Ann Thorac Surg 2007;84:1382-1383
© 2007 The Society of Thoracic Surgeons
Case Reports
Repair of Iatrogenic Distal Tracheal Rupture by Left Thoracotomy
Babar B. Chaudhri, FRCSa,*,
Sum Team Lo, MB, BSa,
Keith Kerr, FRCPathb,
Keith Buchan, FRCSa
a Department of Cardiothoracic Surgery, Royal Infirmary, Aberdeen, United Kingdom
b Department of Pathology, Royal Infirmary, Aberdeen, United Kingdom
Accepted for publication May 7, 2007.
* Address correspondence to Dr Chaudhri, Department of Cardiothoracic Surgery, Western Infirmary, Dumbarton Rd, Glasgow, G116NT, United Kingdom (Email: bchaudhri{at}mac.com).
 |
Abstract
|
|---|
The trachea is readily accessed through a right thoracotomy. Further exposure of the distal trachea may be accomplished using a median sternotomy through a transpericardial approach. We report our experience of a case of iatrogenic tracheal rupture in a patient with a large left-sided posterior mediastinal tumor. Surgical resection of the mass and subsequent repair of the tracheal rupture was accomplished through a left thoracotomy.
|
Introduction
|
|---|
The aims of surgical repair of tracheal rupture are to allow closure for effective ventilation and prevent mediastinitis secondary to the contamination of the mediastinal structures. An approach to the left side of the trachea may be readily accomplished by a right thoracotomy [1, 2]. We present the case of a patient who required a left thoracotomy for resection of a large left-sided posterior mediastinal tumor.
The patient was a 50-year-old woman with a large left-sided mass abutting the mediastinum. On computed tomography, the lesion looked well demarcated with focal calcification, but no radiologically malignant features. Total collapse of the left lung was present preoperatively due to compression of the left main bronchus from behind. Preoperative rigid bronchoscopy demonstrated compression of the left main bronchus posteriorly, which was overcome with the bronchoscope. The lobar orifices were clearly seen. No untoward events occurred during bronchoscopy. A clear view of a normal distal trachea was obtained prior to removing the instrument. Placement of a left-sided double lumen tube was unsuccessful due to distorted airway anatomy. A right-sided tube was difficult to site accurately. Another left-sided tube was therefore passed. During attempts to position it correctly, inability to ventilate the patient and hypoxia was encountered. A right-sided tension pneumothorax was immediately relieved by insertion of a chest drain. Ventilation was re-established with an air leak through an underwater seal drainage bottle. A tracheal injury was suspected and was shown on repeat rigid bronchoscopy. It was a longitudinal tear (1 cm above the superior margin of the left main bronchial orifice) at the junction between membranous and cartilaginous portions of the trachea. During gas insufflation the tear could be seen to open widely, permitting escape of gas into the mediastinum and into the right pleural space.
The tear was treated conservatively for 24 hours, but the air leak was still present. As there was uncertainty about the length of time this lesion may take to heal using a conservative approach with the potential for sepsis in the collapsed lung, it was decided to return to the operating room to resect the tumor and repair the tracheal injury as a combined procedure. Due to the location of the tracheal injury, we anticipated the need to mobilize the aortic arch for access.
Through a left posterolateral thoracotomy through the bed of the fifth rib, an extensive, macroscopically malignant tumor was evacuated from the left chest. The tumor was widely attached to the normal underlying lung and to the chest wall and pericardium, precluding complete removal, but satisfactory re-expansion of the left lung was achieved. The upper four pairs of intercostal arteries were divided at their origins from the aortic arch and upper descending thoracic aorta with metallic surgical clips (Fig 1). The subclavian artery was mobilized by incising the overlying pleura. Tapes were passed around the left subclavian artery and the aortic arch so as to elevate these structures away from the operative field. The supra-aortic esophagus was dissected from the posterior wall of the trachea after identifying the recurrent laryngeal nerve to avoid damaging it. By continuing the separation of the trachea from the esophagus downwards, the tracheal defect was soon uncovered. Interrupted 4-0 polydioxanone sutures were placed, each bite incorporating a portion of healthy adjacent esophagus closing the defect, as previously described for reinforcing a tracheal suture line [3] (Fig 2). The pericardium and parietal pleura were involved with the tumor and therefore were not used as reinforcement of the closure. The repair withstood an airway inflation pressure of 20 cm of H2O without air leak.
View larger version (127K):
[in this window]
[in a new window]
|
Fig 1. (a) View of the surgical field by a left thoracotomy after resection of the mass. Tapes are placed around (1) the proximal descending aorta, (2) the left subclavian artery under which the distal trachea is located, and (3) the upper four pairs of intercostals divided with metallic surgical clips. (b) Inset: (4) at the location of the distal tracheal tear with the oesophagus inferiorly the aorta has been displaced by the surgeon’s hand.
|
|
There were no postoperative complications. There were no signs of spinal cord injury, chylothorax, elevation of the left hemi-diaphragm, nor hoarseness. The patient was discharged home on postoperative day 6. A follow-up bronchoscopy on postoperative day 10 showed no sign of the injury, which indicated a complete healing. The tumour proved to be a malignant solitary fibrous tumor of the pleura. She has been referred for chemoradiotherapy.
|
Comment
|
|---|
In a reported series of surgical repair of tracheobronchial ruptures, the right thoracotomy has been used to readily access the distal trachea [4, 5]. Other means of access (eg, where the left tracheal sleeve pneumonectomy is to be performed) may be accomplished through a left thoracotomy [6]; however exposure can be difficult because of the aortic arch. This technique can be improved with mobilization of the aorta within the arch with division of the ligamentum arteriosum and retraction of the pulmonary artery in opposite directions, and further exposure supplemented with bilateral thoracotomies or a clamshell incision. Our technique involved mobilization of the arch in a caudal direction by dividing the upper intercostal arteries and pulling the arch downward. A median sternotomy is another technique giving excellent exposure [2, 7, 8]. With this technique, the arch, superior vena cava, and right pulmonary artery are mobilized through a transpericardial approach. An additional left thoracotomy may then be performed to allow lung resection.
This case illustrates the use of a left-sided approach to distal tracheal repair. We acknowledge that the trachea is much more easily accessed through a the right chest, but with a nonfunctional left lung this approach would not have been ideal in our patient, and even if it were successful, it would have entailed a bilateral thoracotomy for completion of treatment. The risk of spinal cord injury with this approach is very low, as it is extremely unusual for the major spinal cord arterial supply to arise in the upper part of the thoracic aorta. The left thoracotomy approach to distal tracheal injury is one, although rarely used, is sometimes the best surgical solution, as in this patient’s case.
|
References
|
|---|
- Grillo HC. Carinal reconstruction Ann Thorac Surg 1982;34:356-373.[Abstract]
- Perelman M, Korolva N. Surgery of the trachea World J Surg 1980;4:583-591.[Medline]
- Goldstraw P. Pneumonectomy and its modificationsIn: Shields TW, editor. General thoracic surgery. 4th ed.. Philadelphia, PA: Lippincott Williams and Wilkins; 1994. pp. 415-427.
- Leinung S, Ott R, Schuster E, Eichfeld U. Tracheobronchial ruptures: classification and management Chirurg 2005;76:783-788(in German).[Medline]
- Carbognani P, Bobbio A, Cattelani L, Internullo E, Caporale D, Rusca M. Management of postintubation membranous tracheal rupture Ann Thorac Surg 2004;77:406-409.[Abstract/Free Full Text]
- Mitchell JD, Mathisen DJ, Wright CD, et al. Clinical experience with carinal resection J Thorac Cardiovasc Surg 1999;117:39-52.[Abstract/Free Full Text]
- de Perrot M, Fadel E, Mercier O, Mussot S, Chapelier A, Dartevelle P. Long-term results after carinal resection for carcinoma: does the benefit warrant the risk? J Thorac Cardiovasc Surg 2006;131:81-89Epub 2005 Dec 5.[Abstract/Free Full Text]
- Maeda M, Nakamoto K, Tsubota N, Okada T, Katsura H. Operative approaches for left-sided carinoplasty Ann Thorac Surg 1993;56:441-445.[Abstract]
Top
Abstract
Introduction
