The need for tracheal resection and reconstruction arises with airway obstruction (<5 mm luminal diameter) secondary to postintubation stenosis, primary or secondary benign or malignant tumors, or trauma. Patients who present acutely with symptoms of stridor should be stabilized first by establishing a clear airway. Resection and repair are often delayed to permit adequate time for radiologic and diagnostic studies to aid in surgical planning. Emergency tracheal resection is rarely warranted. Lack of a suitable prosthetic replacement for the trachea limits the amount of this organ that can be resected without placing undue tension on the anastomosis (maximum resection length 5 cm). For this reason, the initial operation must be well planned and executed. Anastomotic dehiscence and other late complications of an unsuccessful first operation are difficult to reverse given the limited material the surgeon has to effect a repair.
General Surgical Principles
The surgical approach to an upper airway tumor depends on its location. Proximal tracheal lesions require resection of the trachea and possibly the cricoid cartilage or larynx. Segmental resection of the trachea with direct end-to-end anastomosis is used to remove tracheal main body lesions. Removal of tumors that involve the distal trachea, carina, or mainstem bronchus requires some form of carinal resection, with the extent of airway resection determining the mode of reconstruction. If the disease process involves the lobar orifices, resection can be accomplished by including contiguous resection of the affected lobes.1,2 Lymph nodes should be resected whenever possible for staging, although extended lymphadenectomy can devascularize remaining airway tissue and should be avoided.
Preoperatively, patients should stop smoking and be weaned from steroids 2 to 4 weeks before resection to avoid deleterious effects on anastomotic healing.1 Bronchoscopic techniques can be used, if needed, for temporary palliation for patients with severe obstruction while surgery is delayed. The anesthesiologist should place an epidural catheter preoperatively and have experience with complex airway management. Anesthetic management should include inhalation induction and short-acting medications to permit early extubation, which will decrease pressure on the airway anastomosis. For carinal resections, mediastinoscopy should be performed at the time of resection both for staging and to develop the pretracheal plane to improve mobility of the upper airway and lessen the chance of subsequent injury to the left recurrent laryngeal nerve when the distal trachea is dissected free at thoracotomy.1 Ventilation during airway resection is achieved by distal airway intubation with an armored-type endotracheal tube connected to sterile anesthesia tubing across the surgical field. A sterile camera bag also can be used to house the airway tubing that is passed across the surgical field. The endotracheal tube is pulled back into the proximal airway by the anesthesiologist before airway incision.
After the distal resection margin is incised and the airway is divided circumferentially, the distal airway is intubated by the surgeon while the anesthesia team switches to the sterile circuit. If necessary, both lungs can be ventilated separately for carinal resections.3 Either a double-lumen endotracheal tube or a long single-lumen tube with selective intubation of the contralateral mainstem bronchus or a bronchial blocker positioned in the ipsilateral bronchus can be employed for mainstem bronchi resections.4 If necessary, the ipsilateral lung can be ventilated across the operative field if single-lung mobilization is poorly tolerated. The size and inflexibility of double-lumen tubes can present difficulties in procedures that involve carinal resection, and the extra-long single-lumen tube advanced into a mainstem bronchus to provide single-lung ventilation is preferable.1 The remaining mainstem bronchus is intubated across the operative field as resection proceeds.1 For carinal resections, the original long endotracheal tube is advanced into the bronchus after the ...