INDICATIONS/CONTRAINDICATIONS

The trachea traverses the entire neck and enters the chest through the thoracic inlet where it turns posteriorly, eventually occupying a posterior location within the mediastinum. This makes access to the entire trachea through one approach difficult. It is also a rigid tube with very little flexibility; hence, resection of great lengths poses challenges to producing a tension-free reconstruction. However, ensuring a tension-free anastomosis is amongst the most important factor for acceptable postoperative outcome after tracheal resection.

Cantrell and Folse determined a biologic dangerous tension limit of 1,700 g for ensuring the integrity of the tracheal anastomosis. The length of trachea that can be resected using cervicomediastinal mobilization and neck flexion varies with each individual; however, it ranges from 4 to 6 cm, or approximately seven tracheal rings. During certain situations, greater lengths of trachea need to be resected. When such situations arise, mobilization of both tracheal ends through different release maneuvers is employed for ensuring a tension-free anastomosis. Pearson et al. performed pericardial hilar release in 47% of tracheal resections in a series of 32 patients.

While laryngeal release is commonly used in upper tracheal resections, the hilar mobilization through pericardial release maneuvers is more helpful in lower tracheal, carinal, and mainstem bronchial procedures. However, hilar release maneuvers are rarely performed for benign stenotic lesions and are more often reserved for patients with malignant lesions who can tolerate extensive surgery. In the largest series of carinal resections published in 1999, Grillo et al. described 143 cases, performing release maneuvers in 64 patients. These consisted of 49 hilar pericardial releases, 3 laryngeal releases and both maneuvers in 12 cases.

A lengthy midtracheal lesion or extended microscopic disease that was not anticipated preoperatively might necessitate mobilization of both ends of the trachea. In some cases the introduction of a previous tracheostomy might add to the lengthy stenotic segment.

In carinal resections the left mainstem bronchus is usually fixed by the aortic arch and most of mobilization comes from the tracheal side to ensure an end-to-end anastomosis between the trachea and the left mainstem bronchus. In this case, if the gap (resected trachea) exceeds 4 cm, tension will be exerted on the anastomosis even with maximal release maneuvers. In such cases, Grillo et al. demonstrated that hilar release is mandatory, with subsequent anastomosis of the right main bronchus to the trachea and anastomosis of the left main bronchus either to the right mainstem bronchus or the bronchus intermedius.

Contraindications

Contraindications to performing pericardial release maneuvers during tracheal resections are mainly technical. Excessive fibrosis resulting from previous surgery or mediastinitis/pericarditis that obscures the anatomy renders these maneuvers more risky. Excessive inflammation from recently failed tracheal reconstruction can result in a more technically challenging procedure and bleeding can rarely be problematic during hilar release. Some patients will not tolerate more extended morbid incision added solely for the purpose of hilar release. In these patients, a two-staged operation might offer another option. Video-assisted thoracoscopic surgery (VATS) pericardial hilar release is also possible in experienced hands.

PREOPERATIVE PLANNING

Evaluation of the extent of tracheal disease is of enormous value in planning tracheal resection. The decision to proceed with a release maneuver is dependent on the length of trachea to be resected. The length of trachea that is possible to resect using cervicomediastinal mobilization and without extensive release maneuvers is up to 6 cm. This varies depending on factors such as age, body habitus, posture, and previous tracheal surgery. Suprahyoid release techniques add approximately 1 to 2 cm of length that can be resected and are most useful for resections of the upper and midtrachea. Suprahyoid release adds very little to resections of the lower trachea and carina. The technique for suprahyoid release is discussed in Chapter 31. Pericardial hilar release maneuvers can allow additional resection of up to 3 cm during lower tracheal resections. With the aid of release maneuvers, more than half of the trachea can be resected.

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