Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

28. Staged Reconstruction of the Cervical Trachea

Peak Woo

INTRODUCTION

The laryngotracheal system is a challenge for all reconstructive surgeons. Physiologic restoration requires that the reconstruction performed after ablation satisfies the specific physiologic requirements for breathing, speaking, and swallow. Any permanent loss of any of the above functions results in severe quality of life deficiencies that can cause great emotional distress for the patient. The unique nature of the composite tissue required for adequate reconstruction of the trachea has challenged reconstructive surgeons over many decades. Consistent results for replacement of longer trachea loss after tumor surgery, trauma, and intubation have eluded excellent surgeons despite reports of grafts, prosthesis, and free flaps. This situation continues today.

Multiple very sophisticated techniques have been proposed since the use of local flaps was initially proposed for laryngotracheal reconstruction. These include mucosal flaps, muscle flaps, pedicled flap, perichondrium flaps, and free tissue transfer flaps. Despite this, great challenges remain in the reconstruction of tracheal and laryngeal defects after ablation for cancer and defects caused by trauma and infection. Any use of metallic or foreign materials has a tendency for extrusion due to pressure necrosis. In the trachea, repetitive motion from respiration and infection are the main factors contributing to long-term failure. Despite these challenges, the staged cervical tracheal reconstruction approach is worthy of consideration in selected patients with long-segment tracheal defects.

Resection of the cervical trachea, sometimes in conjunction with resection of the skin of the neck with the larynx still being intact, requires reconstructive techniques that will bring tissue together as a hollow tube. The hollow tube is necessary in order to permit continued respiration, phonation, and swallowing through an intact larynx and pharynx. While the trachea may be thought of as a static tube for airway maintenance, the cervical trachea is subject to great movement during flexion, extension, and swallowing. Small regional flaps in the neck may routinely be used for rehabilitation of limited defects if the surgical defect is less than 50% of the circumference of the larynx and trachea. Larger defects in this area may require resection and anastomosis, use of free tissue transfer, or staged reconstruction. For example, a small primary cancer of the subglottis or localized tracheal invasion by a low-grade cancer of the thyroid may result in a small defect that can be immediately repaired by rotation of composite tissue or a small muscle flap with free graft of cartilage into the area to maintain stability of the segment. With endolaryngeal or tracheal stenting, such small defects can be reliably reconstructed immediately. The reconstructive procedure of choice for small to medium circumferential defects of the trachea is by primary resection and anastomosis as popularized by Grillo, however, some patients are not suitable candidates. If this stenosis or tumor involvement involves less than four tracheal rings and the patient’s neck anatomy is favorable, primary resection and anastomosis of up to 4 cm may be accompanied easily by primary resection, tracheal release, and direct approximation of the two ends of the trachea. In the patient with a short neck, in patients who have had previous radiation therapy, and in the patient with previous surgery involving the mediastinum, the ability to transpose the trachea superiorly in order to perform primary anastomosis is much more limited. This is especially so in the patients who have previously failed attempted laryngotracheoplasty. When the defect goes beyond the limits of primary anastomosis or the surgery is limited by an ability to mobilize and transpose the trachea without tension, a staged augmentation approach should be considered.

Complications that result in tracheal stenosis should be separated on the basis of whether it is due to tumor resection, to mechanical external trauma, or to trauma from prolonged intubation or tracheostomy. Defects due to resection of primary cancer in the cervical trachea are rare and more likely are due to tracheal invasion by thyroid cancer. In this group of patients, primary tracheal reconstruction usually has a favorable outcome due to the uninvolved nature of the trachea from scarring and intubation. In patients with complications of the trachea due to motor vehicle trauma or industrial accident, early diagnosis and treatment and primary treatment may be able to be performed by primary repair and stenting around an indwelling T tube or Montgomery laryngeal stent. Early diagnosis and treatment in most instances can prevent the progression to late cicatricial stenosis.

Management of acute tracheal trauma is dictated by the need for establishment of an adequate airway, to control bleeding, and by the urgency of medical attention needed for other systems injury treatment. If possible, the laryngeal and tracheal area suspected of injury should be inspected early. Hematoma, fracture, and laceration and dislocations may be sutured and reconstituted by internal stenting. Endotracheal stent using a soft Silastic tube or endotracheal tube is usually left for 2 to 3 weeks. Small fragments and lacerations may be repaired with sutures, and stabilization of the indwelling stent using wires or external fixation with Silastic buttons. If there has been extensive mucosal loss from trauma, the airway lumen should be stabilized by indwelling stent for 3 weeks to 2 months depending on the extent of mucosal injury. By use of early stenting, there is less likelihood of need for late staged reconstruction.

In patients who develop laryngeal or tracheal stenosis as a complication of intubation, the defect is usually recognized late. This occurs as failure of decannulation from tracheotomy, or the patient may present with progressive stridor after decannulation. This group of patients with iatrogenic intubation-related injury should be considered separately from tumor or trauma cases. They can be considered to be at higher risk for development of laryngeal and tracheal stenosis. Poor wound healing and scar formation risk factors for laryngeal tracheal stenosis include diabetes mellitus, asthma and chronic obstructive pulmonary disease, acid reflux and nonacid reflux of abdominal contents into the trachea, autoimmune disease, and systemic illness that require chronic corticosteroid use. In these patients, preoperative evaluation of the position and size of the stenosis before surgery should be accompanied by medical evaluation to optimize systemic factors such as diabetes, pulmonary disease, and acid reflux. The use of 24-hour pH hour probe study should be entertained if there is persistent granulation or chronic inflammation at the stenosis site. The patient should be weaned off all systemic steroids before surgery. The ideal state of the patient before undergoing tracheal reconstruction should be a mature white scar at the site of the tracheal stenosis. Granulation tissue and chronic inflammation should be reversed or limited only to the area that is to be resected.

Accurate assessment of the laryngotracheal stenosis is accomplished by radiography as well as by endoscopy. Endoscopic examination with biopsy will be able to check the area of stenosis as well as to differentiate the area of stenosis as to whether it is circumferential or local. Examination under anesthesia with bronchoscopy will also identify areas of malacia that may need resection. A biopsy of the area of concern will usually be able to tell if the stenosis is a mature scar or whether this is actively inflamed with chronic and acute inflammatory changes. If there is chronic inflammation on the preoperative tissue biopsy, surgical resection should go beyond the area of chronic inflammation into more healthy tissue in order to avoid repeat stenosis. Radiographic imaging is accomplished by CT scan with 1-mm cuts through the trachea. This scan can be reconstructed as a virtual bronchoscopy with three-dimensional reconstruction. In addition, a CT scan can differentiate easily between circumferential wine bottle–type stenosis versus isolated tracheal stenosis. In the patient who has already failed previous laryngotracheal reconstruction, evaluation using CT scan can be especially helpful to decide whether the restenosis can be treated by endoscopic means or whether open surgical intervention may be needed.

Some patients with tracheostomy dependence and laryngotracheal stenosis are not good candidates for reconstruction. Poorly controlled diabetes mellitus, renal failure with cortical steroid dependence, chronic bacterial tracheitis, and chronic bronchitis are some of the reasons for deferment of patients for tracheal reconstruction. One example of such is the patient with poor mucosal hygiene and tracheotomy care. Chronic infection of the tracheotomy site in patients with chronic indwelling tracheostomy tubes results in copious granulation tissue, tracheitis, and mucopurulent discharge. Despite the best efforts of the health care team, sometimes it is not possible to restore the tracheostomy stenosis site to a healthy enough state to consider reconstruction. In these patients, premature surgical intervention can result in worse outcome with stricture formation, granulation tissue, and complete stenosis. In these patients, it may be preferable to delay reconstruction as long as possible until the traumatized area has undergone complete cicatricial formation. Attention in the meantime should be directed to allow all the necrotic tissue to be absorbed, the granulation to become healthy epithelium, and the tracheostomy site to be odorless and clean. This may take as long as 18 months after the initial injury.

If the stenosis is less than 2 cm in length, a direct resection and approximation of the proximal and distal ends may be done without tension. This can be performed as a single-stage procedure. If the two ends of the tracheal cartilage of the anastomosis are solid, internal stenting is not necessary. In patients who have favorable anatomy to permit a tension-free closure and when the site can be directly approximated, this is the most expedient technique with the least complications.

The indications for staged tracheal reconstruction are defects greater than 4-cm circumferential tracheal stenosis, long-segment tracheal stenosis where pull-up primary anastomosis is not possible, combined laryngeal and tracheal stenosis, tracheal stenosis after ablative surgery without donor vessels for free tissue transfer, and tracheal stenosis in patients with prior resection.

When surgery involves multiple sites such as cricoid cartilage and tracheal resection, direct closure may not be feasible. After primary resection of the scar tissue, the lumen can be established. For short segments of raw tissue devoid of mucosa, resurfacing by allowing the surrounding epithelium to grow in may need to be followed by prolonged internal stenting. Stabilization of the lumen with the use of an internal stent is usually done with a soft Silastic T tube or a conforming internal laryngeal stent made of soft Silastic. Local mucosal flaps have a limited role in the trachea. The trachea does not lend itself easily to mucosal flaps from other tracheal tissue due to damage to the donor site. Small rotation flaps from the posterior wall of the trachea are limited to a small triangle of tissue that is at most 5 mm in length. In selected situations, a small mucosal flap may be transposed to cover defects. An alternative technique is to transfer the mucosal by a mucosal grafting technique. This requires stenting and is sometimes unreliable due to excessive movement of the stent against the trachea.

Evaluation: The patient will have already undergone the appropriate radiographic study and endoscopy to determine the necessity of a staged procedure. Consent is obtained for excision of tracheal stenosis with cervical advancement flap and placement of endoluminal stent.

The use of a staged rehabilitation by flap transposition technique has a long and colorful history that first challenged reconstructive surgeons after the First World War. Rehabilitation by flap transposition may be accomplished using local or regional flaps, flaps in combination with skin or mucosal grafting, or distant flaps migrated into position. More recently, the development of free tissue transfer has made a significant contribution to the need for staged reconstruction. However, staged reconstruction continues to have a role in tracheal reconstruction since free tissue transfer is often limited by soft tissue bulk. The development of tracheal staged reconstruction follows the staged reconstruction techniques for the esophagus.

Many surgical procedures have been devised to manage laryngotracheal stenosis resulting from trauma. Laryngotracheal atresia is the most severe form and the most difficult to repair. To correct larger defects without primary repair, epithelial grafting may be considered. Free partial-thickness skin grafts can be used around a stent. This is hard to stabilize, and infection and slough of the graft are common. The contraction of the splitthickness graft after placement is another concern that prevents its use in the trachea.

Since the trachea is a composite tissue of thin soft and hard tissue, the geometry of reconstruction of the composite tissue is critical. Single-stage autologous tissue transfer is difficult to simulate the architectural requirements of the defects after trauma, intubation, or disease processes. Composite tissue can be transferred after creation in a distant donor site and transferred into place, or there may be staged procedures whereby soft and hard tissue is fabricated in the recipient site. For small defects of the anterior trachea, the use of solid tissue support may not be necessary, and Eliacher has advocated the use of the rotatory trap door flap as a single-stage procedure. This has the advantage of a single-stage procedure and does not need rigid expansion or support, but it is limited by the small anterior defects. For small defects of the anterior trachea, muscle flaps with titanium plates have also been proposed.

Some regenerative capacity of the trachea from the resection margin can be expected over time. This mucosa can be expected to resurface the muscle or perichondrium placed over the defect so that it could more closely simulate normal tracheal mucosa. This technique requires placement of a long-term endoluminal stent of 6 to 12 months until secondary contraction and scar healing is complete. Long-term stenting is used to avoid the need for treatment of secondary stenosis. This approach is best used when the posterior trachea is still intact so that there is sufficient healthy mucosa to grow into the defect.

For long-segment stenosis, a staged reconstruction is necessary. Reconstruction of the cervical trachea using cervical skin was described by Montgomery in 1964. This is one of the first descriptions of staged reconstruction. He reported the use of a staged procedure with rib grafting to maintain patency in a single patient. Conley described a similar approach in 1970. The tracheal trough is first lined by thin non–hairbearing skin. The trough is then matured by inserting a semisolid mold or a T tube that traverses the defect. After a suitable period of maturation that is variable from 3 to 6 months, a secondary procedure is done by placing a roof over the trough. Since the initial reports in the 60s, other reconstructive surgeons have reported successful use of this approach for longer segments of the trachea where primary anastomosis is not feasible.

Extraluminal integrity to maintain the semisolid state of the trachea can be maintained by internal stenting with secondary reconstruction with Silastic, rib cartilage, or titanium mesh. For very long segments, it is best to maintain long-term stenting using a long indwelling T tube with a permanent tracheotomy without attempt at complete decannulation. In this way, the problem of longer-term tracheal collapse over time and plugging can be overcome by easy removal and cleansing of a long-term internal stent by having a permanent tracheal stoma. For long-segment stenosis that requires long-term stenting, one then has to be satisfied with having a phonatory system using lung-powered speech with plugging of the internal stent. The patient has to be satisfied with long-term internal stenting without decannulation.

The Meyer procedure is a three-stage operation that provides structural support that is covered with mucosa. A laryngotracheal trough is created, and a carved trough-shaped cartilage graft is placed above and lateral to it in the first stage. The skin over the graft is replaced by buccal mucosa in the second stage. In the last stage, the cartilage graft with overlying mucosa is swung onto the trough as a composite flap replacing the anterior and lateral laryngeal and tracheal walls.

The creation of a new tracheal conduit using cervical flaps first came out of creation of laryngotracheal stoma after cancer extirpation. Especially, for peristomal recurrent cancer, regional flaps were used to cover great vessels and avoid wound breakdown after radiation therapy. When tracheal resection was performed as part of oncologic surgery, it became necessary to split the sternum in order to gain access to the mediastinum. Placement of the inferior stump of the trachea required chest flaps or regional flaps in order to secure a tracheal stoma. Myocutaneous flaps were used to obliterate large dead space and protect the great vessels. It is from the experience of oncologic surgery that experience was gained for reconstruction of the trachea for air passage using cervical skin flaps.

Surgeons using regional flaps must take into consideration factors of wound healing. Patients who have received external beam radiation therapy in the past will have progressive fibrosis with telangiectasia. Postradiated skin rarely can be used as a regional skin flap. Similarly, skin grafts placed into a radiated bed have a high incidence of infection and failure. Patients who are on corticosteroids or on immunosuppression similarly risk failure of the reconstruction from wound breakdown while patients with chronic inflammation and autoimmune disease suffer the risk of repeat stenosis from progressive wound contracture.

Local cervical flaps use the inverted cervical skin for internal lining of closure of a stoma. Large non–hair-bearing cervical flaps from the inferior aspect of the neck are obtainable from the female but may be a problem in the male. In tracheal reconstruction, the approach is similar to that of reconstruction of the cervical esophagus with the exception of need for a semirigid tube that does not collapse with inspiration. After excision of the stenosis, the tube and the end of the tracheal stoma are sutured onto the cervical flap. Subsequently, the stoma and the skin from the cervical flap are then tubed with various degrees or types of hard tissue to permit the reconstruction of a rigid tube. Regional tissue from the cervical flap is then used to construct a roof over the rigid trough. The local skin defect after construction of the skin-lined tube is closed by a second flap to accomplish external skin surface closure. The closure of the skin donor defect may be accomplished by a local rotation cervical flap or by the use of a deltopectoral flap. Although the deltopectoral flap is a highly versatile flap that has been used for esophageal reconstruction, its use in reconstruction of the lining of the trachea has been limited.

The staged procedure is classically described as a three staged procedure. The first and second stage may be combined in some patients. The first stage is the resection of the stenosis and bridging of the tracheal defect by the cervical skin flap to create a trough. The second stage is performed to create a rigid wall for the conduit for air by the insertion of titanium mesh or cartilage into the wall of the skin flap. The third stage is the closure of the trough by using the local reinforced tissue to close the “roof” of the trough and close the skin donor defect. In large defects, there may even be a fourth stage where the third stage is closed but still leaving a small tracheostomy in place for later decannulation after it is certain that the patient can tolerate removal of the tracheostomy. Clearly, some patients with extensive defects or those with major medical morbidities may complete only some stages of the reconstruction. In those cases, the patient has the benefit of speech and can be plugged with long-term indwelling internal stent. The patient is taught the care for indwelling long-term T tube and the rest of the reconstruction is delayed, sometimes indefinitely.

Stage I

Resection of the Stenosis Followed by Skin-Lined Trough Creation

The patient is placed in a supine position with the indwelling endotracheal tube sutured downward. The anesthesiology team is on the patients left side. The tracheostomy tube is removed and replaced with an anode tube. The anode tube is sutured in the midline on the sternum with two 2-0 silk sutures with a 2- to 3-cm distance of endotracheal tube to the stoma. The cuff is prepped into the wound. The above maneuver is to allow the surgical team to remove and replace the endotracheal tube at will during the operation. The surgical team is at the head and each side of the neck. The prep incorporates the head, neck, and any local flaps that may be anticipated to do the resection and the first stage of the reconstruction. If the plan is to insert rib cartilage at the time of the first stage, the right chest over the lower costal cartilage is also prepared. One goes from the clean to the dirty operative site. So before the resection and insertion of the costal cartilage graft, the costal cartilage graft would be harvested and set aside for later use.

Planning of the Incision

Most of the patients with tracheostomy dependence and tracheal stenosis will already have a hypertrophic scar in the midline. When the segment of stenosis is long, a vertical incision is preferred to perform the resection. In some selected cases, two parallel horizontal incisions can be used if the skin in the midline is healthy. This requires an exact knowledge as to the size of the defect to be lined. It also makes it a bit more difficult to do the resection. For this reason, the majority of tracheal resections are done with a vertical incision. After the tracheal resection is complete and the size of the defect is known, the cervical advancement flap is designed and completed. At the end of the resection of the stenosis, a double cervical advancement flap from each side is used to suture together on top of the cervical esophagus. This is usually not a problem by simple advancement since the trachea has been resected. To achieve a tension-free closure, a Burroughs triangle may be resected as part of the flap design (Fig. 28.1).

FIGURE 28.1 Incision for the advancement flap and resection of the poor quality skin and the tracheal stenosis. The final design of the cervical advancement flap should be created after the resection is complete.

Resection of Stenosis

Resection of stenosis is done by resection of the abnormal skin and the scarred trachea. It is critical to resect the abnormal skin and reach healthy tissue both at the skin level and the trachea. In the trachea, it is usually necessary to resect the entire tracheal stoma in order to reach healthy tissue. This may need dissection behind the sternum, and the cervical trachea must be mobilized adequately as in a tracheal resection and anastomosis. Healthy, granulation-free tissue must be reached both proximally and distally in order to become the two ends of the new tracheal conduit (Fig. 28.2.)

FIGURE 28.2 Resection of the stenosis from the cervical tracheal stenosis.

Creation of the Flap

The distal tracheal stump is secured by sutures to the skin of the neck at the inferior end of the incision. The skin of the neck that is sutured to the inferior wall of the trachea may need to have the adipose tissue removed so that full-thickness skin is advanced without tether. The angulations of the trachea should not be disturbed by the suture and kinking of the trachea should be avoided. 4-0 Vicryl suture is used for this purpose.

Bilateral cervical advancement skin flaps are now created and advanced to the midline. The size of the skin flap should be just enough to fill the tracheal defect without tension. The skin advanced to create the new lining of the trachea should be full thickness and should not include platysma muscle. Therefore, the distal 2 cm of each flap is thinned out until only the skin is present. The distal end of the flap is trimmed of excessive adipose tissue such that the skin flap that is laid down is skin on muscle (Fig. 28.3).

FIGURE 28.3 Bilateral cervical skin advancement flaps are created and advanced into the tracheal defect. Thinning of the cervical flap at the most medial 1 cm of the flap to a full-thickness flap to line the trough is nec¬essary to create the trough.

If the posterior tracheal wall is intact, the skin is advanced as a bilateral cervical advancement flap. The skin is sutured to the membranous portion of the trachea using 4-0 Monocryl. If there is complete stenosis and a complete relining of the trachea is necessary, the skin flaps are approximated in the midline using a 4-0 Vicryl. Sutures are buried, so there are no knots in the lumen side.

Several tacking sutures are placed on to the cervical advancement flap against the sternomastoid muscle. This reduces the tension on the cervical skin flaps and allows the new tracheal skin trough to be formed around a stent. The proximal and the distal ends of the trachea are sutured to the horizontal portion of the cervical flap. It is important that the skin flap lies flat and the skin and tracheal tissue make a smooth transition without redundancy of the skin.

Insertion of the T-tube stent for maintenance of the trough packing is done last (Fig. 28.4). Penrose drain is placed under the flap for drainage. Soft Silastic T-tube or finger cot packing is used. The finger cot pack is made by using iodoform gauze packed into a no. 8 finger cot glove and coated with antibiotic ointment. The finger cot is then sutured into the skin flap so as to create the trough by using a Prolene suture through the top and bottom of the skin flap and pulling the flaps to each other. The Prolene is placed through the top of the finger cot so as to keep the finger cot to prevent displacement. Two sutures secure the packing in place and keep the stent in place while maintaining the trough. The tracheostomy is used to replace the endotracheal tube at the end of the case.

FIGURE 28.4 A T tube or a Montgomery laryngeal stent is placed into the defect and secured in order to create and allow the trough to mature.

Stage II

Stage II is done by inserting the cartilage or titanium mesh for hard tissue reconstruction.

Once the flap has matured, the patient is brought into the operating room for the second stage. At least 6 weeks should elapse after the first stage for the trough to mature and the flap to revascularize. This procedure can be done under local anesthesia and uses titanium mesh inserted below the skin to make the lateral wall of the new trachea. Alternatively, cartilage from the ear or costal cartilage can be used. This depends on the surgeon’s preference.

The skin over the skin flap is infiltrated with lidocaine. The strips of titanium (1.3-mm mesh screen, Synthesis, West Chester, PA) are cut into 8 mm × 4-mm strips. Several 5- to 7-mm incisions are made over the top of the trough and the skin is elevated as several tunnels for the placement of the mesh. Each mesh is separated from the others by 4 to 5 mm of soft tissue. It is important to create a pocket bigger than the mesh to be implanted so that during the insertion of the mesh there is no kinking of the mesh. The pocket must be created just under the skin so that there is no excessive bulk. Once the strips of titanium mesh are placed, the skin incisions are closed with 4-0 Monocryl.

Stage III

Closure of the Tracheal Defect

Central to the concept of bringing cervical skin to reline the air conduit is the building of an epithelial-lined tube that will stand up to the rigors of respiration, cough, and phonation. The final stage of the reconstruction is performed when the skin flap has returned to good perfusion along the site of the mesh. If the local skin is used for the roof of the tracheal trough, it must be thin and viable. It must also be closed with enough room for swelling to accommodate the edema of the skin flap that invariably accompanies the tubing of the flap for the final stage. Therefore, the decision as to when it is appropriate to perform the final stage is based on the evaluation of the skin and the donor site. If the skin has good perfusion and it is not edematous, it should stand up to the rigors of the final stage.

Most of the time, the surgeon will want to know if closing the tracheal stoma will cause any airway distress. One can test for this by removing the T tube and inserting a tracheostomy tube below. The stoma above the tracheostomy tube can be taped closed in order to see if there is any collapse of the newly constructed tube. One can even put in a fenestrated no. 5 Jackson tracheostomy tube ahead of time and tape the whole area closed. In this way, one can be sure if there is any other narrowing of the airway such as laryngomalacia, sleep apnea, paradoxical airway closure, or psychological barrier to decannulation. One would obviously like to be quite secure that the last stage will not result in unwanted return to the operating room for replacement of the tracheostomy tube. The final closure of the tracheostomy should therefore be done only if the first two stages have been completed successfully and all the factors that can be optimized for success have been done. Figure 28.5 shows a schematic of the closure of the skin-lined tube. Closure of the roof of the tracheal trough is done under anesthesia and is done with an endotracheal tube in place.

FIGURE 28.5 A schematic of the closure of the skin-lined tube at the last and final stage. This shows the design of the skin-lined flap used to cover the tracheal defect.

Closure with slight tracheal skin tube redundancy is the key to success. The skin flap is incised lateral to the end of the titanium mesh. Usually, a 1-cm flap is all that is necessary. The full-thickness skin flap is raised to the edge of the titanium mesh. If the titanium mesh is splayed outward too much, dissection is done sharply to go deep to the mesh. The skin flap and the titanium mesh are then raised as a composite flap. It is important not to go too deep on the dissection and to free up the entire mesh and skin as the scarring laterally gives some integrity and provides the blood supply to the flap.

On the opposite side, only the skin is incised right at the old incision for the insertion of the titanium mesh and it is elevated only enough to achieve closure with the skin flap from the other side. The skin flap is sutured over to edge of the opposite side. Closure is done with interrupted sutures with no tension. Figure 28.6 shows the design of the skin flap at the third stage prior to closure for reconstruction of the cervical trachea. Figure 28.7 shows the defect without the T tube or the Montgomery laryngeal stent in place.

FIGURE 28.6 This clinical photograph shows the design of the skin flap incision at the third stage prior to closure for reconstruction of the cervical trachea. Note that the patient has been intubated from above.

FIGURE 28.7 This clinical photograph shows the defect without the T tube or the Montgomery laryngeal stent in place.

A single cervical rotation flap or a double rotation flap is done. Design of the skin flap should be done without pinching the tubed new trachea below. A drain is placed. The key to tubing the flaps for internal lining is to maintain a rectangular airway with the rigid structural support laterally. By keeping the flaps approximated with some redundancy, postoperative edema of the flap will not compromise the airway (Fig. 28.8). Figure 28.9 shows the final coverage of the reconstruction with the cervical advancement flap to cover the skin defect after tracheal reconstruction.

FIGURE 28.8 Closure of the tracheal trough is done by rotating the skin flap and the titanium mesh to close the tracheal defect using skin supported by the titanium mesh.

FIGURE 28.9 The overlying donor skin defect is then closed by a cervical advancement flap from the contralateral side.

Decannulation is either carried out at the final stage of reconstruction or by leaving a small tracheostomy in place for later decannulation. If the patient has a well-established trough that has been occluded without a T tube in place, the third and final stage of closure is done with the tracheostomy removed. The patient is then admitted to the hospital afterward for observation of air leak and airway management. The patient is given humidified air and antitussives. Discharge is done if the patient is infection free after 1 day. In large defects of greater than 4 cm, the T tube is removed at the time of the final reconstruction and a small metal Jackson tracheostomy tube is left in place. The patient is discharged the next day with a small indwelling tracheostomy tube. Once the edema from the surgery has subsided, the tracheostomy can be capped and removed as an outpatient. The remaining small fistula can be closed under local anesthesia in the office or in the operating room once the reconstruction is complete and the absence of a need for tracheostomy is verified by capping the tube for 2 weeks. Beside more security for decannulation, the residual tracheostomy diverts the airway away from the reconstruction, prevents air leak into the cervical flap, and allows the reconstruction of a safety valve from the dynamics changes that may be experienced from coughing, swallowing, and respiration during the immediate postoperative period.

Complications after staged reconstruction can be divided into short-term complications and long-term complications. Short-term complications include edema, granulation, and infection with compromise of the airway. Long-term complications include positional stridor, skin and hair in the transposed tube, malacia of the reconstructed segment, and restenosis.

Management of Local Stenosis at the Stomal Anastomosis Site

The worst complication that occurs with this approach is the failure of the air conduit to be stable through all the requirements for the patient. Stomal stenosis and malacia is the most common problem. By keeping the reconstruction of the roof high, the chance of edema in the immediate postoperative period is reduced. This, however, increases the size of the keratin-bearing skin that is in the neck over the long term. This can result in infection and foul odor.

If the patient has severe chronic obstructive lung disease, malacia of the tissue may occur over time. This may need dynamic evaluation to assess the presence of malacia. This can be done by fiberoptic laryngoscopy with bronchoscopy or a dynamic CT scan. Management of late tracheal malacia is difficult and the use of longterm T tube should be considered.

The CO₂ laser can be used to trim local stenosis and granulation tissue. This can be accompanied by the use of Mitomycin and steroid injection. Radial dilation of the stenosis may be helpful but should be reserved for thin areas of restenosis.

In some male patients, the hair-bearing skin causes infection and disturbance due to obstruction. CO₂ laser debulking of flap may be done. In severe cases, open resection and removal of the epithelium of the flap may be necessary.

In some patients with titanium mesh, there may be extrusion of the titanium mesh into the skin. This can occur many years after the completion of the reconstruction. This can cause local irritation, and the patient must return for removal of the mesh.

Staged reconstruction of the trachea using local skin flaps should be considered when immediate end-to-end anastomosis cannot be performed. The different stages can be halted without completion to complete decannulation to allow creation of a skin-lined tube that is clean and permit lung-powered speech by internal stenting. Its utility is good in allowing the patient to go on to a clean conduit with lung-powered speech and regain quality of life without an open tracheotomy tube. With care in long-segment tube creation, thin full-thickness skin reinforced by titanium mesh or cartilage can be created to allow for a stoma-free existence.

• When creating skin flaps for the stage I, make sure the flaps are well perfused and designed on a broad pedicle.

• Meticulous stage I reconstruction will result in less granulation tissue and a better long-term result.

• If the skin flaps are not carefully sutured to the mucosa of the trachea, granulation tissue will form.

• Patients who have been previously exposed to radiotherapy may not heal well.

• Standard head and neck surgical set

SUGGESTED READING

Grillo HC. Surgical treatment of postintubation tracheal injuries. J Thorac Cardiovasc Surg 1979;78(6):860–875.

Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33(1):3–18.

Eliachar I, et al. Combined rotary door flap and epiglottic laryngoplasty for reconstruction of large laryngotracheal defects in dogs. Laryngoscope 1986;96(10):1154–1158.

Maddaus MA, et al. Subglottic tracheal resection and synchronous laryngeal reconstruction. J Thorac Cardiovasc Surg 1992;104(5):1443–1450.

Wang Z, et al. Endoscopic diode laser welding of mucosal grafts on the larynx: a new technique. Laryngoscope 1995;105(1):49–52.