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J Thorac Cardiovasc Surg 2000;120:115-118
© 2000 The American Association for Thoracic Surgery

GENERAL THORACIC SURGERY

Surgical approaches to membranous tracheal wall lacerations

From the Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Pisa, Italy.

Address for reprints: Carlo A. Angeletti, MD, Division of Thoracic Surgery, Cardiac and Thoracic Department University of Pisa, Via Paradisa, 2, 56124—Pisa, Italy (E-mail: c.angeletti{at}dc.med.unipi.it ).

	Abstract

Top Abstract Introduction Patients and methods Results Discussion References

 
Background: Smaller postintubation tracheal tears are often misdiagnosed and, when recognized, they are effectively managed in a conservative fashion. Large membranous lacerations, especially if associated with important manifestations, require immediate surgical repair. We report our experience over the past 7 years.
Methods: From 1993 to 1999, 11 patients with a postintubation posterior tracheal wall laceration were treated in our institution. One patient was male and 10 were female, with a mean age of 68 years. Ten patients underwent orotracheal intubation under general anesthesia for elective surgery, 4 of whom were treated with a double-lumen selective tube. One patient underwent emergency intubation because of anaphylactic shock. In 9 cases the tracheal tear was promptly repaired, by way of a thoracotomy in 4 and by way of a cervicotomy and longitudinal tracheotomy in 5. In 2 cases the tear was small and was consequently managed conservatively.
Results: All surgical procedures proved effective in repairing the laceration, and there was no mortality or morbidity in the perioperative period. Early and late endoscopic follow-up showed no signs of tracheobronchial stenosis.
Conclusions: When repair of membranous tracheal laceration is required, the surgical approach should be through a thoracotomy if the tear involves the distal trachea, a main stem, or both, and through a cervicotomy when the laceration is located in the proximal two thirds of the trachea. Performing a longitudinal tracheotomy to reach and suture the posterior tracheal wall is a reliable, quick, and safe procedure, and it avoids lateral and posterior dissection of the trachea.

	Introduction

Top Abstract Introduction Patients and methods Results Discussion References

 
Posterior tracheal wall laceration is a rare and serious complication of general anesthesia. It may occur in association with apparently uneventful tracheal intubations, and the first signs of its presence generally are hemoptysis and subcutaneous emphysema. ^1-4 Diagnosis is usually made by means of bronchoscopy, which also obtains information about certain features of the lesion, such as site, length, and depth. Although smaller and superficial tears may heal spontaneously, deeper and longer lacerations, especially if the patient has symptoms, require prompt surgical repair. ^1,4,5 We review 11 cases of membranous tracheal laceration consequent to endotracheal intubation that we have treated during the past 7 years. Nine were immediately repaired, 4 through thoracotomy and 5 through a simple and safe cervical approach recently reported. ⁴

	Patients and methods

Top Abstract Introduction Patients and methods Results Discussion References

 
From March 1993 to March 1999, 11 patients received our attention because of suspicion of membranous tracheal wall rupture related to endotracheal intubation. Ten patients were female and 1 was male, with a mean age of 68 years (range, 35-92 years). The orotracheal intubation related to the tear was carried out under general anesthesia for elective surgery in 10 patients and as an emergency procedure as a result of anaphylactic shock in 1 patient. In 4 patients intubation was with a double-lumen selective tube.

A tracheal tear occurred during the upper lobectomy for lung cancer in 1 case and during the removal of a giant posterior mediastinal goiter in the another, both operations being performed through a right thoracotomy. In these patients the anesthesiologist reported recurrent episodes of desaturation and bleeding from the tracheal tube. Meanwhile, during the operation, the surgeon observed the appearance of mediastinal emphysema. A bronchoscope was immediately inserted through the double-lumen tube, and it revealed a juxtacarinal membranous tracheal tear involving the right main bronchus in 1 patient and the left main-stem bronchus in the other. In both cases surgical repair was directly performed through the same right thoracic incision.

In the other 9 patients the most common signs and symptoms were hemoptysis, dyspnea, and subcutaneous emphysema (Table I). These symptoms usually developed just after extubation and always within 12 hours of extubation. Chest radiography revealed a pneumomediastinum in 7 patients. Bronchoscopy confirmed the clinical suspicion in 8 patients. In 1 patient the diagnosis was made during bronchial aspiration. Two patients, both of whom had small mucosal tears (ie, not gaping during respiratory air flow) and no signs or symptoms of full-thickness involvement of the tracheal wall (eg, subcutaneous emphysema and pneumomediastinum), were treated conservatively.

	Results

Top Abstract Introduction Patients and methods Results Discussion References

 
All surgical procedures proved effective. There was no mortality or morbidity involved. In the 2 patients in whom the tracheobronchial tear was discovered after the initial operation, the average duration of the surgical procedure through an elective right thoracotomy was 110 minutes. On the other hand, the mean time required for the cervicotomy procedure was less than 1 hour. All patients were immediately extubated at the end of the surgical procedure.

The postoperative course was uneventful in all cases, and the patients were discharged on average after 5.7 days (range, 3-8 days). The mean postoperative hospital stay was 4.6 days in the 5 patients who underwent the cervical approach (range, 3-6 days). Endoscopic follow-up after 10, 30, and 60 days showed a perfect healing process of the laceration in all cases, with no symptoms or signs of tracheal or bronchial stenosis.

	Discussion

Top Abstract Introduction Patients and methods Results Discussion References

 
Tracheal laceration is a rare complication of general anesthesia, which generally involves the posterior membranous wall. The relatively high incidence in our series (11 cases in 7 years) may be explained by the fact that ours is a tertiary referral center for tracheal surgery in our country. Similar to our experience, in the literature tracheal lesions have been reported to be associated with both double-lumen selective and single-lumen intubations, and women seem to be more prone to the complication than men. ^1,2,4-6 Many factors may be responsible for producing the lesion: repeated attempts at a difficult intubation, ^7,8 as in one of our cases; the presence of tracheal abnormalities ⁹; and overdistention or rupture of the tube cuff. ^5,10 However, many times a tracheal laceration occurs after an intubation carried out with no apparent difficulty, ^1,2,4 as in the other cases of our report.

The diagnosis is not a difficult one if the physician keeps in mind such a possibility. The first signs often appear immediately after the extubation or within the first 12 hours. ^1,4 These symptoms are hemoptysis; subcutaneous emphysema of the head, neck, and upper chest ^1,4; and, in severe cases, dyspnea and cyanosis. ¹¹ Chest x-ray films usually show a pneumomediastinum, as in 7 of our patients, and in some cases, especially when the laceration is in the lower part of the trachea or has extended to one main bronchus, a pneumothorax. ^12,13

Tracheobronchoscopy can confirm the diagnosis and establish the location and the extent of the tear, thus allowing the surgeon to plan the correct surgical approach. ² When a tracheoesophageal fistula is suspected, an esophagoscopy is also required. ¹⁴

In the literature several isolated cases of postintubation tracheal tears managed successfully by means of conservative therapy have been reported. ^6,11,15 They were mainly small tears in patients in stable condition with at most minimal and nonprogressive manifestations, such as subcutaneous emphysema, pneumomediastinum, and pneumothorax. We likewise treated 2 patients in our series with these same features. In these cases endoscopic findings, rather than clinical manifestations, have influenced our strategy of treatment. We believe that only short and superficial tears may spontaneously heal without a significant risk of early and late complications.

Still, definitive single-stage surgical repair remains the preferred choice of treatment in most cases of tracheobronchial laceration. It should be performed as soon as possible to avoid both early complications, such as descendent mediastinitis, and belated sequelae, such as tracheal stenosis. ^2,3,5,12

Juxtacarinal membranous tracheal lacerations are generally managed through a right thoracotomy, especially if they involve a main bronchus. This was our approach in 4 patients with a tracheobronchial lesion. On the other hand, when the tear involves the proximal two thirds of the posterior tracheal wall, a cervical approach would be more fitting, ¹⁶ as in the case of the remaining 5 patients in our report. Traditional technique would provide for a left cervicotomy, sometimes extended to a sternal split, followed by a lateral and then posterior paratracheal dissection to isolate the trachea and to reach the membranous wall for suturing. ^5,16 In contrast, in all our patients who underwent the cervical approach, we used the technique reported by Jacobs in 1978 and recently revised and modified by Angelillo-Mackinley, ⁴ with a slight twist on the airway management. Jacobs and colleagues ¹⁴ first reported 2 cases of posterior tracheal laceration as a complication of tracheostomy that were promptly repaired with a single-layer closure through the same tracheotomy. In a case report, Angelillo-Mackinlay described suturing a tear through a cervical mediastinoscopy–like approach and making a vertical incision in the anterior wall of the trachea. His patient was intubated with a small single-lumen tube retracted laterally to allow the suturing of the tear. Our approach was almost the same, but we substituted the orotracheal tube with a smaller one inserted into the distal trachea across the field of operation, as is usually done for tracheal resection and reconstruction. This allowed us to easily alternate suturing with ventilation and afforded us optimal maneuverability in repairing the distal end of the laceration when the tube was removed and the patient was in an apneic state. Moreover, during this procedure, we realized that it may be possible to repair tears extending all the way to the carina without the necessity of a sternal split.

In conclusion, we concur with those authors who opt for conservative management in patients with minimal and nonprogressive symptoms and signs and with small tears that do not gape during respiration. However, these cases are the exception and not the rule. Early surgical repair is the mainstay of treatment; it offers good results, and prognosis generally depends on the underlying disease and not on the injury itself. When surgical repair is required and the tear is above the carina, we suggest the transcervical-transtracheal approach. This minimally invasive technique, although very quick and easy to perform, provides excellent results and avoids lateral and then posterior dissection of the trachea (necessary to reach the membranous tracheal wall) and consequent exposure of the recurrent laryngeal nerve to injury.

	References

Top Abstract Introduction Patients and methods Results Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alfredo Mussi Gianfranco Menconi Carlo Alberto Angeletti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mussi, A. Articles by Angeletti, C. A. Search for Related Content PubMed PubMed Citation Articles by Mussi, A. Articles by Angeletti, C. A.