Case report of successful management of intraoperative tracheal rupture during thoracoscopic esophageal resection in patient with esophageal cancer

Posterior membranous tracheal injury during mckeown oesophagectomy. A case report with literature review

Minimally invasive techniques such as thoracoscopic or robotic surgical approaches for oesophageal pathologies have been gaining traction as the preferred method of surgical technique. McKeown's minimally invasive oesophagectomy has been shown to reduce hospitalisation, with reduced cardiopulmonary morbidities. However, it is not without complications, and an iatrogenic tracheobronchial injury (TBI) could occur intraoperatively during anatomical plane dissection. We report a case of iatrogenic posterior membranous tracheal injury during the thoracic dissection of a McKeown's oesophagectomy, detected intraoperatively and patient recovered without any complications. The diagnosis of TBI involves a multicentric approach. Confirmation of the diagnosis and classification of TBI based on clinical signs, radiological studies, and endoscopy procedures such as bronchoscopy are necessary to tailor the best possible management for the patient. In cases where a full-thickness airway defect exceeds 2 cm and is detected intraoperatively, immediate primary repair is advised to optimize outcomes. TBI pose significant clinical challenges, particularly in cases of iatrogenic injury during procedures such as minimally invasive oesophagectomy. While the overall incidence of TBI remains low, awareness of risk factors and vigilant monitoring during procedures is paramount. While TBI remains rare, its management shares principles with oncological oesophageal surgery, making this case pertinent to surgical oncology practice. The evolving landscape of diagnostic techniques, including bronchoscopy and advanced imaging modalities, facilitates prompt and accurate identification of injuries, enabling timely intervention.

Management of the ventilation in intraoperative tracheobronchial injury with manual occlusion of the rent-An unusual case report

Intraoperative tracheobronchial injury is one of the most serious complications of any thoracic surgery. Its management is really challenging both for the surgeons as well as for the anesthesiologists. We present a rare case of intraoperative tracheobronchial injury during esophagectomy and the management of the ventilation by intermittent manual occlusion of the rent as a rescue method. The left-sided bronchus got injured near the carina, while the patient was on one-lung ventilation in a lateral position and the left lung was being ventilated with a left-sided double-lumen tube (DLT). Surgeons decided to repair it in a lateral position and required the right lung to be deflated for surgical access. The endobronchial part of the tube was taken out in the trachea, and the patient was intermittently ventilated by occlusion of tracheal rent by the surgeon as a rescue measure. Intermittent apnea and ventilation were conducted, and the repair of tracheal rent was conducted in the apnea period. A negligible air leak was present after the repair. Manual occlusion of the rent can help restore ventilation in an emergency situation when other options are technically difficult.

Tracheal repair with sternocleidomastoid flap in mediastinoscopic surgery for esophageal cancer

Tracheal injury during mediastinoscopic esophagectomy is a life-threatening complication that is challenging to manage. However, no precise treatment has been defined. An 80-year-old male patient with upper esophageal cancer underwent a mediastinoscopic esophagectomy and gastric tube reconstruction through the posterior mediastinal route. When the esophagus was separated from the trachea using a bipolar vessel sealing system, the left side of the membranous trachea incurred a 3-cm defect 7 cm below the sternal notch. We successfully repaired the tracheal injury not by directly suturing the defect but by reinforcing it with a pedicle sternocleidomastoid flap. The gastric tube was placed over the tracheal repair for esophageal reconstruction via a posterior mediastinal route. As a result, the patient recovered well and was discharged. A sternocleidomastoid flap might be another surgical option for reinforcement flaps in tracheal injuries.

Management of an intraoperative tracheal injury during a Mckeown oesophagectomy: A case report

INTRODUCTION AND IMPORTANCE

Tracheobronchial injuries are uncommon complications during oesophagectomies adopting blind dissection or thoracoscopy. Neoadjuvant chemo-radiotherapy is considered a risk factor while double-lumen endotracheal tube insertion and direct surgical damage are other related causalities.

PRESENTATION OF CASE

A 65-year-old male underwent a Mckeown oesophagectomy with a right thoracotomy for a mid-oesophageal carcinoma. During the latter stages of cervical dissection and oesophageal mobilization, a 2-cm tracheal injury was noted in the posterior membranous trachea. It was repaired with 2.0 prolene with interrupted sutures and local transposition muscle flap using prevertebral muscles. Post-operatively, he was ventilated in view of prolonged surgery and the probability of airway oedema with the double-lumen ET tube. A transient bubbling of the intercostal drain was managed conservatively and attributed to a secondary pneumothorax. He was extubated and made an uncomplicated recovery. At 2 years, he did not have any tracheal stenosis.

CLINICAL DISCUSSION

If diagnosed intraoperatively and for sizes >2 cm, tracheobronchial injuries should be repaired. Various techniques exist with differing evidence. Repair with non-absorbable sutures, use of synthetic grafts, innate tissue such as intercostal and pectoral muscle flaps, and pericardial and pleural flaps are all being used. Early extubation might be useful provided other criteria for extubation are met.

CONCLUSION

Tracheobronchial injuries during oesophagectomies present a surplus challenge to both the anaesthetist and the surgeon. Collective decision-making tailored to the patient and close monitoring during the postoperative phase would result in good outcomes.

Robotic Intraoperative Tracheobronchial Repair during Minimally Invasive 3-Stage Esophagectomy

Tracheobronchial injury (TBI) is an uncommon but potentially fatal event. Iatrogenic lesions during bronchoscopy, endotracheal intubation, or thoracic surgery are considered the most common causes of TBI. When TBI is detected during surgery, concomitant surgical treatment is recommended. Herein we present a case of successful robotic primary repair of iatrogenic tracheal and left bronchial branch tears during a robot-assisted hybrid 3-stage esophagectomy after neoadjuvant chemoradiotherapy. A robotic approach can facilitate the repair of this injury while reducing both the potential risk of conversion to open surgery and the associated increased risk of postoperative respiratory complications.

New acute respiratory management in tracheal rupture caused by chest trauma

We report a case who is a 33-year-old man admitted to our Emergency room for chest trauma caused by the factory's mechanical arm. Despite the endotracheal tube, the patient's respiratory state was poor and the oxygen saturation did not improve and the subcutaneous emphysema progressed. To improve distressed breathing, we first proposed the concept "mechanical ventilation with dual ventilator" to maintain oxygen saturation of the patient. This is, to our knowledge, the first report of using a special mechanical ventilation method in emergency surgery.