Tracheostoma

• feine Ein-Zinkel-Hacken
• 3-0 PDS Fäden mit kleinen und scharfen Nadeln.
• mit Finger Trachea nach kaudal tunneln (wie bei Mediastinoskopie), damit Trachea mobilisiert wird.

Tracheaverletzung

Transcervical repair Wien

202312112231 sehr guter Artikel!!!
The treatment of tracheobronchial injury is depedent on the location and extent of the injury (More than 3 cm), time diagnosis, and dynamic changes of symptoms, patient’s condition, and additional injuries of neighboring structures.
Wiener algorithm 202412092317

• The vast majority of tracheobronchial injuries are mainly superficial tracheobronchial tears; and patients have hardly any symptoms. These cases can be managed conservatively.
• Symptomatic patients with ‚ full: thickness tracheobronchlal Injury require a surgical repair to avoid the development of mediastinitis and other sequela.

Despite some reports on endoscopic techniques, the open-surgical repair of tracheobronchial injuries remains the standard treatment. 5-7 Traditionally, tracheobronchial injuries in ** the upper and middle third of the trachea are approached through a cervical incision, whereas the lower third and the main bronchi are usually approached by a right-sided posterolateral thoracotomy. **8-12

AIRWAY MANAGEMENT

Until surgical repair, the endo-tracheal tube was positioned distal to the laceration orinto the contralateral bronchus. For patients receiving acervical approach, the endotracheal tube was retrievedonce the trachea was transected. Thereafter, cross-tableventilation was initiated, and surgery was performed inintermittent apnea. For patients receiving thoracotomy,the cross-table tube was placed in the contralateralbronchus. Although available, jet ventilation was notapplied in our patient cohort as sufficient oxygenationcan be usually achieved with intermittent apnea andselective distal intubation. After completion of thesurgical repair, the endotracheal tube was reintroducedundervisual guidanceora tracheostomywasperformed during the surgical repair.

Suturing

Mucosal suturing : 5-0 mit kleinem Nadel, fortlaufend von proximalem Riß nach distal, dann wieder zurück genaht nach proximal.

Anterior longitudinal split closed by continuous 4-0
polydioxanone suture; partial horizontal trachealincision approximated with 4-0 polydioxanone singlestitches. Anterior gap can be left open and used astracheostomy.

Indikation

With increasing experience the indication for
thoracotomy is currenty limited to patients with complete separation of the main bronchus, injuries extend-ing distally to the main bronchi, or to patients witconcomitant injury requiring surgical repair. Even tracheobronchial injuries extending into the membranous portion of main bronchi can be repaired througthe transcervical approach by retracting the tracheacephalad and using an appropriately long needle driver.

In our opinion, the transcervical approach has severaladvantages over thoracotomy. First, only the avascular, anterior aspect of the trachea has to be dissected,thereby fully preserving the lateral tracheal blood sup-ply. Another advantage is the avoidance of single-lungventilation during the surgical procedure. Consideringthe often significant underlying comorbidities of pa-tients with tracheobronchial injury, single-lung ventila-tion might not be tolerated. In general, the resultingsurgical trauma can be minimized using the transcervical approach by avoiding thoracotomy, and thatmight also contribute to the more favorable outcome ofpatients receiving a cervical renai

Kontraindikation

Patients who were referred more than 48 hours after injury were usually not considered surgical candidates.

### meine Kommentar
manchmal ist die Mucosa bzw. Hinterwand so auseinander gerissen, sodass ein direkter Verschluss nicht möglich ist. Oder führt es zu Einengung oder zu starker Spannung. In dem Fall kann man überlegen, mit PeriGuard-Patch die Hinterwand zu rekonstruieren (wie Perikard-Patch bei Thorakotomie). Der PeriGuard-Patch kann auch gegebenenfalls als Trennung oder Schutz des Ösophagus dienen.

Um die Spannung der Nähte zu reduzieren, oder gar einen direkten Verschluß möglich zu machen, muss man ggf. doch die Trachea mobilisieren, besonders an der Hinterwand.

Konservative nicht-operative Behandlung

Fall 202412092316