Seven-Ring Tracheal Resection for Recurrent Papillary Thyroid Carcinoma: Reconstruction With a Pedicled Myocutaneous Flap

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Prolonged tracheal resections (> 4 cm or ≥ 6 rings) are technically demanding due to increased anastomotic tension and the potential compromise of airway vascularity. While release maneuvers (e.g., suprahyoid, hilar mobilization) can provide additional surgical length, they carry added risks, such as dysphagia or vocal changes, and their routine use remains controversial (1, 2). Additionally, extrathoracic pedicled flaps have emerged as effective methods to reinforce airway repairs and protect adjacent vascular structures, as shown in series of carinal and noncircumferential tracheal reconstructions using muscle flaps (3). 

The authors present the case of a 72-year-old woman with recurrent papillary thyroid carcinoma involving the right lateral tracheal wall. After previously treatment with total thyroidectomy, bilateral neck dissection, adjuvant radiotherapy, and ligation of the innominate vein, she developed progressive dyspnea and hemoptysis. Computed tomography (CT) revealed a mass measuring 36 × 23 × 31 mm extending from 1.5 cm below the vocal cords. Bronchoscopy confirmed a 3 cm lesion. Laser debulking failed, and stenting was deemed contraindicated due to its proximity to the vocal cords. 

A multidisciplinary airway board recommended an extended tracheal resection of seven rings with laryngeal preservation, followed by flap reconstruction. Surgical steps included cervical access, meticulous dissection of scarred tissues, and liberation of the right carotid artery. The trachea was opened longitudinally along the lesion and resected. No esophageal invasion was found. Field intubation and trimming of the left tracheal wall avoided telescoped anastomosis. A posterior and left lateral end-to-end anastomosis with 3-0 Vicryl was performed without tension. 

The residual defect (approximately 2 cm) was reconstructed using a pedicled myocutaneous flap from the left pectoralis major, based on the thoracoacromial vessels. The flap was tunneled over the clavicle into the right neck. A cutaneous island was sutured into the tracheal lumen, and the muscle and fat components were secured over the anastomosis and great vessels. 

Bronchoscopy at postoperative day seven revealed a well-perfused flap without necrosis or dehiscence. At one- and three-months control, the airway remained patent with no stenosis. The patient had no dyspnea and retained her preoperative vocal cord paralysis. 

This instructional video documents a novel salvage technique in a deeply scarred field following oncologic reoperation and radiotherapy, achieving extended resection and airway continuity without complex release maneuvers. The combination of flap reconstruction not only reinforced the anastomosis but also preserved laryngeal function, representing a valuable addition to reconstructive options in challenging tracheal surgery. 

References

1. Mohsen, T., Abou Zeid, A., Abdelfattah, I., Mosleh, M., Adel, W., & Helal, A. (2018). Outcome after long-segment tracheal resection: study of 52 cases. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 53(6), 1186–1191.
2. Elsayed, H. H., El-Nori, A. A., Mostafa, A., Elsayegh, M. T., Bassiouny, S., Refaat, A., Elkahely, M. A., & Zaki, M. (2025). Virtues of routine suprahyoid release during tracheal resection and anastomosis in patients with post intubation stenosis. Updates in surgery, 77(1), 209–215.
3. Ris, H. B., Krueger, T., Cheng, C., Pasche, P., Monnier, P., & Magnusson, L. (2008). Tracheo-carinal reconstructions using extrathoracic muscle flaps. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 33(2), 276–283.

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