Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis Paolo Macchiarini, MD, PhDa, Jean-Philippe Verhoye,

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Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis Paolo Macchiarini, MD, PhDa, Jean-Philippe Verhoye, MDb, Alain Chapelier, MD, PhDb, Elie Fadel, MDb, Philippe Dartevelle, MDb The Journal of Thoracic and Cardiovascular Surgery Volume 121, Issue 1, Pages 68-76 (January 2001) DOI: 10.1067/mtc.2001.111420 Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Chest radiograph of a patient with a postintubation subglottic stenosis showing an extremely overinflated cuff of the orotracheal tube, a usually common scenario in the histories of these patients. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Diagram showing the U-shaped cervical incision used to approach subglottic resections. Inferiorly, the incision can be prolonged vertically just below the manubrial notch to include an upper median sternotomy. The management of the tracheal stoma is done as in other tracheal operations. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Operative view after careful vascular-sparing dissection of the airway from the level of the inferior border of the cricoid ring above and the inferior limit of the stenosis below. Dissection is maintained against the outer surface of the airway to protect the recurrent laryngeal nerves, which are frequently obscured by peritracheal dense scarring. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 Operative view showing division of the trachea below the damaged area and distal ventilation through insertion of an armored endotracheal tube in the distal tracheal segment by using sterile connections across the operative field. Arrow indicates inferior border of the cricoid arch. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Diagram showing the lines of proximal and distal transections. The proximal division starts anteriorly either at the inferior border of the thyroid cartilage or the superior border of the cricoid arch, depending on the distance between the stenosis and the vocal cords. It extends posteriorly and inferiorly through the lower margin of the cricoid plate below the point of entry of the recurrent laryngeal nerves. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 6 Operative view proximally showing the complete resection of the anterior cricoid arch and distally showing the distal ventilation through an armored endotracheal tube. The resection of the anterior cricoid was not subperichondrial, and this is highlighted in the insert. This 30° to 40° oblique cricoidectomy gives a maximal overture at the subglottic level, where the thyrotracheal anastomosis can be made safely. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 7 A, Diagram showing the posterior continuous 4-0 polydioxanone suture placed between the remnants of the posterior mucosa (proximally) and the healthy trachea (distally). This running suture usually picks up the residual healthy mucosa. For very proximal stenoses, we do use this suture, even on the diseased mucosa, high in the posterior larynx because the big cross-sectional cricotracheal diameter resulting from the oblique incision allows the regression of the inflammatory mucosal phenomena and has no long-term sequelae. One might, however, avoid using the running suture on the bare posterior cricoid plate, and the posterior flap, as described by Grillo and colleagues1 would then be the solution. B, Operative view after completion of the anterior anastomosis made here between the uppermost tracheal cartilage and lower margin of the thyroid cartilage with interrupted 3-0 polyglactin sutures, the knots of which are tied outside. When present, the air leakages are usually seen in the middle of the anterior anastomosis, are minimal, and are treatable conservatively by simply opening the tissue layers overlying the air leakage. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 8 Preoperative (A) and postoperative (B) operative tomograms of a patient undergoing a subglottic resection and anastomosis. A, The stenosis was 1.5 cm below the vocal cord. B, The postoperative tomogram shows the direct anastomosis between the uppermost healthy trachea and the thyroid cartilage, as per Fig 7, B . The Journal of Thoracic and Cardiovascular Surgery 2001 121, 68-76DOI: (10.1067/mtc.2001.111420) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions