A video-assisted endotracheal suture technique for correction of distal tracheal laceration after intubation

The incidence of tracheal laceration is 1 of 20,000 intubations. The most frequently affected area is the posterior tracheal wall (membranous). Risk factors include several forced attempts at intubation, inexperience of the clinician, tracheal introducers (guidewires) that protrude beyond the tip of the tube, and emergency procedures. Surgical treatment of tracheal lacerations can be by a transtracheal suture technique or a right thoracotomy. Using the concept of minimally invasive surgical procedures, we reported the treatment of 2 patients with tracheal lacerations greater than 5 cm in the distal trachea that were treated with endotracheal video-assisted suturing using a cervical incision.     

A new technique for complete intraluminal repair of iatrogenic posterior tracheal lacerations

Tracheal laceration is a rare complication of endotracheal intubation. Early surgical treatment is mandatory in cases of pneumomediastinum with difficulty in ventilation to prevent mediastinitis and stricture. Surgical access to the posterior tracheal wall is via a right posterolateral thoracotomy, transcervical tracheotomy or tracheostomy, each of which is associated with specific morbidities. We developed a new optical needle holder consisting of a 12° HOPKINS telescope in a fixed attachment with an endoscopic needle holder to allow for complete intraluminal repair of posterior tracheal wall lacerations. Four patients were admitted with an iatrogenic tracheal laceration due to emergency intubation. In all cases, the repair of the tracheal laceration started with the introduction of a 14-mm rigid tracheoscope and subsequent jet-ventilation. Three of the tears were successfully repaired endotracheally with a running suture. In one case, the repair had to be converted to an open closure via posterolateral thoracotomy. Two patients were discharged extubated for further treatment of their underlying diseases. One patient died from a third cardiac infarction two days after the tracheal repair. We think that an exclusively endoluminal repair of longitudinal tracheal lacerations is feasible. This repair has convincing advantages including little surgical trauma, lack of scars and diminished postoperative pain.     

Postintubation tracheal tear repair by cervicotomy and longitudinal tracheotomy

BACKGROUND: Membranous tracheal lacerations are a serious complication of endotracheal intubation. Smaller tears are often better managed with a conservative treatment. Larger ruptures, especially when associated with important manifestations, need an early surgical repair. METHODS: In the last 3 years, three female patients with a posterior tracheal wall laceration, related to endotracheal intubation, underwent surgical procedure in our institution. All tracheal tears were repaired with a running suture through a small cervical collar incision and longitudinal tracheotomy. RESULTS: All surgical procedures were effective and lasted less than 1 hour. Patients were discharged on average after 5 days. Endoscopic follow-up showed a perfect repair of the tear without signs of tracheal stenosis. CONCLUSIONS: This is a reliable, quick, and safe approach to a rare but insidious complication of general anesthesia. It avoids lateral and posterior dissection of the trachea, reducing the risk of a recurrent laryngeal nerve injury.     

Intrathoracic tracheal rupture following blunt chest trauma

Intrathoracic tracheal rupture following closed chest trauma is a potentially lethal injury which can be successfully repaired if the diagnosis is made early. Dyspnoea, mediastinal emphysema and pneumothorax which do not respond to intercostal tube drainage should alert the clinician to the possibility of intrathoracic tracheal rupture. A case is described. A 17-year-old boy sustained two longitudinal lacerations of the membranous portion of the intrathoracic trachea in association with blunt chest trauma. The diagnosis was delayed because of coexisting head injury. The tracheal lacerations were successfully repaired via a right thoracotomy. The principles of management in such injuries are reviewed.     

Surgical approaches to membranous tracheal wall lacerations

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.     

Acute tracheal trauma in sheep caused by percutaneous tracheostomy

The aim of our study was to compare dilation forceps tracheostomy and sequential dilator tracheostomy in anaesthetized live adult sheep with respect to the characteristics of the stoma formed and the associated injury. We performed percutaneous tracheostomy on adult sheep randomly allocated to receive either dilation forceps or sequential dilators. Sheep were sacrificed immediately after insertion of the percutaneous tracheostomy and the tracheas dissected. Specimens were examined for site, shape and size of stoma, mucosal lacerations, and posterior wall trauma. Ten sheep had dilation forceps tracheostomy and ten had sequential dilator tracheostomy. All of the specimens were found to have cephalo-caudal mucosal tears, usually crossing tracheal rings. The dilation forceps technique was found to have a larger stoma (28.8 mm vs 24.0 mm, P=0.023). The incidence of posterior needle trauma and mucosal lacerations were common (35% and 50% respectively), but they were not statistically different between the two groups. The role of the mucosal tears in the development of tracheal stenosis is reviewed in the discussion.     

Bronchoscopic diagnosis of an extensive tracheal laceration

Tracheal lacerations resulting from endotracheal intubation are extremely rare. We report a case where the initial diagnosis was misled by the radiological findings. Our case uniquely emphasizes several issues pertinent to the management of tracheal lacerations. We review the published works on this topic and emphasize the role of fibre-optic bronchoscopy in the assessment of airway injuries before operative management.     

Tracheobronchial injuries. Conservative treatment

Tracheal lacerations are iatrogenic, localized, low impact injuries with longitudinal tears (in about 1:20,000 intubations). In contrast traumatic tracheobronchial ruptures are high velocity injuries with horizontal transections. Between 1986 and 2002, we treated 27 tracheobronchial injuries (8 bronchial 3 of them iatrogenic, 19 tracheal 17 of them iatrogenic (+1 horizontal rupture+1 tracheoesophageal stabbing)). Extension of the tears 5-12 cm. All bronchial ruptures, the tracheal rupture as well as six iatrogenic tracheal tears have been managed operatively. All the other underwent conservative treatment. Indications: (1) critically ill patients, (2) delay in diagnosis >72 h, and (3) refusal of operation. It consists in endotracheal intubation for 5-9 days. This way we prevent pressure peaks as well as retention achieving a continuous control. Conservative group: 12/13 patients survived, neither stenosis nor megatrachea. Operative group: 1 patient died (MOF), 1 postoperative stenosis (Montgomery tube for 2 months). Tracheobronchial ruptures have to be operated. Lacerations show frequently discrete clinical signs, but typical X-rays. They can be dealt with conservatively in the majority of cases as well as operatively. According to our experience, conservative treatment is safe and shows a mortality as low or lower than operative procedures.     

Treatment of iatrogenic injury of membranous trachea with intercostal muscle flap

Iatrogenic injuries of the membranous trachea are rare but potentially lethal, and most commonly require surgical treatment. Such injuries occur intraoperatively during specific thoracic surgery procedures or are associated with endotracheal anesthesia. Special technical difficulties in managing them surgically are encountered when lacerations are in proximity to the rigid rings of the trachea because of the lack of membranous tissue distal to the tear. We describe our technique used in a patient with such an iatrogenic tracheal injury during resection of invasive lung carcinoma.     

Extensive posterior-lateral tracheal laceration complicating percutaneous dilational tracheostomy

BACKGROUND: An extensive posterior-lateral longitudinal tracheal laceration is an uncommon but serious complication of percutaneous dilational tracheostomy (PDT). We report the successful management of three ventilator-dependent patients whose percutaneous tracheostomy was complicated by an extensive longitudinal posterior-lateral tracheal laceration requiring operative repair. METHODS: A retrospective review of 134 cases of PDT with concurrent bronchoscopy was performed between April 1997 and July 1999 and compared with a review of 124 cases of open tracheostomy. Tracheal lacerations were primarily repaired and augmented with intercostal muscle pedicle buttress. RESULTS: Three cases of an extensive posterior-lateral longitudinal tracheal laceration that required operative repair were reported in the PDT group. None were reported in the open tracheostomy group. The 3 patients were managed with an adult high-frequency oscillating ventilator or pressure control ventilation during the postoperative period to limit barotrauma, and all healed without evidence of tracheal leak or stenosis. CONCLUSIONS: The increasing popularity of PDT, particularly among nonsurgical disciplines, may generate an increasing number of complications requiring operative attention. Thoracic surgeons need to be cognizant of the pitfalls of PDT technique and be prepared to manage these difficult clinical scenarios.     

医用胶粘合术治疗头面部小伤口

【摘要】〓目的〓探讨医用胶在头面部裂伤中应用。方法〓选取我院急诊科550例新鲜头面部表浅创面,清洗伤口后,使用医用胶粘合创面。结果〓545例新鲜创面一期愈合。5例伤口术后开裂后二期愈合。结论〓医用胶粘合术在治疗头面部表浅创面时,具有操作简单、减轻患者痛苦、愈合后疤痕小、护理方便等优点。     

Tracheal resection and anastomosis in a mallard duck (Anas platyrhynchos) with traumatic segmental tracheal collapse

A male mallard duck (Anas platyrhynchos) presented for examination for acute respiratory distress and lethargy. The duck had experienced recurrent episodes of respiratory distress since being attacked by a raccoon the previous year, resulting in neck lacerations. Diagnostic tests, including a complete blood count, plasma biochemical analysis, radiography, and tracheoscopy, revealed a collapsed trachea. Surgical correction of the collapsed tracheal segment resulted in resection of 9% of the total tracheal length and subsequent anastomosis. Tracheoscopy performed 2 and 3 months after surgery revealed a healthy mucosa, minimal reduction of the tracheal lumen in the area of anastomosis, and minimal suture granuloma formation.     

Efficacy of fleece-bound sealing system (TachoSil®) in delayed anterior tracheal lacerations secondary to ischemic tracheal necrosis after total thyroidectomy

Thyroidectomy is one of the commonest surgical operations performed in endocrine surgery; results are generally excellent and morbidity and mortality usually are negligible. Total thyroidectomy's complication rates are low, with an overall incidence of 4.3% among experienced surgeons: the most frequent complications are vocal cord paresis or paralysis, hypoparathyroidism, hypocalcemia, haematoma and wound infection. Tracheal injury following thyroidectomy is even more rare. As reported from some authors, inadvertent tracheal injury has an incidence of 0-0.6% during thyroidectomy. Tracheal laceration (generally located in the posterolateral surface) is often recognized and repaired immediately, during the same intervention. Rarely, following a total thyroidectomy, a delayed tracheal rupture may occur secondary to an ischemic damage of the trachea. This has been described in few cases reported in literature. In this paper we report of a case in which delayed tracheal lacerations appeared 10 days after the patient underwent total thyroidectomy: a prompt surgical operation was efficient using both direct sutures of tracheal breaches and a patch of fibrinogen-thrombin coated collagen fleece covering the entire surface.     

Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity lacerations

Lacerations comprise a significant number of emergency department referrals for pediatric patients. Management of lacerations with sutures involves the use of needles and the injection of local anesthetic and represents a unique challenge in the wound management of an already distressed and frightened child. Octylcyanoacrylate, a new-generation, medical-grade tissue adhesive, has been found to be an effective alternative to replace skin sutures on virtually all facial lacerations and has been employed in low-skin tension wound management. Its use, however, has generally been avoided in the management of high-skin tension lacerations. Over the last 10 months, 32 children with high-skin tension (hand, feet, and over joints) lacerations were managed at our center by octylcyanoacrylate tissue adhesives. Skin closures and splints were applied to restrict movement of the affected area to overcome the limitation of adhesive application. Octylcyanoacrylate adhesive applied with optimal immobilization was found to be an effective method of skin closure in high-skin tension lacerations. Advantages of tissue adhesives for incision and laceration include quick application, excellent cosmetic results, patient preference, and cost effectiveness.     

Management of postintubation membranous tracheal rupture

BACKGROUND: Postintubation tracheobronchial laceration is a rare complication of general anesthesia. A renewed interest in this disorder induced us to review our experience on its treatment, focusing on the evolution of the surgical approach, and describing a technical variation of the transcervical approach. METHODS: From January 1994 to December 2002 we treated 13 patients with diagnosis of postintubation tracheobronchial laceration. The treatment was nonsurgical in 3 patients (1-cm-long tear) and surgical in the other cases. Two lesions extending to the main bronchi were repaired through a right thoracotomy as well as four lesions limited to the trachea observed before January 2001. After this date we used the transcervical approach for entirely intratracheal lesions: in three cases we performed an anterior transverse tracheotomy and in one case a transverse and midline vertical incision (T tracheotomy). RESULTS: Both conservative and surgical therapy were successful in all the cases. Two patients in the thoracotomy group had a transient right vocal cord palsy. No morbidity was observed with the cervical approach. Normal healing of the sutures was evidenced by an endoscopic follow-up 30 days later. CONCLUSIONS: In our experience nonsurgical treatment is advisable in small (length < 2 cm) uncomplicated tears. Concerning surgery, thoracotomy is indicated in tracheal lacerations extending to the main bronchi, whereas the transcervical approach is preferred for intratracheal tears because of its efficacy in reaching and suturing the lesions extending to the carina and for its limited invasiveness.     

A new approach to the management of pretibial lacerations

This paper describes a technique for the management of pretibial lacerations by deep reinforced suturing through steristrips, which are applied parallel to the wound edges. This is carried out under local anaesthesia and followed by application of gentle localised compression dressing. Typical victims of pretibial lacerations are the elderly and patients on long-term systemic steroid therapy. This suturing technique, which was used on both flap and linear lacerations, obliterates the dead space in the wound and prevents tearing of the thin, fragile skin of these patients. The dressing technique used, has a great advantage over the toes to knee pressure dressing currently used for such lacerations, because it frees the foot of bandaging and allows the patients (especially the elderly with decreased mobility) to wear their normal footwear immediately post-operatively and to maintain their normal mobility. In the total sample of 147 patients treated by this method, the average healing time was 26 days for 112 patients with flap lacerations, and 16 days for the remaining 35 patients with linear lacerations. This is significantly shorter than that reported in the medical literature using both non-operative methods and simple suturing. Moreover, none of these patients required skin grafting or hospitalisation (except for social reasons).     

Laryngotracheal Trauma: Up-to-date Report of Two Cases of a Challenging Problem

Abstract Background: Laryngotracheal trauma is still a challenging problem to the emergency surgeon. Prompt diagnosis and correct classification are mandatory in order to plan the treatment. Methods: Two particular cases of an upper airway trauma are presented. Case 1 refers to a 53-year-old woman with a blunt fracture of the thyroid cartilage. Case 2 is a 43-year-old man with a penetrating tracheal trauma and cervicomediastinal emphysema. Results: Patient 1 was treated conservatively, by intravenous fluid, antibiotics and steroids, and had a good outcome. Patient 2 had a progressive respiratory distress and underwent surgical repair of the tracheal lacerations. Follow-up examination revealed a good healing of the injuries. An up-todate information about the upper airway trauma and its management is given. Conclusion: Upper airway trauma requires a rapid evaluation and establishment of the airway. Subsequent imaging may address the correct treatment by allowing a precise classification of the injury. Long-term results may be good in the majority of the patients.     

Case reports: Iatrogenic bronchial rupture following the use of endotracheal tube introducers

Purpose

Endotracheal tube introducers are often used in difficult tracheal intubations, but they are rarely deemed responsible for airway injuries. There have been only a few reports of severe complications, such as pharyngeal perforation, mainstem bronchus bleeding, perforation of the tracheal mucosa, and tracheal abrasion associated with hemopneumothorax. Using a computed tomography (CT) scan, we illustrate two cases of non-severe airway injuries related to endotracheal tube introducers.

Clinical features

We present two cases of distal bronchial lacerations caused by introducers. The first occurrence was caused by a Muallem ET Tube Stylet (METTS) in a patient who underwent surgery for a total thyroidectomy and presented hemoptysis at suction after tracheal intubation. The second occurrence was caused by an Eschmann? Tracheal Tube Introducer (gum elastic bougie) in a patient whose trachea was intubated before a radiofrequency ablation of a single lung metastasis. There was evidence of blood on the tip of the bougie after withdrawal. In both cases, a CT scan showed a post-traumatic bronchial laceration with an acquired bronchial ectasia surrounded by ground-glass opacity due to alveolar hemorrhage. The patients had no other clinical complications, and bronchial lesions resolved spontaneously at control CT scan.

Conclusion

These two cases show that airway damage related to endotracheal tube introducers may not be exceptional. It is not unusual to have some blood on an airway management device, and the rate and severity of these lesions are unknown. However, damage to the airway can be avoided by adapting preventive techniques during tracheal intubation.     

Posterior wall laceration of the thoracic trachea: the transcervical–transtracheal approach

A large membranous wall laceration of the thoracic trachea was surgically treated. The surgical approach consists on a low collar incision followed by a longitudinal tracheotomy. The membranous tear was repaired with a running suture and tracheotomy sutured with interrupted crossed stitches. The procedure was effective and endoscopic follow-up showed a perfect healing process with no signs of tracheal stenosis. This new technique proved to be a reliable, quick and safe procedure, which allows to repair membranous lacerations as far as the carina, avoiding thoracotomy.     

Bedside Percutaneous Tracheostomy: Prospective Evaluation of a Modification of the Current Technique in 100 Patients

Percutaneous dilatational tracheostomy (PDT) is being increasingly used. Concerns have been raised as to its safety, especially when it is done at the bedside. A prospective evaluation was conducted of 100 consecutive, unselected critically ill patients with PDT. The mean intensive care unit (ICU) stay before PDT was 12 days. One surgeon performed PDT alone (5 cases) or assisted residents (95 cases) in all operations; 84 were performed at the ICU bedside. Only the first six patients were taken to the operating room solely for tracheostomy. A modified technique was used: (1) the endotracheal tube was left in place during sequential dilations; (2) dilators were inserted in a 60-degree cephalad orientation to the skin and directed caudally after penetration of the anterior tracheal wall; (3) a digit was inserted through the tracheal opening to guide withdrawal of the endotracheal tube to the level of the vocal cords; and (4) size 8 tracheostomy cannulas were inserted over 28F dilators. The average time from skin incision to insertion of the tracheostomy tube was 12 minutes (< 10 minutes, 41 patients; 10 to 15 minutes, 37 patients; > 15 minutes, 22 patients). Sixty-five percent had unfavorable anatomic conditions due to spinal precautions or diffuse neck edema. Postoperative complications occurred in four patients; surgical emphysema after tracheal lacerations in three, cannula dislodgment in one. All complications were successfully managed without an operation by tube exchange (n= 3) or observation (n= 1); there was no procedure-related mortality. Forty patients were available for long-term follow-up (6–18 months after tracheostomy) by telephone; one had persistent hoarseness without respiratory difficulty. We concluded that bedside PDT is safe and easy to teach when performed with a technique that ensures correct instrumentation.