The principles of tracheal resection are derived from elementary surgical tenets: a healthy anastomosis will result from meticulous mucosal apposition between well-vascularized tissues opposed without undue tension. To that end, the following corollaries hold: (a) the limits of tracheal resection must extend to healthy, normal tissues, and (b) circumferential dissection beyond the resected ends should be minimized so as to not jeopardize the segmental nature of tracheal blood supply. Up to half of the trachea (about 12 cm) may be resected with primary end-to-end anastomosis. However, if more than three to four cartilaginous rings are resected, then tension-releasing maneuvers beyond flexion of the head and mediastinal mobilization within the avascular pretracheal plane must be considered. Such maneuvers include the suprahyoid release, as described by Montgomery, and the hilar release, with each of these permitting an additional 1 to 2 cm of resection. In general, dissection immediately adjacent to the tracheal wall will prevent injury to the recurrent laryngeal nerves and esophagus. An exception is the posterior cricoid plate, behind which the recurrent laryngeal nerves ascend to enter the cricoarytenoid joint on either side. When the condition to resect back to healthy tissue cannot be met, for example, in many inflammatory conditions where there are multiple affected segments in series or globally inflamed mucosa, then surgical candidacy for tracheal resection must be questioned.

The cartilaginous skeleton of the larynx, which houses the vocal cords, is comprised of the thyroid, cricoid, and arytenoid cartilages. The narrowest fixed part of the airway is marked by the cricoid ring. The recurrent laryngeal nerves lie in the tracheoesophageal groove and enter the larynx at the level of the inferior cornu of the thyroid cartilage.
When attempting to excise unhealthy mucosa overlying the posterior cricoid plate, the excision should not be carried >2 cm proximal to the inferior edge of the plate to avoid injury to the cricoarytenoid joint.

The surgical approach is dictated by the location and extent of diseased trachea. Malignant lesions involving the upper and mid-thirds of the trachea and benign conditions extending down to within four rings of the carina may be managed through a cervical incision. This may require a partial sternotomy for adequate visualization. Malignant lesions involving the distal third and benign conditions extending to within four rings of the carina may be accessed via a right thoracotomy, although a transsternal approach can also be considered. The latter approach allows an exposure of the carina by incising the posterior pericardium while retracting the superior vena cava to the right and the ascending aorta to the left.

The management of the airway requires synchronized communication between the surgeon and anesthesiologist. At the start of the procedure, assessment by bronchoscopy guides whether initial dilatation with a ventilating scope is required to permit the passage of an orotracheal endotracheal tube beyond the stenosis. In the setting of nearly obstructive lesions, induction via inhaled agents should be employed to preserve spontaneous ventilation. If possible, intubation across the lesion is performed following dilatation. Sterile anesthesia tubing and connectors are passed to the anesthesiologist for use across the operative field. Upon tracheal division, the orotracheal tube is retracted out of the field, and a sterile cuffed 6-0 flexible armored endotracheal tube is intermittently inserted into the cut end of the distal trachea to provide cross-table ventilation. Alternatively, a jet ventilation catheter can be directly placed into the cut distal airway from the field or a separate jet catheter can be advanced from within the lumen of the partially withdrawn oropharyngeal endotracheal tube. Once the posterior half of the anastomotic sutures is complete, the original orotracheal tube is advanced into the distal airway during completion of the procedure.

The steps of tracheal resection and reconstruction can be reduced to the following: (1) localize the diseased segment, (2) mobilize the trachea, (3) transect the trachea, (4) resect the affected area, (5) employ release maneuvers if necessary, and (6) reconstruct.

The patient is placed supine with an inflatable roll beneath the upper back to extend the neck. An esophageal bougie (size 30 Maloney) or nasogastric tube can be placed to facilitate later dissection of the trachea from the esophagus. A transverse cervical incision centered at the cricoid cartilage is made. Skin flaps are elevated in the subplatysmal plane, extending from the superior extent of the larynx to the sternal notch inferiorly. The strap muscles and thyroid isthmus are divided along the midline. Blunt dissection to separate the superficial and deep strap muscles facilitates exposure and subsequent tracheal mobilization. The pretracheal plane is bluntly developed with a finger in the anterior mediastinum toward the carina.

The level of the tracheal stenosis is usually evident through the outward appearance of narrowing, dense scar, and surrounding inflammation. If in doubt, the tracheal stenosis can be localized with the use of a flexible bronchoscope inserted through the endotracheal tube from above. Under bronchoscopic control, the stenosis is then identified by transillumination or by direct localization using a transtracheal 25-gauge needle. The tracheal wall at this point is then marked with a fine stitch. After mobilization is complete, circumferential tracheal dissection at the level of the affected segment is performed sharply, taking care to remain close to the tracheal wall in order to minimize risk of injury to the recurrent laryngeal nerves and to avoid airway devascularization.

Before the trachea is incised, proximal and distal full-thickness 2-0 silk traction sutures are placed 1 to 2 cm away from the proposed line of resection on either side in the mid-lateral position. The trachea is partially transected anteriorly through the stenotic segment (Fig. 3). Subsequent parallel incisions can be made distally until the airway lumen is sufficient to allow direct tracheal intubation and cross-table ventilation. Transection of the posterior wall of the trachea is performed under direct vision from the luminal as well as external aspects, using the esophageal bougie as a guide to help avoid esophageal injury when separating the membranous wall of the airway from the esophagus. The caliber and thickness of the airway wall at the distal extent of the resection is evaluated. If the distal end is not free of disease, then further resection is done, incising 1 to 2 mm at a time in a “breadloaf” fashion to avoid removing normal airway.