Tracheal resection

Tracheal resection

Anesthesia type	General
Airway	Invasive Airway(ETT, Tracheostomy)
Lines and access	Large bore, PIV, Arterial line, CVC dependent on comorbidities
Monitors	Standard ASA monitors, Arterial line, +/- CVP, +/- TEE, foley
Primary anesthetic considerations
Preoperative	Location and extent of airway stenosis, Presence of tracheostomy and of what lifespam
Intraoperative	Minimize FiO2 as airway is in surgical field, +/- neuromonitoring
Postoperative	PONV
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Overview

Tracheal resection is a surgical procedure performed to remove diseased or obstructive segments of the trachea, often to treat benign or malignant tumors, traumatic stenosis, or congenital anomalies. The affected segment is excised, and the healthy ends are anastomosed to restore airway continuity. This procedure can significantly improve airway patency and patient quality of life.

Indications

• Most commonly due to "acquired stenosis" typically caused by prolonged intubation or tracheostomy.
  • Typically this stenosis is so severe and has failed attempts at ballon dilation or stenting.
• Malignant tumors of the trachea(<0.01% of all tumors, and 0.2% of respiratory tract tumors)
• Benign tumors causing airway obstruction
• Tracheal stenosis due to trauma, post-intubation injury, or radiation
• Congenital anomalies such as tracheal stenosis or malformation
• Tracheal trauma or injury repair

Surgical procedure

• Patients with airway stenosis often have prexiitng tracheosotmy, which can be intubated directly with ETT. In other cases, the procedure can be done with rigid bronchoscopy or via anterior cervical approach.
• Three distances must be measured when planning the resection portion of the procedure: vocal cords to the carina, distal tip of the lesion to the carina, and proximal tip of the lesion to vocal cords.
• The diseased segment is resected with clear margins.
• Resection for patients with severe subglottic stenosis high in the cervical trachea may require partial excision of the cricoid cartilage.
• End-to-end anastomosis is performed with absorbable sutures, ensuring tension-free closure.
• Consider releasing maneuvers (e.g., suprahyoid release) if tension is high.
• Use of intraoperative bronchoscopy

Preoperative management

Patient evaluation

System	Considerations
Airway	The anatomic location and percentage of obstruction were assessed endoscopically and graded I to IV. (Cotten Classification Ascertain location and extent of stenosis Stenosis can be classified as structural or fixed(intraluminal or extraluminal) Stenosis can be classified by dynamic vs. functional Rigid bronchoscopy may be used intraoperatively for airway access. Maintain spontaneous ventilation during critical phases if possible. Be prepared for elective or emergent conversion to alternative airway management (e.g., cross-field ventilation).
Neurologic
Cardiovascular	Invasive arterial line for continuous blood pressure monitoring. Preparedness for cardiopulmonary bypass (CPB) or ECMO if needed.
Pulmonary
Gastrointestinal
Hematologic
Renal	Foley, monitor urine output
Endocrine
Other

Intraoperative management

Monitoring and access

Standard ASA monitors: ECG, pulse oximetry, non-invasive blood pressure, capnography.

Induction and airway management

Preoxygenation, followed by

Positioning

Supine, often with shoulder roll(especially if done under rigid bronchoscopy)

Postoperative management

Disposition

• Transfer to ICU for close observation.
• Patients often extubated on post-op day 5-7
• Continuous respiratory and hemodynamic monitoring.
• Assess for airway patency and adequacy of ventilation, often requiring multiple bronchoscopies for monitoring and visualization of anastomotic integrity

Pain management

• Adequate analgesia using minimal opioids, NSAIDs, and local anesthetic techniques.
• Avoid excessive coughing or strain to protect the anastomosis.
• Non-narcotic pain management are encouraged to prevent postoperative nausea, leading to vomiting, neck hyperextension, and potential aspiration.

Potential complications

• Anastomotic dehiscence or restenosis
  • Most commonly cacused by tension on the anastamotic line.
• Airway obstruction
  • Laryngeal edema.
• Hemorrhage, can be lifethreatening via tracheoinnominate fistula when anterior anastomosis has become dehiscent
• Infection
• Recurrent laryngeal nerve injury causing hoarseness or airway compromise
• Tracheoesophageal fistula (rare)

Procedure variants

	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications