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Ann Thorac Surg 2000;70:984-986
© 2000 The Society of Thoracic Surgeons

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How to do it

Transcervical–transtracheal endoluminal repair of membranous tracheal disruptions

^a Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Paris-Sud University, Le Plessis Robinson, France

Address reprint requests to Dr Dartevelle, Department of Thoracic and Vascular Surgery Marie-Lannelongue Hospital, 133 Ave de la résistance, 92350 Le Plessis Robinson, France
e-mail: pdartevelle{at}ccml.com

	Abstract

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Tracheal lacerations are rare and potentially hazardous complications of tracheal intubation. Surgical repair is the treatment of choice of tracheal injuries although nonoperative management is occasionally appropriate for well-selected patients. We describe our personal technique of anterior transcervical–transtracheal endoluminal suture of iatrogenic lacerations of the membranous trachea and our results with this approach in 8 patients. This method is less invasive than conventional cervical or transthoracic approaches.

	Introduction

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Intubation-related tracheobronchial disruptions result from a complex interplay of mechanical, anatomic, and clinical factors [1]. The surgical options most commonly used have been tracheal repair through a right posterolateral thoracotomy or simple suture from outside the trachea through cervical incisions [1, 2]. To reduce the morbidity that results from extensive operations and to decrease the potential for recurrent nerve injuries, and maximally to preserve both tracheal and esophageal blood supply, we have adopted a transcervical endoluminal approach as the method of choice to repair iatrogenic lacerations of the cervical and mediastinal trachea.

	Technique

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Patients are supine with their neck hyperextended and a transverse anterior cervical incision that extends caudad to the sternal notch is made. In all single-lumen tube injuries ventilation is assured by preliminary intubation above the laceration site followed by intubation of the distal trachea through the operative field once the tracheal lumen has been exposed.

The infrahyoid muscles are dissected in the midline and the thyroid isthmus is divided if necessary. The pretracheal fascia is eventually entered longitudinally and the anterior aspect of the trachea is dissected digitally down to the level of the carina. The endoluminal approach consists of an anterior transverse stab tracheotomy between two cartilage rings opposite to the top of the laceration site (Fig 1). The wound edges are retracted with the aid of two traction sutures, the tracheal lumen is exposed. The tear is carefully checked to decide whether simple endoluminal repair or repair in conjunction with segmental tracheal resection will the method of choice.

View larger version (42K): [in this window] [in a new window]   Fig 1. Anterior transverse tracheotomy between two cartilage rings opposite to the top of the laceration site. The wound edges are retracted with the aid of two traction sutures, thus the tracheal lumen is exposed.

The repair is most often with a caudad-to-cephalad double 4-0 polydioxanone running suture. Video assistance through a rigid endoscope introduced in the tracheal lumen can facilitate visualization of the posterior tracheal wall. The light brought into the lumen of the distal trachea by the video increases visibility considerably and consequently improves the quality of the suturing procedure (Fig 2). The posterior membranous wall is closed with 4-0 polydioxanone running suture and the anterior tracheotomy with everting interrupted 3-0 polyglactin sutures. Once completed, the anastomosis is tested with sterile saline. When the laceration of the trachea is associated with damage to a tracheal ring, segmental tracheal resection and reconstruction are combined with repair of the membranous disruption.

View larger version (45K): [in this window] [in a new window]   Fig 2. The posterior membranaceous wall is closed with a caudad-to-cephalad double 4-0 polydioxanone running suture. Video assistance with a rigid endoscope illuminates the distal trachea.

	Results

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A total of 8 single-lumen lacerations of the cervical or mediastinal trachea were surgically repaired at our institution by an anterior transcervical–transtracheal approach during the period from 1990 to 1999. Tracheal injuries were extended for a mean of 3.8 cm (range 3 to 5 cm), located in the cervical trachea in 5 patients and involving both the cervical and mediastinal tract in 3 cases. One of the injuries extended down to the carina and had been repaired by this transtracheal approach. Five of the repairs were by a transtracheal endoluminal suture and 3 were in combination with a tracheal resection–reconstruction because the laceration of the tracheal membrane was associated with damage to a tracheal ring.

The operations were successful in all cases. There were no intraoperative complications and no deaths. Postoperative fiber optic tracheobronchial examinations were conducted as follow-up 1 and 3 months after the operations. Stenosis, dehiscence, and granulation tissue was not observed at follow-up.

	Comment

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The treatment for iatrogenic tracheal tears include both nonoperative management and surgical repair. We reserve nonoperative management for stable patients with linear tears smaller than 1 cm or lacerations not involving more than one third of the tracheal circumference [3, 4]. In our view nonoperative management has potential for long-term strictures and their related sequelae, and so this method should be reserved for patients with very small lacerations and for individuals whose condition otherwise makes them very poor anesthetic and surgical risks [3, 4]. Surgical repair is currently indicated for patients requiring mechanical ventilation support, in the presence of acute respiratory distress, unrelenting pneumomediastinum or subcutaneous emphysema, and esophageal injuries. However, this surgical procedure is accompanied by significant morbidity, especially when right thoracotomy incisions are used, and when there have been lengthy delays between the occurrence of the tracheal tears and definitive diagnosis [1, 2, 5].

We are convinced that the choice of the surgical repair should be dictated by the characteristics of the lacerations as well as its location and length. The cervical incision we suggest allows the surgeon to gain easy access to the cervical and mediastinal trachea with no need to split the sternum. The approach through the neck entails neither major ventilatory disturbances nor the adverse effects of thoracotomies. The blood supply to the cervical trachea is primarily from the inferior thyroid artery and the vessels divide, just before arriving at the trachea, into branches destined for the esophagus or trachea [6]. Thus, the trachea must be dissected gently so as to allow preservation of its blood supply, avoiding inadvertent esophageal and recurrent nerve injuries and achieving identification of the site of rupture.

The repair can be accomplished either by suture of the membranous trachea through a single transtracheal approach or by combining conventional segmental resection and reconstruction. Angelillo-Mackinlay described a transtracheal repair through a vertical tracheotomy for membranous laceration [5]. We believe that the single transversal tracheal opening permits repair of longer tracheal lacerations, even those that extend down to the level of the carina. Also, we think that the transverse tracheal approach is easier to close, particularly when a tracheal resection anastomosis is required for tracheal ring laceration associated. The endoluminal approach is usually suitable and preferable because a transverse tracheal opening generally provides direct control of the rupture site. Furthermore, the endoluminal approach eliminates the need for any tracheo-esophageal dissection and the consequent risk of tracheal ischemia and recurrent nerve injuries. Only those tracheal injuries that involve the bronchi or lacerations discovered at the time of otherwise indicated major thoracic operations require a conventional right thoracotomy approach.

Postintubation tracheal disruptions are challenging complications that require early diagnosis and prompt surgical management. To reduce the surgical trauma and perform an effective repair, we recommend a transcervical approach to the cervical and mediastinal trachea. Depending on the characteristic of the laceration, the surgeon may select either a resection–reconstruction technique or a transtracheal endoluminal suture.

	References

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1. Massard G., Rougé C., Dabbagh A., et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483-1487.[Abstract/Free Full Text]
2. Marty-Ané C.H., Picard E., Jonquet O., Mary H. Membranous tracheal ruptures after endotracheal intubation. Ann Thorac Surg 1995;60:1367-1371.[Abstract/Free Full Text]
3. Ross H.M., Grant F.J., Wilson R.S., Burt M.E. Nonoperative management of tracheal lacerating during endotracheal intubation. Ann Thorac Surg 1997;63:240-242.[Abstract/Free Full Text]
4. D’Odemont J.P., Pringot J., Goncette L., Goenen M., Rodenstein D.O. Spontaneous favorable outcome of tracheal laceration. Chest 1995;99:1290-1291.[Abstract/Free Full Text]
5. Angelillo-Mackinlay T. Transcervical repair of distal membranous tracheal laceration. Ann Thorac Surg 1991;59:531-532.[Abstract/Free Full Text]
6. Salassa J.R., Pearson B.W., Payne W.S. Gross and microscopical blood supply of the trachea. Ann Thorac Surg 1977;24:100-107.[Abstract]

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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): Paolo Macchiarini Philippe G. Dartevelle Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lancelin, C. Articles by Dartevelle, P. G. Search for Related Content PubMed PubMed Citation Articles by Lancelin, C. Articles by Dartevelle, P. G.