Tracheal Surgeries Depend On Coordination

Rarely do surgeons and their teams rehearse before a procedure; however, the unique coordination inherent in tracheal surgeries requires the surgeon, anesthesiologist, and operating room team to review each step of the procedure before the first incision is made. This intense level of coordination and cooperation is necessary because the surgeon and anesthesiologist must each function in what is traditionally the other's surgical field.

Tracheal surgeries are commonly performed to remove a tumor, benign or malignant, that has grown from the lungs into the trachea or grown inside the trachea itself. Also, surgery is sometimes necessary to remove scarred portions of the trachea that have stenosed due to previous surgical activity in the trachea or previous prolonged intubation.

"The trachea is a very delicate organ," said Michael Grosso, MD, Attending Cardiothoracic Surgeon, Deborah Heart and Lung Center. "It can easily scar, causing narrowing, if an endotracheal tube is inserted too quickly or roughly during any surgery." Both ventilation and delivery of anesthesia during tracheal surgery become difficult as the trachea is resected during the operation and the traditional means of oxygen and anesthesia delivery through the endotracheal tube become impossible.

"The primary difference between anesthesia for tracheal surgery, as opposed to other types of anesthesia, is the surgeons are working in an area upon which the anesthesiologist is dependent for delivery of ventilation," said Roger A. Moore, MD, Chairman, Department of Anesthesia, Deborah Heart and Lung Center. "If the surgeon and anesthesiologist are not working as a team, both anticipating each other's moves as well as having full and open communication, the result can be loss of airflow to the patient."

"Deborah Heart and Lung Center is one of a small number of hospitals in the Delaware Valley with surgeons properly trained to perform tracheal surgeries," according to Dr. Grosso, who performs one to two of these delicate operations every other month, meeting with the anesthesiology and nursing teams to "rehearse" prior to each procedure. Together, they review the procedure so everyone involved knows what is expected and is prepared to deal with techniques and equipment that are not part of their routine activities in the operating room. "Normally, the nursing team is not involved with anesthesia and the anesthesiologist is not involved with the surgical field," said Dr. Grosso. "By going through the tracheal surgery ahead of time, step-by-step, the entire team becomes familiar with the procedure."

The careful changes in the delivery of anesthesia occur in three steps during the surgery (see illustration). It begins like most other surgeries, with the endotracheal tube inserted by the anesthesiologist into the mouth and through the trachea. This tube is often the traditional polyvinyl chloride tube used in other surgeries. When the surgeon is ready to resect the stenosed area, the anesthesiologist quickly pulls back the endotracheal tube so it will not be damaged by the incision. The trachea is opened, and the surgeon inserts a new endotracheal tube directly into the trachea, not from the mouth but from the surgical field. "At this point, the endotracheal tube passed off the field by the surgeon is an anode tube with a metal coil running through its sides," explained Dr. Moore. "The metal coil prevents the tube from accidentally being twisted or bent during surgery, thereby obstructing the airflow." Simultaneously, the anesthesiologist uses a variety of monitors, such as the end-tidal CO2 and the pulse oximeter, to ensure constant maintenance of adequate oxygenation during the procedure. As the surgeon begins to repair the trachea, heightened awareness of the endotracheal tube in the surgical field is required from all participants. The surgical team must be careful not to damage the tube, thus interfering with ventilation and releasing anesthetic into the air and the sterile surgical field, possibly causing the surgeon to inhale anesthesia and the patient to become infected.

When the surgeon is ready to reattach the sections of the resected trachea, the anode endotracheal tube is removed by the surgical team and a new polyvinyl endotracheal tube is inserted by traditional means through the mouth (Fig. 3). The trachea is then stitched together, and the anesthesiologist again has direct control over the movement of the tube as the surgical field is closed. "This entire procedure requires exact coordination and skill, as well as intergroup team work and a high level of communication between all parties," said Dr. Moore. "The traditional boundaries of the surgeon's concerns and the anesthesiologist's concerns become blurred during a tracheal surgery," said Dr. Grosso. "Both professionals need to be aware of each other's activities. For this reason, preparation, coordination and communication are paramount to the surgery's success."

Roger A. Moore, M.D., Chairman, Department of Anesthesiology