How To: A Novel Hybrid Procedure Combining Resection and Tracheoplasty for Complex Laryngotracheal Stenosis

INTRODUCTION

Open surgical treatments for laryngotracheal stenosis in adults commonly include primary resection with anastomosis, such as cricotracheal resection (CTR)/tracheal resection (TR) or staged laryngotracheoplasty (LTP). The indications, techniques, advantages, and disadvantages of these two approaches differ. Airway resection with primary anastomosis is optimal for shorter-segment (<3 cm), high-grade (Grade 3–4) stenosis, and has maximum potential for creating normal luminal diameter. Additional benefits include a single-stage procedure not requiring stent placement; however, a tension-free anastomosis is challenging in long-segment stenosis (>4 cm). High anastomotic tension may lead to anastomotic dehiscence, which is a serious and possibly fatal complication. Other risks include glottic airway edema or vocal fold paralysis due to proximity of anastomosis to the vocal folds or injury to the recurrent laryngeal nerves (RLN), respectively.

LTP is an alternate technique for open airway management when the stenosis is not amenable to primary resection and anastomosis. LTP is preferred in cases of long-segment or multilevel stenosis, infraglottic involvement, or when primary resection is not possible due to excessive anastomotic tension. LTP does not require dissection lateral or posterior to the trachea, thus decreasing the risks of RLN or esophageal injury; however, LTP is a multistage surgery that often necessitates maintaining a stent such as a T-tube between stages. Additional limitations include decreased efficacy in addressing high-grade stenoses, risk for persistent anterior wall collapse, and poor mucociliary clearance.

In this report, we highlight a unique hybrid surgery technique combining the respective benefits of both primary resection with anastomosis and LTP. The hybrid procedure is best suited for the management of complex long-segment or multilevel airway stenosis that is not optimally treated with either procedure alone. In the proposed technique, high-grade subglottic or proximal tracheal stenosis is treated with resection and anastomosis, and the remaining tracheal stenosis, the tracheostoma site, or tracheomalacia is treated with the LTP technique. This leads to better results than using either surgical approach individually and successful long-term decannulation of the tracheostomy-dependent patient.

METHODS

The hybrid procedure commences with airway assessment using suspension direct laryngoscopy and bronchoscopy under general anesthesia. The patient is ventilated via a flexible endotracheal tube through the existing tracheostomy site. The length and severity of stenosis are determined to plan for resection and anastomosis.

The neck is prepared and draped in standard fashion for open-airway surgery. A horizontal cervical incision incorporating the existing tracheostomy is made. Subplatysmal flaps are raised from the thyroid cartilage to the clavicle. Dissection is performed in the midline to divide and lateralize the strap muscles. The thyroid gland is divided in the midline and the laryngotracheal complex is skeletonized from the thyroid cartilage to the sternal notch. Substernal pre-tracheal dissection is performed bluntly with finger dissection, or mediastinoscopy when needed, to mobilize the trachea.

Intraoperative flexible bronchoscopy is performed to identify the superior level for airway resection. Ideally, the airway stenosis is managed by primary resection and anastomosis. The decision to perform a hybrid procedure depends on the surgeon’s comfort and experience with long-segment resection and mobility of the trachea for tension-free anastomosis. If tension-free anastomosis cannot be achieved after tracheal mobilization and other release maneuvers, a hybrid procedure is performed. The high-grade stenosis is resected and anastomosed, and the remaining stenotic tracheal segment is treated with tracheoplasty.