Tracheal Resection and Reconstruction

Cross-field airway handover - when the trachea is divided the surgeon passes a sterile armoured tube into the distal segment and ventilates on a second circuit, then hands it back for the anastomosis. Agree the sequence, the tubes and who holds what before induction.

Imaging and endoscopy first - look at the CT and the bronchoscopy yourself. Lesion length, distance from the cords and from the carina, and the narrowest diameter decide the tube you choose and where its tip has to sit. A reported grade is not enough.

Sedative premedication - a patient with stridor or a critical lesion gets none. Respiratory drive and posture are holding that airway open, and some cannot lie flat at all. Sedate in the anesthetic room and you lose the airway with nobody scrubbed.

Induction with a tight stenosis - keep them breathing. Sevoflurane in oxygen with slow deepening preserves an airway you cannot yet rescue. A fixed obstruction usually tolerates positive pressure through a proximal tube; a dynamic one may collapse.

Rigid bronchoscopy at the head - the surgeon is scrubbed and in the room before you touch the airway, ready to pass a rigid scope past the lesion or open the trachea below it. Work to current difficult airway guidance rather than a fixed default plan.

Tubes on the trolley - uncut tubes down to 5 mm, a range of blades and an armoured tube for the distal segment. Getting a usable caliber past the lesion may take gradual dilation with successive tube sizes or with the rigid scope.

Relaxant timing - do not paralyze an airway you have not secured and ventilated. Once the tube is past the lesion and ventilation is proven, full relaxation is what keeps the patient still while the surgeon works on an open trachea.

Infusions over vapor - the tube is changed and disconnected repeatedly, so inhaled agent is delivered unreliably and vents into the room. Propofol and remifentanil infusions hold depth through the open phase and blunt cough at the end.

Ventilation during the open phase - if a distal tube crowds the field, the options are jet ventilation through a small catheter, apnoeic oxygenation between suture runs, or rarely bypass. Lesion level, access and open-airway time decide.

Oxygen and cautery - diathermy on an airway carrying a high inspired oxygen fraction is the whole fire triad. Bring the oxygen down to the lowest the saturation allows before the surgeon cuts into the trachea, and say out loud when it is down.

Lines in the left arm - retraction can compress the innominate artery and damp the right side. Site the arterial line and drip on the left so pressure and infusion survive those periods, and leave a right-hand oximeter on to show when it happens.

Neck flexed at closure - the anastomosis is tied with the neck flexed and often held there by a chin-to-chest suture for days. Extending that neck can pull the repair apart. Say it at every handover and protect it through transfer and recovery.

Extubate in the operating room - a tube and positive pressure sit on a fresh suture line, and reintubation means passing a tube blind toward the anastomosis. Wake them enough to protect the airway and take it out before bucking starts.

Cord function before leaving - both recurrent laryngeal nerves lie in the dissection. Check cord movement by laryngoscopy before the patient goes; the voice can sound normal with bilateral palsy, which shows up as stridor rather than hoarseness.

Most tracheal resections are done for stenosis after prolonged intubation or a previous tracheostomy; the rest for primary tumor (adenoid cystic or squamous carcinoma), external trauma, radiation injury, granulomatous disease or idiopathic subglottic narrowing. The narrowed segment is fixed, so flow is limited in both directions and does not improve with bronchodilators, and the picture is often mistaken for asthma until the lumen is critically small. Up to about half the trachea can be removed and the ends joined primarily, though longer resections need laryngeal and hilar release to reach without tension. Upper and mid-tracheal lesions are approached through a collar incision; lower tracheal and carinal lesions need a sternotomy or a right thoracotomy. The anastomosis will not tolerate tension, which is why the neck is held flexed afterwards.

Assessment - CT and bronchoscopy define the length of the lesion, its distance from the cords and the carina, and the residual lumen; that determines the approach and the tube that will fit.

Approach - transverse low collar incision for upper and mid-tracheal disease; cervical incision plus sternotomy, or a right thoracotomy, for lower tracheal and carinal lesions.

Mobilization - the trachea is freed anteriorly and posteriorly, with circumferential dissection confined to the segment being removed so the blood supply of the remaining trachea is preserved. The recurrent laryngeal nerves are protected in the lateral dissection.

Division - the trachea is opened, the oral tube is withdrawn into the proximal trachea and a sterile armoured tube is passed into the distal segment across the operative field.

Resection - the diseased rings are excised back to a healthy complete ring of cartilage above and below.

Anastomosis - interrupted absorbable sutures are placed but left untied; the field tube is removed, the oral tube is advanced across the repair, and the sutures are tied with the neck flexed to take off tension.

Closure - a chin-to-chest suture holds the neck flexed for several days, a drain is placed, and the patient is extubated wherever possible.

The airway watch does not end at extubation - edema at the suture line, a nerve palsy or a neck hematoma can all narrow the airway over the following hours. Nurse the patient where the airway can be reassessed and where reintubation would be a planned senior fiberoptic event rather than an emergency.