Surgical techniques of tracheostoma reconstruction
The simplest method of widening the stoma is the dilatation of the stenosis by the use of cannulas and buttons. However, this is usually only a temporary solution as it does not remove the stenotic scar tissue and may aggravate it.
General principles
Various more or less elaborate techniques have been described to reconstruct a stenotic tracheostoma. Previous radiotherapy does not preclude reconstruction, but can make surgery more difficult. Excision of the stenotic scar tissue is the first step, which has to be performed to prevent recurrent stenosis. Excess subcutaneous tissue and fat have to be excised as well as overhanging skin flaps. If necessary, the remaining thyroid lobe has to be lateralized if it is bulging into the stoma borders.
Sometimes it is also necessary to resect the sternal heads of the sternocleidomastoid muscles if they deepen the lateral walls of the tracheostoma, and when one has already been removed as part of a neck dissection, the opposite sternal head should be cut to obtain a symmetrical surface. Apart from these common steps, the reconstructions can be classified into three categories. In each category minor variations have been described but the principles are essentially the same within each group.
Category 1
The first technique consists of removing the stenotic part of the stoma with about a centimeter of skin and simple suture of the skin to the tracheal wall. This so-called ‘doughnut method’ is probably the oldest method.4 It has the disadvantage that it does not interrupt the line of circular wound healing which is prone to recurrent stenosis. Most of the variations of this technique consist of the creation of lateral traction of the walls in an attempt to prevent a new stenosis.12 Some also advocate the use of radial incisions with subsequent dilatation with cannulas.12 We believe this latter method to be more likely to cause recurrent stenosis, since lack of primary wound healing may lead to more fibrosis.
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Category 2 The second group of reconstructions consists of inserting a cutaneous flap in the dorsal part of the upper trachea.1,4,13,14 Not only does this result in widening of the diameter of the stoma but it also causes an interruption of the circle of scar tissue, thereby decreasing the risk of a new stenosis (figures below). Several modifications have been described but they all have in common the use of a posterior skin flap.2,5,15,16 This technique usually succeeds in increasing he diameter of the stoma, but it can interfere with prosthetic voice rehabilitation, since the dorsal part of the tracheostoma becomes covered with skin. That part of the tracheostoma is the location of the tracheoesophageal (TE) fistula and thus the voice prosthesis. Therefore, if a prosthesis is already in situ, it may have to be removed and reinserted at a later date. Consequently, the patient loses his voice for at least several weeks. Furthermore, the thickness of the skin might complicate the insertion of a new prosthesis. The common wall of trachea and esophagus may become too thick for the current types of prostheses. |
a). Incision circumventing the stoma. An incision is also made through the tracheal mucosa, and vertically in the back wall of the trachea (not shown on the diagram).
b). After suturing the skin incision to the tranchea, note that the posterior skin flap has been insinuated into the posterior vertical incision, thus precluding the placement of a prosthesis in this position.
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Category 3 The last technique, which we call the lateral flap technique, also consists in interrupting the line of circular scar contracture by inserting two cutaneous flaps in the lateral walls of the stoma4,12 by using a double Z-plasty (figures to the left). A modification consists of a superiorly-based bilateral skin flap, which is rotated into the lateral walls of the trachea.14 Another modification which we prefer is the so-called “fish-mouth technique”. It consists in the splitting of the first two tracheal rings at 3- and 9-o’clock positions, where after two laterally-based V-Y flaps are inserted into the split tracheal walls (figures below).17 Essentially these methods are based on the same principles as the dorsal flap, i.e. interruption of the line of a circular scarring. However, they do not have the potential disadvantage of interfering with the location of the voice prosthesis. |
Category 3 techniques, involving two lateral
plasties. In the posterior tracheal wall a Provox voice posthesis is shown.
Category 3 techniques, involving lateral V-Y
plasties. In the posterior tracheal wall a Provox voice prosthesis is
shown. |
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These techniques can also be used when combining the reconstruction of the stoma with a closure of a TE fistula. In this case, after removal of the voice prosthesis and closure of the fistula, the posterior tracheal wall may be strengthened by interposing other tissue, usually muscle, between the trachea and esophagus. The aim of such a procedure is to achieve a stoma with a proper diameter with a strengthened posterior tracheal wall (figure left). A secondary tracheoesophageal puncture can be performed after complete healing of the reconstructed stoma, after approximately six weeks. |
One year after the procedure. The scar of the V-Y flap can still be seen to the right of the stoma. |
