cartilaginous ring to the bronchial bifurcation distally. The bronchus was quite small in diameter; it would barely admit the tip of the surgeon's little finger. It was thought that primary closure would have resulted in stenosis.
The bronchus was repaired by primary reapproximation of the cartilages and reconstruction of the posterior membranous portion with the pleural surface of a vascularized flap of intercostal muscle (Fig 1
). The intercostal muscle of the fourth interspace was mobilized with its vascular supply and parietal pleura and easily reached the proximal portion of the bronchus. Interrupted simple sutures were placed in the proximal portion of the membranous tear beginning at the apex near the carina and proceeding distally along each side of the injury. These were then placed along the margins of the pleural surface of the pedicle flap. The proximal and distal bronchial segments were then reapproximated with interrupted sutures along the circumference of the cartilages. The membranous tear of the distal segment was then repaired by continuing the incorporation of the muscle flap. The completed repair was tested and showed no evidence of air leak and full expansion of the left lung.
Postoperatively the patient was maintained on pressure-controlled ventilation; sedation and paralysis were continued for 13 days. Once sedation was weaned, the patient was extubated on postoperative day 18. Repeat bronchoscopy was performed as needed. Final examination revealed no evidence of stenosis at the site of repair. Two years later, the patient is doing well with no evidence of stenosis on follow-up bronchoscopy.
Patient 2
This 21-year-old man presented with bilateral pneumothoraces after a motor vehicle accident. Bronchoscopy confirmed an extensive tear of the membranous portion of the trachea. At operation the trachea was exposed through a right fourth interspace posterior lateral thoracotomy. When the mediastinum was opened, it became impossible to maintain ventilation with the double-lumen endotracheal tube. The area was packed off to maintain ventilation while the patient was heparinized and cannulated for cardiopulmonary bypass with a two-stage right atrial cannula and an ascending aortic arterial return cannula (Fig 2). Cardiopulmonary bypass was instituted; physiologic shunting of oxygenated blood through the heart and nonventilated lung approximated 40% of the total cardiac output. The placement of a BioMedicus (Eden Prairie, MN) pump for augmented venous drainage reduced the shunting and permitted completion of the procedure. Thereafter, the tracheal wound was reexposed and its borders defined. The rupture extended in the midline of the membranous trachea from the neck root slightly above the thoracic inlet to the bifurcation of the trachea. An intercostal muscle pedicle flap was prepared using the fifth intercostal bundle. A series of interrupted sutures were placed in the apex of the tracheal injury and continued down both sides of the membranous trachea so as to onlay the intercostal pedicle flap. When all the sutures had been placed and tied, the endotracheal tube was withdrawn to an appropriate location. The patient was ventilated and a small air leak was repaired by closing the mediastinal tissues over the leak. The patient was weaned from cardiopulmonary bypass. He subsequently was supported using mechanical ventilation and was eventually discharged from the hospital 3 weeks after undergoing repair. At the present time, 1 year later, he is doing well. The trachea is widely patent at bronchoscopy.
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Comment
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The diagnosis of tracheobronchial injury in the setting of blunt trauma is suggested by clinical findings such as subcutaneous emphysema and sternal tenderness, and by radiographic signs including cervical emphysema, pneumomediastinum, pneumothorax, air around a bronchus, or unusual orientation of the endotracheal tube [2]. Bronchoscopy is highly sensitive for major airway trauma and should be performed in all cases of suspected injury [3]. Bronchial tears less than one third the circumference of the bronchus or those involving only the membranous portion may be managed nonoperatively if tube thoracostomy results in full expansion of the lung and early cessation of the air leak [4]. When necessary, operative repair should be undertaken early with the goal of primary airway repair with resection of as little lung as possible. Primary repair, with or without the aid of cardiopulmonary bypass, can usually be completed successfully. A significant late complication of primary repair is airway stenosis at the site of the anastomosis. This method of repair, which widens a small bronchus by using an intercostal muscle pedicle as an onlay patch, allows for an increase in circumference in an attempt to prevent stenosis. Repair of the bronchus with a vascularized serosal surface should allow healing and reepithelialization in a fashion similar to that shown by Thal and associates [5] in their serosal repairs of the intestine. The use of an intercostal muscle flap as reported here also provides an additional tension-free technique to deal with complex injuries of the tracheobronchial tree.
Exposure, visualization, and repair of these complex tracheobronchial ruptures can be facilitated by division of the ligamentum arteriosum, the use of cardiopulmonary bypass, the use of an open interrupted suture technique, and the use of intercostal muscle pedicled onlay flaps.
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Footnotes
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Address reprint requests to Dr Williams, 300 E Town St, 12th Fl, Columbus, OH 43215.
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References
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- Baumgartner F, Sheppard B, de Virgilio C, et al. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg 1990;50:569–74.
- Ramzy AI, Rodriguez A, Turney SZ. Management of major tracheo-bronchial ruptures in patients with multiple system trauma. J Trauma 1988;28:1353–7.[Medline]
- Symbas PN, Justicz AG, Ricketts RR. Rupture of the airways from blunt trauma: treatment of complex injuries. Ann Thorac Surg 1992;54:177–83.[Abstract]
- Mulder DS, Burkun JS. Injury to the trachea, bronchus and esophagus. In: Moore EE, Mattox KL, Feliciano DV. Trauma, 2nd ed. Norwalk, CT: Appleton and Lange, 1988:343–56.
- Thal AP, Sukhnandan R, Arbulu A, Hatafuku T. Patch grafting of the gastrointestinal and urinary tract. Minn Med 1966;49:45–9.[Medline]
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Abstract
Introduction
