Hello -- Thanks for taking time to assist me with this..
here is the op-report (ENT surgery)
HISTORY: admitted secondary to COVID-19 infection with secondary pneumonia and respiratory insufficiency requiring mechanical ventilation and ECMO therapy. On xx/xx/xxxx, she underwent a percutaneous tracheotomy by the pulmonology team with placement of an 8-Shiley cuffed tracheotomy tube. Per the operative report, there was no significant bleeding at the time of placement. However, xxxxxxxxxxx, was contacted urgently on xx/xx/xxxx for a tracheotomy site bleeding. Reportedly, the patient was having persistent air leak and low tidal volumes, and therefore decision was made to exchange the tracheotomy tube. When that occurred, there was profuse bleeding from the tracheotomy wound. Cardiovascular Surgery,xxxxxxxxxx, was contacted and placed a finger in the wound for pressure hemostasis. This was held until the patient was taken down to the operating room and the wound was explored.
After removal of digital pressure, the trachea stoma was inspected and the wound was packed with Nu-Knit and two 2-0 Prolene figure-of-eight sutures were used to control the bleeding at the stoma. In the ensuing two days, the patient has been without recurrent bleeding. The ENT service was asked to re-consult for placement of a tracheotomy. Patient is currently orally intubated and remains on ECMO. Most recent COVID testing on xx/xx, xx/xx, and xx/xx returned as not detected.
We reviewed xxxxx presentation, the risks, benefits, alternatives, and indications for revision tracheotomy. I highlighted the risk for possible further significant bleeding. I noted that the team did obtain a CTA of the neck and there was no evidence of arterial bleeding and, per personal discussion with XXXXXXXX xx did not feel an arterial bleed was present. In addition, we discussed the risk of infection, the difficulty of placement of the trach given pt body habitus, the potential for loss of airway, potential for subcutaneous air, pneumomediastinum and pneumothorax, cardiovascular and pulmonary complications with potential risk for death, risk of anesthesia and medication reactions. We also discussed long-term risk of airway stenosis with difficulty breathing, which could cause long-term difficulty with breathing and/or hoarseness. xx expressed understanding and wished to proceed.
Of note, I asked that Dr.xxxxxx attend as well given the significant challenge of the surgery. The challenges include the patient's morbid obesity with weight of approximately 300 pounds, prior tracheotomy, prior major bleeding after tracheotomy, and expectation of significant scar and inflammation from prior surgery.
FINDINGS: A 6 cuffed proximal XLT nonfenestrated Shiley tracheotomy tube was placed. Exposure was very difficult as anticipated, though there were no immediate complications evident during the surgery. Positioning of the tracheotomy tube was confirmed both with CO2 and with flexible tracheoscopy. Secretions in the airway were cleared with suctioning. Patient maintained airway pressures and ventilation after the tracheotomy tube had been placed.
DETAILS OF PROCEDURE: xxxxx was brought to the operating room, placed on the OR table in the supine position. She was maintained on ECMO with a perfusion team present. Next, a shoulder roll was positioned for neck extension. Four-inch tape was placed per Dr. xxxxx to help retract the skin and soft tissue added below the shoulders to help maximize exposure.
Inspection of the wound revealed two Prolene sutures in a figure-of-eight fashion which had closed the wound. There was no egress of air and no subcutaneous emphysema. The area was broadly prepped and draped sterilely and infiltrated with approximately 3 mL lidocaine with 1:100,000 epinephrine. Our plan was to make a horizontal incision off the prior percutaneous dilation site.
We began by removal of the Prolene sutures. The Nu-Knit hemostatic dressing was then carefully removed using DeBakey forceps under headlight illumination. There was no evidence of significant bleeding as this was performed. The tract extended deep, nearly 7 cm into the neck. However, this did not clearly end in the airway. Indeed, the portable flexible laryngoscope was sterilely opened and used to investigate the tract and it did not lead into a patent airway, nor could this be confirmed with finger palpation. However, at the distal tip of the tract, one could palpate the innominate artery low in the neck. It should be noted that the incision itself was relatively low near the sternal notch, which is understandable given patient's body habitus. However, Dr.xxxxx and I discussed our surgical approach and we agreed that we would try to begin a fresh dissection down to the anterior tracheal wall on the more proximal trachea in an effort to avoid the great vessels in the mediastinum.
Incision was made horizontally extending out from the prior circular 1.5 x 1.5 cm percutaneous incision site. This was then dissected down into the subcutaneous tissue. All of the dissection was difficult owing to fibrotic and scarred tissue. Bleeding was never more than mild, though was meticulously addressed after each division of tissue with bipolar electrocautery. I continued dissection deep through in the midline neck through the subcutaneous tissue until strap muscles were encountered. Again, this was very fibrotic inflammatory tissue and I would emphasize that the assessment of landmarks was initially very limited. As such, we continued our dissection a bit more superiorly and laterally and then used Lone Star hooks to assist with retraction.
We did achieve a landmark breakthrough once we were able to identify the cricoid cartilage superiorly in the midline. This was quite helpful in assessing the remainder of the dissection plan as well as orienting relative to the prior percutaneous dilation. It appeared that the dilation was headed toward the distal trachea and perhaps a little left of midline. As such, we did not wish to re-enter the prior plane of dilation. Of interest, there was no evidence of air or fluid extending out of the trachea despite ongoing endotracheal intubation with ventilation and, as such, it was felt possible that the prior tracheotomy site had completely healed. We also pulled up the prior CTA scan of the neck intraoperatively as we were dissecting to help reassess landmarks relative to our intraoperative findings. Again, it was not certain from the CTA where the prior tracheotomy was placed, though we did assess the area of the aorta and the innominate artery relative to the trachea.
Returning to the dissection, we used some Floseal, which was gently compressed with 4 x 4 pledgets and then removed. This was then irrigated. We continued dissection in the midline using the cricoid as our landmark. Once deep to the straps, it was likely we were dividing the thyroid isthmus. However, even this had such poor definition in terms of its inflammation and density of tissue that this could not be confirmed as thyroid isthmus. However, it was successful in that, once the tissue was divided, we were able to palpate what was clearly now trachea. Further dense fibrotic fascial-type tissue was removed off the anterior tracheal wall and Kittner was used to clean. Again, hemostasis was checked with bipolar electrocautery throughout.
Next, we prepared both Anesthesia and our surgical scrub team for entry into the tracheal airway. The patient was pharmacologically paralyzed. Ventilation was stopped. xxx baseline saturations tended to range in the high 80s to 92%. We then made a horizontal incision between approximately 2nd and 3rd tracheal rings with an 11-blade scalpel. This was then widened with a hemostat and a vertical incision was made directly down to create a T-shaped tracheotomy. The vertical component was approximately 1.5 cm. The leaflets were then dilated with a three-prong trach spreader. Initially, we did place a #8 proximal XLT tracheotomy at the tracheotomy site. However, it did not pass easily. We elected to stop and place a #5 endotracheal tube directly through the tracheotomy site and ventilate back up from the 70s to saturations in the high 80s and 90% range. The endotracheal tube was then removed and we switched it to a #6 proximal XLT Shiley tracheotomy tube. Of note, a cricoid hook was used to elevate the cricoid superiorly throughout our efforts. The trach was placed appropriately and then the obturator was removed and replaced with the inner cannula. The ventilator circuit was attached and the cuff was inflated and CO2 return was confirmed. Initially, pressures were a bit low. We then used a flexible laryngoscope to perform tracheoscopy and confirmed positioning of the tracheotomy tube in the tracheal airway. However, there were still some secretions at the level of the stoma. These were cleared with suctioning and pressures and oxygenation did improve. Of note, the anesthesia team also performed bronchoscopy with evacuation of secretions during the surgery.
Having secured the tracheotomy tube with return to baseline pressures and oxygenation, the tube was secured in place using interrupted 3-0 chromic sutures at the flange laterally and in the midline inferiorly. Arista powder was then sprayed into the wound bed for further hemostasis. The vertical component of the skin edge was closed using interrupted vertical mattress 3-0 Vicryl sutures. One interrupted 3-0 Vicryl suture was also placed laterally to close the tracheotomy incision partially under the flange. A trach gauze was then positioned. The trach tie was secured about the neck.
