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Ann Thorac Surg 2000;69:243-244
© 2000 The Society of Thoracic Surgeons

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Original Articles

Postintubation tracheal tear repair by cervicotomy and longitudinal tracheotomy

^a Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Pisa, Italy

Address reprint requests to Dr Angeletti, Division of Thoracic Surgery, St. Chiara Hospital, University of Pisa, Via Roma 67, 56100 Pisa, Italy
e-mail: c.angeletti{at}dc.med.unipi.it

	Abstract

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Background. Membranous tracheal lacerations are a serious complication of endotracheal intubation. Smaller tears are often better managed with a conservative treatment. Larger ruptures, especially when associated with important manifestations, need an early surgical repair.

Methods. In the last 3 years, three female patients with a posterior tracheal wall laceration, related to endotracheal intubation, underwent surgical procedure in our institution. All tracheal tears were repaired with a running suture through a small cervical collar incision and longitudinal tracheotomy.

Results. All surgical procedures were effective and lasted less than 1 hour. Patients were discharged on average after 5 days. Endoscopic follow-up showed a perfect repair of the tear without signs of tracheal stenosis.

Conclusions. This is a reliable, quick, and safe approach to a rare but insidious complication of general anesthesia. It avoids lateral and posterior dissection of the trachea, reducing the risk of a recurrent laryngeal nerve injury.

	Introduction

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Posterior tracheal wall laceration can occur in association with apparently uneventful tracheal intubations, presenting most frequently with hemoptysis and subcutaneous emphysema [1–3]. When the diagnosis is made, surgical repair of the tear should be immediate [1, 3]. We report three cases repaired through a simple and safe surgical procedure [3].

	Patients and methods

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Patient 1
In September 1996, a 92-year-old woman underwent emergency endotracheal intubation. The physician who performed the intubation charted the procedure as being problematic. Once the acute respiratory failure resolved, she was extubated but soon experienced massive subcutaneous emphysema of the head, neck, and chest wall, associated with hemoptysis. X-ray chest film showed a pneumomediastinum. Bronchoscopy revealed a 5-cm longitudinal laceration of the posterior tracheal wall arising 3.5 cm cephalad to the carina. She was brought to the operating table 6 hours after the emergency intubation.

Patient 2
A 35-year-old woman underwent cholecystectomy under general anesthesia, in April 1997. Thirty minutes after extubation, she had hemoptysis. During the following 12 hours, progressive subcutaneous emphysema developed. X-ray chest film showed a pneumomediastinum. Bronchoscopy showed a 3-cm membranous tracheal laceration arising 4 cm from the carina. She reached the operating table 12 hours after cholecystectomy.

Patient 3
In March 1998, 4 hours after an intervention using general anesthesia with orotracheal intubation at our ophthalmology clinic, a 65-year-old woman came to our attention. She reported having dyspnea and presented with conspicuous subcutaneous emphysema. Chest radiography showed a marked pneumomediastinum. Bronchoscopy revealed a 3-cm membranous tracheal laceration arising 4.5 cm from the carina. She was immediately brought to the operating table.

Technique
All patients had surgical repair of the tear performed within 12 hours of the intubation. They underwent general anesthesia and were again intubated with a 5.5-mm (inner diameter) single low-pressure cuffed orotracheal tube (Bivona Aire-cuf, Gary, IN) under bronchoscopic view. Their necks were hyperextended as for mediastinoscopy, and a small collar incision, 2 cm above the jugulum, was made. Once the anterior tracheal wall was reached, it was incised longitudinally along the midline, for four to seven rings in length, in exact correspondence to the injury as assessed by fiberoptic bronchoscopic guide. Tracheotomy edges were retracted laterally, and, while the orotracheal tube was withdrawn, a second 4.5-mm (inner diameter) sterile, low-pressure, cuffed, flexible, armored endotracheal tube (Bivona Aire-cuf) was inserted into the distal airway through the tracheal incision, across the operating field. During the suturing of the laceration, the endotracheal tube was withdrawn several times to allow good exposure of the tracheal tear. The laceration was repaired with a 4-0 Dexon II running suture (Davis & Geck, Wayne, NJ), starting from the distal end of the tear. While the patients were in apnea, the anesthesiologist monitored their vital signs to decide when ventilation was necessary. Once the laceration was repaired, the anesthesiologist advanced the original orotracheal tube beyond the suture. The longitudinal tracheotomy was closed using 3-0 Dexon II interrupted crossed stitches (Davis & Geck).

The duration of each intervention was less than 1 hour. All patients were immediately extubated at the closure of the operative procedure. The postoperative course was uneventful, and they were discharged respectively at the sixth, fifth, and fourth postoperative days. Endoscopic follow-up showed a perfect repair of the posterior tracheal wall tear, and there were neither symptoms nor signs of tracheal stenosis.

	Comment

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Membranous tracheal laceration is a rare complication of endotracheal intubation, especially if the procedure is problematic [4], as in our first case, if tracheal abnormalities are present [5], or in the event of overdistention or rupture of the endotracheal tube cuff. But it also can occur after an intubation performed with no difficulties [1–3], as it apparently happened in the other two cases of our report.

The first signs of its presence usually appear within 12 hours of intubation [1, 3]. They are hemoptysis and subcutaneous emphysema of the head, neck, and upper chest [1, 3], and, in severe cases, dyspnea and cyanosis [6]. X-ray chest film usually shows a pneumomediastinum, as in our patients, and a pneumothorax when the laceration is in the lower trachea or extends to a main bronchus [7].

The diagnosis is confirmed by endoscopy, which establishes the location and the extent of the tear and allows planning of the best surgical approach [2]. When a tracheoesophageal fistula is suspected, an esophagoscopy is required, too [8].

The first choice of treatment falls on immediate definitive single-stage repair to avoid both early complications, such as secondary mediastinitis, or belated sequelae, such as tracheal stenosis [2, 7].

Juxtacarinal membranous tracheal lacerations are better managed through a right thoracotomy, especially if they involve a mainstem bronchus. On the other hand, when the tear involves the proximal two thirds of the posterior tracheal wall, a cervical approach would be preferable [9], and so we acted accordingly in our three cases. Jacobs and colleagues [8] first reported two cases of posterior tracheal laceration as a complication of tracheostomy, which were repaired directly with a single-layer closure through the same tracheotomy. As in our experience, they alternated suturing with ventilation. Recently, Angelillo-Mackinley [3] proposed a new technique to take on this intubation-related complication. He performed a cervical mediastinoscopy incision and sutured the tear through a vertical incision made in the anterior wall of the trachea. This is very similar to the procedure we used in our three cases. In Angelillo-Mackinley’s report [3], the patient was intubated with a small single tube, retracted laterally to allow the suturing of the tear. We preferred to substitute the orotracheal tube with a smaller one, inserted into the distal trachea across the operative field, as is usually done for tracheal resection and reconstruction. This allowed us to easily alternate suturing and ventilation to have the best maneuverability in repairing the distal end of the laceration. In agreement with Angelillo-Mackinley [3], we believe that this is a minimally invasive technique, very quick and easy to perform, which allows the surgeon to achieve excellent results and to avoid lateral and subsequent posterior dissection of the trachea, with the consequential exposure of the recurrent laryngeal nerve to the risk of being injured.

	Addendum

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During the review, another case (fourth) with almost the same features has been treated by the same approach and with the same results.

	References

Top Abstract Introduction Patients and methods Comment Addendum References

 

1. Kumar S.M., Pandit S.K., Cohen P.J. Tracheal laceration associated with endotracheal anaesthesia. Anaesthesiology 1977;47:298-299.[Medline]
2. Orta D.A., Cousar J.E., Yergin B.M., Olsen G.N. Tracheal laceration with massive subcutaneous emphysema. Thorax 1979;34:655-669.
3. Angelillo-Mackinley T. Transcervical repair of distal membranous tracheal laceration. Ann Thorac Surg 1995;59:531-532.[Abstract/Free Full Text]
4. Serlin S.P., Daily J.R. Tracheal perforation in the neonate. J Pediatr 1975;86:596-597.[Medline]
5. Thompson D.S., Read R.C. Rupture of the trachea following endotracheal intubation. JAMA 1968;204:995-997.[Abstract/Free Full Text]
6. Kirsh M.M., Orringer M.D., Behrendt D.M., Sloan H. Management of tracheobronchial disruption secondary to non-penetrating trauma. Ann Thorac Surg 1976;22:93-101.[Abstract]
7. Zimmerman J.E., Dumbar B.S., Klingenmaier C.H. Management of subcutaneous emphysema, pneumomediastinum and pneumothorax during respiratory therapy. Med Ann D C 1974;43:107-109.
8. Jacobs J.R., Thawley S.E., Abata R., Sessions D.G., Ogura J.H. Posterior tracheal laceration. Laryngoscope 1978;88:1942-1946.[Medline]
9. Grillo H.C. Surgical approaches to the trachea. Surg Gynecol Obstet 1969;129:347-352.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gianfranco Menconi Alfredo Mussi Marcello Carlo Ambrogi Carlo Alberto Angeletti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Janni, A. Articles by Angeletti, C. A. Search for Related Content PubMed PubMed Citation Articles by Janni, A. Articles by Angeletti, C. A.