INDICATIONS/CONTRAINDICATIONS

Occasionally, during tracheal resection, a length of trachea needs to be resected such that an anastomosis between the ends of the trachea cannot be completed without undue tension. The length of trachea that can be resected for such a situation to arise varies for each individual. This depends on factors such as age, body habitus, tracheal length, posture, and previous tracheal surgery. The technique for tracheal resection is described in Chapter 36 of this book. By utilizing cervicomediastinal mobilization and mild neck flexion up to 30 degrees one is typically able to resect 4 to 6 cm of trachea, or approximately seven tracheal rings. In most situations, this is sufficient for a satisfactory anastomotic result; however, in certain situations, such as resection for malignant tracheal tumors or complex stenosis; a longer resection may be necessary. In these circumstances, multiple maneuvers can be used to allow an additional length of trachea to be released and still permit an anastomosis without tension. Options include suprahyoid release, right hilar mobilization, pericardial release, and in extreme situations transplantation of the left mainstem bronchus.

The suprahyoid release was first described by Montgomery in 1974. It is most useful for resection of the upper and middle trachea. These procedures are typically attempted through a cervical or cervicomediastinal approach. The suprahyoid release contributes very little to resection of the lower trachea or supracarinal region. The additional length that is gained from a suprahyoid release is 1 to 2 cm.

Contraindications

There is no specific contraindication to suprahyoid release in patients who are otherwise candidates for tracheal resection. The deterioration of aspiration postoperatively is a possibility. Patients who undergo surgery for postintubation stenosis, especially elderly patients, typically have an element of subclinical aspiration. The evolution of aspiration in patients with postoperative aspiration is multifactorial, and the addition of a suprahyoid release may be additive but is certainly not a sole contributor. Certainly, a laryngeal nerve injury poses much more important problems. Therefore, the presence of mild aspiration is not a contraindication. Assessment with a barium esophogram and with a speech pathologist may reveal severe aspiration. If this cannot be improved before surgery, then an external breathing device such as permanent tracheostomy or T-tube may be a better option in these patients.

PREOPERATIVE PLANNING

The preoperative evaluation is the same as that for patients undergoing evaluation for tracheal resection. The evaluation is geared toward identifying the etiology of the stenosis and then identifying the level and amount of trachea that is involved and will need to be subsequently resected. A history and physical examination, radiographic imaging of the airway, and bronchoscopy are essential in the preoperative evaluation. Imaging of the trachea can include radiographs of the neck and chest and computed tomography (CT). CT is a simple test that can show the entire airway, mediastinum, and lung fields. It is absolute in patients with malignant disease. The addition of intravenous contrast also helps visualize clearly the great vessels within the mediastinum. High-resolution CT scan with three-dimensional reconstruction is helpful in providing a road map for surgical planning prior to bronchoscopy.

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