Surgery of the extrathoracic trachea

image of Surgery of the extrathoracic trachea
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The trachea extends from the cricoid cartilage of the larynx to the carina at the level of the heart base, where it divides to form the mainstem bronchi. This chapter covers anatomy and physiology, indications for surgery of the extrathoracic trachea, tracheal trauma, tracheostomy, tracheal collapse syndrome, masses causing tracheal obstruction, segmental tracheal stenosis, and tracheal resection and anastomosis.

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8.1 Cross-sectional anatomy of the trachea. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.2 The segmental blood supply to the trachea is derived from the cranial and caudal thyroid arteries. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.3 A West Highland White Terrier presented with bite wounds to the neck; marked subcutaneous emphysema was evident on (a) physical examination and (b) cervical radiography. (c) Ventral neck exploration revealed tracheal perforation through the annular ligament of the trachea. (d) Primary repair of the tracheal laceration was performed using simple interrupted sutures.
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8.4 (a) Lateral cervical and (b) thoracic radiographs of a cat that developed extensive subcutaneous emphysema 10 days following general anaesthesia for routine ovariohysterectomy. The cat had a tear in the dorsal tracheal ligament at the level of the thoracic inlet consistent with an injury secondary to endotracheal tube cuff inflation.
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8.5 Temporary tracheostomy placement in a cat with upper respiratory tract obstruction secondary to laryngeal inflammation. (a) Stay sutures are placed through the trachea proximal and distal to the proposed site of annular ligament incision for the tracheotomy. (b) A tracheotomy is performed using a scalpel blade to incise through the annular ligament. (c) Manipulation of the stay sutures to open the tracheostomy can aid insertion of the tracheostomy tube. (d) The tracheostomy tube is inserted and will then be secured around the neck of the cat using umbilical tape.
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8.6 A paediatric tracheostomy tube used for management of upper respiratory tract obstruction in a puppy; owing to the small size of the tube there is no removable inner cannula.
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8.7 A tracheostomy tube with a removable inner cannula, which facilitates regular cleaning of the tube to prevent obstruction. The inner cannula can be interchanged between a cannula that can connect to an anaesthesia breathing circuit, for use during placement (as shown), and a shorter cannula for use in the conscious patient.
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8.8 Complete obstruction of a tracheostomy tube with mucus secretions.
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8.9 A permanent tracheostomy in a Yorkshire Terrier, which was performed for management of grade 3 laryngeal collapse and upper respiratory tract obstruction. (a) Three days postoperatively. (b) Two months postoperatively.
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8.10 (a) Lateral radiograph and (b) post-mortem image of a dog with ‘traditional’ tracheal collapse characterized by flattened tracheal rings and weakened, stretched dorsal trachealis muscle. (c) Lateral radiograph and (d) post-mortem image of a dog with a tracheal ‘malformation’, characterized by W-shaped tracheal cartilage rings, located most commonly at the thoracic inlet. In (c), note the radiographic pathognomonic sign of a dorsally located tracheal lumen (arrowed) due to the deviated rings.
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8.11 Serial images of canine tracheas. (a) Note the segmental blood supply originating from the dorsolateral tracheal margins. (b) The recurrent laryngeal nerve (arrowed) is often located on the lateral tracheal wall. (c) Initial placement of extraluminal tracheal ring prostheses in a patient with tracheal collapse. (d) Completed tracheal ring prostheses demonstrating closer but imperfectly re-established tracheal anatomy.
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8.12 Partially deployed Vet Stent-Trachea™ within its delivery sheath, demonstrating the low-profile delivery system and stent foreshortening.
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8.13 Serial lateral fluoroscopic images: (a) during 20 cmHO positive pressure ventilation for determination of maximal tracheal diameter; (b) during placement of a tracheal stent delivery system through the endotracheal tube and within the tracheal lumen; (c) immediately following stent deployment.
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8.14 Series of radiographic images of an 8-week-old puppy with a tracheobronchial foreign body (a bead). (a) Bead (arrowhead) located at the carina, resulting in nearly complete airway obstruction. (b) Ventrodorsal radiograph with the bead (arrowhead) in the left mainstem bronchus and a 0.035-inch guidewire (arrowed) passed beyond the bead into the left bronchus. (c) Ventrodorsal radiograph with stone basket (arrowed) adjacent to the bead (arrowhead) bronchial foreign body. (d) Final lateral thoracic radiographic image demonstrating completed removal of the foreign body.
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8.15 Lateral radiographs of a patient with a narrowed tracheal lumen due to malignant obstruction (arrowed). (a) Before and (b) following palliative tracheal stent placement.
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8.16 Resection and anastomosis of the cervical trachea in a Domestic Shorthaired cat for management of segmental tracheal stenosis at the site of a previous temporary tracheostomy (head to the right in all images). (a) A ventral midline exploration revealing the stenotic segment of trachea. (b) Following tracheotomy, a sterile endotracheal tube has been placed in the distal trachea to maintain anaesthesia and oxygenation. (c) Following resection of the stenotic segment, the orotracheal tube has been advanced from the proximal to the distal trachea and simple interrupted sutures have been preplaced ready to perform the anastomosis. (d) The distal and proximal sections of the trachea have been apposed and the sutures in the cartilage ring have been tied to achieve the anastomosis; the sutures in the dorsal tracheal ligament are tied last.
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8.17 Tracheal resection. (a) The cartilage rings can be split (line a) in large dogs. In small dogs and cats, the cut in the trachea is most easily made between rings (line b). (b) Whenever possible, the endotracheal tube should be advanced beyond the site of tracheal excision. If this is not possible, the excision should be planned and the distal tracheal incision made first. (c) A sterile endotracheal tube should be available to secure the airway in the distal tracheal segment. Stay sutures will help to control the airway. The orotracheal tube should be left and will be used once the anastomosis is complete. (d) Whenever possible, the endotracheal tube should be advanced beyond the site of tracheal excision. Stay sutures will help to maintain temporary tracheal alignment whilst sutures are preplaced. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.18 (a) When suturing the trachea, simple interrupted sutures are first preplaced in the dorsal tracheal membrane. (b) Sutures are preplaced around the tracheal rings. If the tracheal rings have been split, the sutures appose the cut cartilage edges. Tension-relieving sutures can be placed around the tracheal cartilages proximal and distal to the anastomosis site. (c) In small dogs and cats, sutures are placed around the tracheal rings, which, when tied, appose the tracheal membrane between rings. Care should be taken not to tighten these sutures such that cartilage rings overlap excessively. (d) Tension-relieving sutures can be placed around tracheal cartilages proximal and distal to the anastomosis site. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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