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SURGICALSURGICALPROCEDURESPROCEDURES

Dr. Ghulam saqulain

E.N.T SURGEON,

CAPITAL HOSPITAL

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LaryngotomyEmergency Procedure

“Laryngotomy is opening the airway through the cricothyroid membrane”

• It is used for acute complete airway obstruction when endotracheal intubation/ ventilation is not possible.

• The procedure can be accomplished in 15 to 30 seconds.

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• Position: Supine with neck extended.

• Skin Incision: A small vertical incision is made in

midline over the thyroid and cricoid cartilages.

Wound spread apart with finger dissection to identify cricothyroid membrane.

• Cricothyroid membrane incision: Membrane is incised horizontally

as close to cricoid as possible.

• Widening of opening and placing a tube.

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TRACHEOSTOMY

•Environment:

•Best performed as an elective procedure under endotracheal anaesthesia, in an adequately equipped operation theatre and aseptic measures.

•Position:

•Supine position with a sandbag under patient’s shoulders to give extension of head and prominence to the trachea and larynx.

•Under local anaesthesia a compromised position of extension will have to be found.

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• Anaesthesia: Endotracheal anaesthesia

or Local anaesthesia (in

obstructive pathologies) obtained by injection of skin and subcutaneous tissues with Xylocaine 2% 1:200000 adrenaline solution.

Drugs which depress resp. system better avoided.

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Elective Tracheostomy

• Incision A Transverse 5 cm

incision 2 cm below the lower border of cricoid cartilage, through skin, S/C fat and deep cervical fascia.

Flaps are raised by undermining with blunt dissection to expose ant. Jugular veins and infrahyoid muscles.

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•Separation of Infrahyoid Muscles

•The fibrous median raphe b/w the sternohyoid muscles is defined and separated with blunt dissection

•The sternothyroid muscles on a deeper plane are identified and retracted laterally.

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•Identification of Thyroid Isthmus:

•Anatomical variations in size and position of thyroid isthmus should be expected

•The thyroid isthmus may be small and not interfere with the approach but in most patients it is of sufficient size to need dividing.

•A small horizontal incision is made in the pretracheal fascia

•Pull thyroid isthmus up or down or

•Divide the thyroid isthmus b/w large haemostats and ligate or are over sewn

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•Opening of the Trachea:

•Trachea is retracted in an anterio-superior direction by a tracheal hook below the cricoid

•A transverse incision into intercartilaginous membrane below the 2nd or 3rd ring and converted into a circular opening.

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•Insertion & fixation of Tracheostomy tube:

•The type of tracheosomy tube should be selected prior to surgery.

•A Soft cuffed tube (ported) will be needed if anaesthesia is to be continued or positive pressure ventilation required or if entry of secretions and blood into trachea are to be avoided.

•Position of tube is retained by tapes passed around the neck and tied to each other on one side of neck.

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• Wound Closure and Dressing:Wound loosely

approximated with skin sutures and sterile sponge trachesotomy dressing is done around the tube.

There should be sufficient space remaining around the tube to minimize the danger of subcutaneous emphysema.

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PaediatricTracheostomy

• Tracheostomy in children and babies causes anxiety to all concerned.

• Needs to be carried out with precision and in controlled conditions.

• It needs to be done under general anaesthesia with: Endotracheal intubation Face mask or laryngeal mask with PPV Bronchoscope

• Local with vasoconstrictor not required.• Slight extension of neck to avoid

thoracic trachea coming up into neck.

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Procedure Incision in midline,

horizontal or vertical midway b/w the cricoid and sternal notch no longer than 1 cm.

Pickup subcutaneous fat and remove a small circle down to deep fascial layer.

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Assistant retracts skin Fascia divided vertically in midline

with scissors to reveal strap muslces.

Strap muscles are separated in midline

Confirm position of trachea with palpation.

If thyroid isthmus is bulky it can be divided in midline with diathermy, or moved up or down out of the way.

Identify cricoid to avoid damage to 1st tracheal ring.

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Put stay suture on either side of midline of trachea.

Traction on these sutures brings trachea to surface

Make a vertical slit in anterior wall of trachea, which gaps.

Prepare a proper size tube by attaching tapes and putting introducer in place.

Insert the tube while the anaesthetist withdraws the endotracheal tube.

If ventilation is uncertain donot remove endotracheal tube and reassess your operation.

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Do not lose control

of

yourself or the airway

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When to do What?

(Non Surgical Versus Surgical Airway)

Dr.Raza RathoreDr.Raza Rathore

Head of Dept of AnaesthesiaHead of Dept of Anaesthesia

Capital HospitalCapital Hospital

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What to Do When?

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Airway Management of High Tracheal Lesion

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Anaesthetic airway management in lower tracheal stenosis.

• Airway management is of paramount importance in tracheal stenosis.

• It is necessary to keep the patient spontaneously breathing until airway is secured.

• Appropriate ventilation technique needs to be employed when trachea is opened for resection: Jet ventilation

Multiple risks. Accurate measurement of end tidal CO2 and tidal volume is impossible.

Distal tracheal intubation Spontaneous ventilation, veno – venous extracorporeal

membrane oxygenator and Special Equipment & expertise.

Cardiopulmonary bypass.

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Use of portex microlaryngeal tube to intubate lower trachea during tracheal reconstruction.

Portex Microlaryungeal tube has several advantages. It is sterile, long, flexible, small outer diameter. Distance from tip to top of cuff is 3.5 cm so can be easily placed in Left main bronchus without causing left upper lobe collapse.

( Case Report: Anaesthetic Management of Lower tracheal Reconstruction by Muhammad Hamid, fazal Hameed Khan & Zafar Mohuddin Omar, JCPSP 2003, Vol.13 (12): 715-6)

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Percutaneous Tracheosmy

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Thank You