Anterior Mediastinal Tracheostomy

This video demonstrates construction of a mediastinal stoma after laryngotrachiectomy using a pectoralis major myocutaneous flap. The procedure was performed in a 53-year-old patient who had a past history of squamous cell carcinoma of the right piriform sinus treated by supraglottic hemipharyngolaryngectomy. In the postoperative course, a right pectoralis muscle flap was used to close a pharyngocutaneous fistula. The patient underwent postoperative radiation therapy. Later on, he presented with a metachronous subglottic carcinoma. The distal trachea was macroscopically tumor free for 7 cm up to the carina.

With the patient positioned supine, the cervical and median skin incision is drawn, while the oval-shaped skin paddle of the flap is outlined along its vascular axis that follows a line from the shoulder tip to the xyphoid process. The approach is a combined collar and median incision, followed by a U-shaped subtotal manubrial resection (with preservation of the adjacent paired rib cartilages) and partial bilateral clavicular head removal, performed only when cervical tumor dissection determines the need for a retrosternal division of the trachea. This limited bone resection allows sufficient access to achieve laryngotrachiectomy associated with subtotal thyroidectomy and cervical and mediastinal lymph node dissection. After cannulation of the distal trachea with a curved tracheostomy tube for proper across-field ventilation, the entire left pectoralis major muscle with the oval-shaped skin paddle is elevated and pedicled on its acromiothoracic blood supply, and then rotated over the cervical and upper mediastinal region. In this patient, since the remaining trachea is long enough to construct a standard stoma above the innominate artery, the distal trachea is passed through a muscular fenestration performed across the inferior part of the pectoral muscle. Thus, the muscle fixed to the circumference of the distal trachea creates a bulky interposition between the tracheal rings and the innominate artery. The tracheal membrane is sutured to the inferior margin of the skin island, while the tracheal ring of the stoma is sutured to the skin overlying the remaining sternum inferiorly. Suction tubes are placed to drain the mediastinum and the neck region. The collar, median incision, and chest donor defect are closed primarily, the latter by mobilizing the lateral chest flaps. Finally, the mediastinal stoma is cannulated with a low-pressure cuff cannula.

After tracheal resection, if the residual trachea is too short to construct a standard stoma, it is relocated below the innominate artery and up to the left innominate vein. Division of the latter is occasionally needed to create sufficient space for the stoma. Thus, pectoralis major myocutaneous flap harvesting might be routinely scheduled on the right side whenever possible. Finally, in the case of relocated stoma, rotation of the flap achieves the muscle interposition between the tracheal membrane and the innominate artery.

This technique has several advantages. First, the limited bone resection prevents a postoperative flail chest phenomenon with the risk of respiratory distress or late poor cosmetic result. Second, the pectoralis major myocutaneous flap provides bulky muscle to fill the dead space after resection and protect the innominate artery from erosion. Last, the cutaneous paddle provides additional coverage, reducing suture line tension to the stoma with the risk of stoma separation, and prevents long-term stenosis [1-3].

References

1. Wurtz AJ, Conti MM, Benhamed LM, Courtois-Purgass N, Porte HL. The pectoralis major myocutaneous flap in mediastinal tracheostomy reconstruction. Ann Thorac Surg 2008;86:1058-9.
2. Conti M, Benhamed L, Mortuaire G, Chevalier D, Pinçon C, Wurtz A. Indications and results of anterior mediastinal tracheostomy for malignancies. Ann Thorac Surg 2010;89:1588-95.
3. Chan YW, Yu Chow VL, Lun Liu LH, Ignace Wei W. Manubrial resection and anterior mediastinal tracheostomy: friend or foe? Laryngoscope 2011;121:1441-5.