Post-Intubation Tracheal Stenosis: Tracheal Resection With Dorsal Mucosectomy and Primary Anastomosis

The PatientThis patient is a thirty-four-year-old man with a previous history of heart surgery during childhood and used a pacemaker. He had a car accident in August 2022 with traumatic brain injury and a need for orotracheal intubation. He remained intubated for five days with conservative treatment for the neurological injury and was hospitalized for four weeks to treat fractures with orthopedics. One month after discharge, the patient developed progressive dyspnea and stridor. A bronchoscopy revealed subglottic stenosis approximately 2 cm from the vocal folds, at the height of initial tracheal rings. A complementary neck CT confirmed the findings. He underwent three tracheal dilations, with a two month interval between them, but symptoms returned. Tracheal resection with primary anastomosis was indicated.The SurgeryThe procedure started with suspension laryngoscopy for airway evaluation and more precise location of stenosis. Orotracheal intubation and passage of a nasogastric tube was performed to facilitate location of the esophagus. The patient was then positioned in a supine position with a subscapular pad and the neck extended.A transverse cervicotomy was performed above the sternal notch with dissection in planes up to the laryngeal cartilages and pretracheal fascia. Digital release of the pretracheal fascia was performed for superior mobilization of the trachea, which would facilitate anastomosis. Anterior tracheotomy allowed for direct visualization of the region of stenosis and decision on the segment to be resected. The orotracheal tube was pulled superiorly, with a new sterile tube passed through the surgical field for ventilation. After resecting the stenotic segment, a wide tracheal lumen suitable for reconstruction was located. Cricoid involvement was then treated through dorsal mucosectomy, preserving the cricoid plate and protecting the recurrent laryngeal nerves. Two points of repair were performed with 2-0 Vicryl to approximate the segments to be anastomosed. The anastomosis began on the posterior wall, with a 4-0 PDS (polydioxanone) thread in a continuous suture, removing the tube with periods of apnea to facilitate execution. Next, the anterior wall anastomosis was performed with separate single sutures of 4-0 PDS. Due to the proximity of the anastomosis to the vocal folds and the risk of edema due to manipulation, a protective tracheostomy was performed through an inferior counteropening, which was planned to be removed during an ear