Name:
04 Trachea
Description:
04 Trachea
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e13fe76f-cc6d-43ae-9791-279fb2eae285/thumbnails/e13fe76f-cc6d-43ae-9791-279fb2eae285.jpg?sv=2019-02-02&sr=c&sig=SzTM23bGRGATKe2SpEpAwPbkXbqyPvzVNK%2BNF8ML0%2Fc%3D&st=2024-05-02T17%3A48%3A24Z&se=2024-05-02T21%3A53%3A24Z&sp=r
Duration:
T00H08M21S
Embed URL:
https://stream.cadmore.media/player/e13fe76f-cc6d-43ae-9791-279fb2eae285
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e13fe76f-cc6d-43ae-9791-279fb2eae285/0420Trachea.mov?sv=2019-02-02&sr=c&sig=UQFmEikg9PkyZni1nNrfKldQccqSii52sN70FU%2BRkXI%3D&st=2024-05-02T17%3A48%3A24Z&se=2024-05-02T19%3A53%3A24Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video we will discuss the proper technique to expose the trachea and larynx.
Segment:1 Objectives.
We will begin by discussing the relevant anatomy, the instruments and positioning, the techniques and exposure, and finally, the tips and pitfalls of this exposure.
Segment:2 Anatomy .
The larynx is located inferior to the pharynx and superior to the trachea. It is composed of three large cartilages the epiglottis, thyroid, and cricoid cartilages, and three smaller paired cartilages the retinoid, corniculate, and cuneiform cartilages, as well as a number of small muscles including the cricothyroid muscles.
The thyroid cartilage is suspended to the hyoid bone by the thyrohyoid membrane, and similarly, the cricoid cartilage is connected to the thyroid cartilage by the cricothyroid membrane. A useful landmark to remember, should one need to perform a cricothyroidotomy. Inferiorly to the cricoid cartilage lies the trachea. The trachea is approximately 10-12 cm in length, extending from below the cricoid cartilage in the neck to its bifurcation into the main stem bronchi in the mediastinum.
Recall that the tracheal rings are incomplete covering the anterior and lateral walls, whereas posteriorly, the wall is membranous. Lying anteriorly over the cervical trachea and larynx are the paired strap muscles including the sternal hyoid and sternal thyroid muscles. Directly overlying the cervical trachea is the isthmus of the thyroid gland, which is attached to the trachea by the Berry's ligament. Within the tracheal esophageal groove is located the pair of recurrent laryngeal nerves, which must be identified and protected during exposure.
Within the mediastinum, the innominate artery lies superficially over the trachea, crossing to the right. Note the location of the left innominate vein as it crosses the mediastinum superficially. The aortic arch overlies the trachea at its termination into the main stem bronchi.
Segment:3 Instruments and Positioning.
The patient should be supine, and if the cervical spine is cleared, a support should be used to extend the neck facilitating exposure for anterior approach.
If lateral exposure is utilized, the neck should be extended and turned to the contralateral side, as for exposure of the carotid artery or the cervical esophagus. Preparations should include the neck and chest in case exposure of the mediastinal trachea is required. A standard neck tray and sternotomy tray should be available.
Segment:4 Exposure and Technique .
The standard landmarks are identified, including the suprasternal notch and the thyroid cartilage. The collar incision is marked approximately two finger breadths above the sternal notch, or midway between the sternal notch and the thyroid cartilage.
A scalpel is then used to incise the skin along the marked collar incision. Electrocautery is used to carry the incision through to the level of the platysma. At the level of the platysma, the anterior jugular veins are identified, ligated, and divided. Subplatysmal skin flaps are then developed superiorly and inferiorly using electrocautery. The extent of the flaps created will depend on the amount of exposure required.
Once adequate skin flaps have been created the median raphe between the strap muscles is then divided in a vertical fashion and the strap muscles ar e retracted laterally. With the strap muscles retracted, the thyroid and cricoid cartilages as well as the cricothyroid membrane are all easily visible. The tracheal hook is useful to mobilize the trachea from within the mediastinum. Note the location of the thyroid isthmus. If exposure is required at this level the thyroid isthmus may be divided, either with electrocautery or between suture ligatures.
With traction placed in a INAUDIBLE manner on the tracheal hook, the pretracheal tissues are divided in a vertical fashion, exposing the underlying tracheal rings. Note the extent of tracheal exposure possible with a standard collar incision. If more distal exposure of the trachea is required, extension to a median sternotomy may be necessary. The skin is incised from the sternal notch's hyphoid process and electrocautery is used to score the sternum.
A finger is passed under the sternum from above and below, and the sternum is divided using a Lebsche knife or a sternal saw. The sternum is then spread manually to allow placement of a sternal retractor. Remember to place the sternal retractor so that the opening is facing superiorly. With the sternum spread in order to expose the underlying trachea, the superficial mediastinal tissues and INAUDIBLE remanent must be divided.
Note the location of the left innominate vein superficially within the mediastinum, and the innominate artery directly overlying the right anterior lateral trachea. The left innominate vein is isolated using a vessel loop and may be divided, if necessary, for exposure. Gentle CARTILAR retraction on the innominate artery may be applied in order to gain further exposure of the trachea. Injuries to the trachea, if involving three rings or less, can generally be repaired primarily.
The edges of the tracheal injury should first be debrided. The trachea is then repaired using an absorbable suture in uninterrupted tight fashion. If more than three rings are injured, then additional mobilization and more complex repairs must be undertaken. On completion of the repair, a muscle flap may be created to buttress the repair using available strap muscle.
The muscle is first dissected and mobilized, and then divided at its insertion into the sternum. Finally, the muscle flap is then placed over the repair and sutured in place either to the trachea or the surrounding tissue. Remember that early extubation is desired; however, if not possible, the endotracheal balloon should be advanced so as not to place direct pressure on the repair.
Though not mandatory, in some cases a tracheostomy may be warranted and may be placed through a standard tracheotomy incision.
Segment:5 Tips and Pitfalls.
Identify and ligate the anterior jugular veins and always divide the strap muscles in the median raphe in order to prevent unnecessary blood loss. Identify and protect the recurrent laryngeal nerves located within the tracheoesophageal groove, especially if tracheal reception is required. Unnecessary circumferential dissection of the trachea will lead to ischemia and breakdown of repairs.
Always remember to debride devitalized tissue prior to repair. The majority of injuries can be repaired primarily with absorbable suture. Remember to advance the endotracheal balloon distal to the repair. Efforts should be made towards an early extubation. Complex injuries may require a muscle flap using the strap muscles to buttress the repair or between a combined tracheoesophageal repair in order to prevent fistulas.
Though tracheostomy is not mandatory, in select complex cases it may be prudent. Thank you.