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Fig 24.1. Laryngeal release procedure to gain length for primary tracheal reconstruction. The anatomic relationships are shown. (a) The muscles attached to the superior surface of the hyoid bone is transected. (b) The lesser corner of the hyoid bone is palpated and transected, separating the hyoid bone from the myelohyoid. Reprinted with permission from Suprathyroid Release for Tracheal Anastomosis. Arch Otolaryngol 99:256. ©1974, American Medical Association.

Fig 24.2. Surgery of the upper trachea. (a) The cervical incision may be extended to a partial median sterno-tomy of any length. (b) Suture repair of the trachea after resection of the lesion. The prior endotracheal tube is pulled back and a flexible armored endotracheal tube is used to intubate the distal trachea across the operative field.

Fig 24.3. Surgery of the lower trachea. (a) Via a right posterolateral thoracotomy, exposure of the distal trachea is achieved. (b) The trachea is transected and the mainstem bronchus intu-bated. The tracheal lesion is resected and primary anastomosis done.

Fig. 24.4. Tracheal reconstruction after carinal resection. a) demonstrates the lines of resection.

b) demonstrates one type of reconstruction in which the right mainstem bronchus is sutured end-to-end to the trachea, and the left mainstem bronchus is sutured end-to-side to the trachea.

In a patient with adenoid cystic carcinoma, assessment of the tumor spread is extremely important because, as mentioned, this tumor can spread for long distances submucosally. Hence, tissue is sampled 1-2 cm above and below the lesion as visible bronchoscopically. Contraindications to tracheal resection are cervical node metastases, esophageal or vena caval involvement, and Horner's syndrome. Relative contraindications may include laryngeal hemiparesis. These patients should undergo radiotherapy and laser obliteration of the tumor endoscopically. It should be noted that an additional technique, besides passing the endotracheal tube across the operative field into the distal trachea or mainstem bronchus, is to use flexible tubes through which high frequency jet ventilation is instituted. These small tubes can be passed down either mainstem bronchus and the operation can be continued in the trachea with minimal disturbance by the tubes.

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