Tutorial

Autologous pedicled pericardial patch repair of tracheobronchial defect

Published: January 27, 2020

DOI: 10.1510/mmcts.2020.005

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An acquired posterior tracheal wall defect, most commonly an acquired tracheoesophageal fistula, is a challenging clinical scenario. Autologous pedicled pericardial patch repair is a versatile and sustainable technique for the repair of a large tracheal defect, from primary management to airway salvage. This video tutorial demonstrates the technical aspects of this technique using step-by-step video.

Our patient is a previously healthy 2-year-old boy referred from another hospital with the diagnosis of tracheoesophageal fistula resulting from an unwitnessed button battery ingestion, with symptoms lasting for more than 3 days. Ventilation was difficult due to the large fistula found following endoscopic removal of the battery and a selective intubation of the right main bronchus was performed to support the transfer and preoperative period.

1 - Patient position and preparation (0:00)

The patient is placed in supine position with a roll under the shoulder. The arterial line is placed via the right radial artery. Near infrared spectroscopic monitoring of cerebral perfusion is instituted. A nasogastric tube is placed.
2 - Median sternotomy, exposure and cannulation (0:21)
3 - Tracheotomy over the site of the defect (0:31)

A horizontal tracheotomy is made over the site of the presumed defect with a cold knife. Stay sutures are placed over both ends to retract the tracheal ends and prevent blood from getting into the bronchial lumen.
4 - Evaluating the defect size and debridement (1:03)

The tracheal defect (a tracheoesophageal fistula in this case) is evaluated. Dissection of the membranous portion of the trachea off the underlying esophagus is performed with sharp dissection. The necrotic tissue around the tracheal defect is debrided sharply until healthy tissue is reached for anastomosis. In this patient, primary repair of the esophagus is performed by general surgeons using 5-0 polypropylene sutures (video not included).
5 - Harvesting the pedicled pericardial patch (1:43)

A strip of superiorly based pedicled pericardial patch is harvested from the right leaflet of the pericardium. The right phrenic nerve is carefully visualized and preserved. The flap is based on the vascularity of the phrenic vessels. Its superiorly based reflection facilitates the transposition of the flap towards the airway and makes it a versatile tissue for reconstruction of airway defects irrespective of its location.
6 - Placing the patch to the site of the defect (2:02)

A tunnel beneath the superior vena cava (SVC) is made and the patch is threaded beneath or over the SVC, depending on the tension of the tissue, to the site of the tracheal defect.
7 - Anastomosis of the patch to the tracheal defect on the posterior wall (2:32)

The free end of the patch is anastomosed to the distal tracheal back wall with continuous 5-0 polydioxanone sutures, taking full-thickness bites on the patch and the trachea, starting from carinal ridge cartilage and running to both ends in this particular patient. The visceral surface of the pericardium is placed in the luminal side of the trachea.
8 - Carinal reconstruction (3:09)

Incorporation of the carinal cartilage maintains the configuration and carinal architecture of a normal airway.
9 - Superior suture line (4:52)

The pedicled end of the patch is reflected onto itself and the reflection border of the patch is anastomosed to the proximal tracheal back wall with running 5-0 polydioxanone sutures from edge to edge in full-thickness bites.
10 - Closing the tracheotomy, placing chest tubes, irrigation catheter, and routine chest closure (6:20)

Endotracheal intubation is performed. The bronchi are suctioned. The tip of the endotracheal tube is adjusted under bronchoscopic control so that it is at the center of the repair.

The tracheotomy incision is repaired using a running 5-0 polydioxanone suture taking only the cartilage and submucosal tissue, completing the tracheal repair. Water immersion is used to test for air leakage. Fibrin sealant glue is applied to the suture line and covered with oxidized regenerated cellulose absorbable hemostat. An irrigation catheter is placed in the mediastinum, exiting from the subclavicular skin. Two chest tubes are placed in the substernal and right pleural space. Routine closure of the chest is done.

Under our institutional protocol for esophageal repair under tension, the patient was paralysed and ventilated for 5 days. The mediastinal irrigation consists of 48 hours of povidone-iodine and normal saline for 72 hours. A pre-extubation bronchoscopy, bronchogram and tube esophagogram 1 week postoperatively showed mild granulations in the trachea and an intact esophagus without leakage. The patient was discharged to the referring hospital without respiratory support on postoperative day 17. On follow-up bronchoscopy 2 months post-operation, there was tracheal granulation over the posterior wall, which was managed by systemic steroid therapy and removed endoscopically.

Autologous pericardium is frequently used to repair congenital cardiac anomalies and has been used to repair tracheobronchial defect or replace the membranous trachea. Pedicled pericardial patch repair of tracheobronchial defect has been used to repair membranous defect of the trachea due to neoplasm and iatrogenic injuries in adults and children .

The pericardium is readily available in the surgical field via a median sternotomy. It is pliable, and it forms an air-tight seal with good adherence to adjacent tissue. The flap is well perfused based on the phrenic vessels, making it resistant to infection, and is re-epithelialized with pseudostratified epithelium within a reasonable time period . Our technique of harvesting the pedicled graft preserves the vascularity of the graft, which may further enhance graft survival and make it less prone to shrinkage and stricture. Vigilant airway surveillance and aggressive endoscopic management such as dilatation and stenting may still be required in some patients. A multi-disciplinary team approach for managing these difficult cases is invaluable .

In conclusion, this detailed demonstration of our current technique of pedicled pericardial patch shows a versatile technique for repair of tracheobronchial defects in children, especially those in the posterior membranous trachea.

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None declared.

Authors
Yi-Ting Yeh^a,b, Madhavan Ramaswamy^a, Arun Beeman^a, Denise McIntyre^a, Amy Heatwole^a, Richard Hewitt^a and Nagarajan Muthialu^a

Author affiliations
^aTracheal Team, Great Ormond Street Hospital for Children, London, UK
^bNational Yang-Ming University, Taipei, Taiwan

Corresponding Author
Nagarajan Muthialu

Tracheal Team,
Great Ormond Street Hospital for Children,
London, UK

Phone: +44-07551-285410
Email: Nagarajan.Muthialu@gosh.nhs.uk