British Journal of Plastic Surgery (1992), 45, l-162

Anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap

M. Shinoda and I. Takagi

Department of Thoracic Surgery, Aichi Cancer Center Hospital, Nagoya, Japan

SUMMARY. We describe the reconstruction of an anterior media&al tracheostomy with a latissimus dorsi musculocutaneous flap. This procedure is safer, more easily carried out, a more reliable means of creating an anterior mediastial tracheostomy and is better suited for chest wound healing than previous methods. In addition, the appearance of the patient’s chest after operation is cosmetically excellent.

The most serious, and often fatal, complication in the reconstruction of an anterior mediastinal tracheos- tomy is rupture of a major vessel (Waddell and Cannon, 1959; Grillo, 1966; Orringer and Sloan, 1979; Terz et al., 1980; Sisson and Goldman, 1981). To avoid this complication, safe techniques have recently been advocated with a pectoralis major musculocutaneous flap which covers the large vessels and improves wound healing (Terz et al., 1980; Sisson and Goldman, 1981; Withers et al., 1981; Gomes et al., 1987). We report a satisfactory result of an anterior mediastinal tracheostomy using a latissimus dorsi musculocuta- neous flap as a concomitant procedure in a patient who underwent resection of an oesophageal carcinoma with a metastatic lymph node which had invaded the trachea at the thoracic inlet.

Case report

A 58-year-old man was admitted with a 2-month history of hoarseness. Endoscopy showed paralysis of the right vocal cord and fungating tumour in the membranous part of the trachea down to 5.5 cm from the carina. This was due to invasion from a metastatic node in the thoracic inlet, the primary tumour being a squamous cell carcinoma of the oesophagus.

Resection involved removal of the sternum down to the second intercostal space and median resection of the right clavicular head, and the right-side first and second ribs (Fig. 1). A right-side latissimus dorsi musculocutaneous flap was designed to cover without tension the entire defect. The flap was led to the anterior mediastinum through a tunnel created by manually separating the major and minor pectoralis muscle.

Total thoracic oesophagectomy with thoracotomy was done, and laryngectomy in addition, leaving a mediastinal tracheal opening. A pharyngogastric anastomosis was used for the reconstruction of the gullet. The site for the proposed tracheal stoma was chosen in the centre of the skin island (Fig. 2) and the trachea, relocated between the innominate artery and vein, was passed through the defect in the flap (Figs 3,4). During this procedure the endotracheal anaesth- etic tube was repeatedly removed and replaced. The edges

of the skin island were sutured to the surrounding skin. The musculocutaneous flap now constituted a seal around the tracheal stoma and protected the major vessels as well as the cut bones in the mediastinum.

Postoperatively, the patient did not require ventilatory support, and no complications such as respiratory problems or necrosis of the skin flap were seen. He remains free from the disease 3 years after surgery.

Discussion

The most serious, frequently fatal, complication in the reconstruction of an anterior mediastinal tracheos- tomy is rupture of a major vessel. Two crucial problems are encountered in preventing this.

Firstly, tension on the suture line between trachea and skin has to be avoided. Relocation of the tracheal stump to the right of the aortic arch and innominate artery may help to decrease the tension (Waddell and Cannon, 1959). If need be, the trachea can be further displaced inferiorly and to the right of the innominate artery and vein, as described by Orringer and Sloan (1979). The distance between the trachea and skin may be shortened by l-2 cm through this manoeuvre.

Secondly, adequate coverage of major vessels needs to be provided. Bipedicled upper thoracic apron flaps or thoracoacromial rotational flaps were not satisfac- tory for this and interposition of a pectoralis muscle flap between the trachea and innominate artery has been advocated as a safe technique by Terz et al. (1980), Sisson and Goldman (1981), Withers et al. (1981) and Gomes et al. (1987). Musculocutaneous flaps are effective in providing bulk to fill the dead space and cover the major vessels and cut bones, and to improve wound healing.

Although the use of a latissimus dorsi musculocuta- neous Aap was earlier suggested by Terz et al. (1980) and Gomes et al. (1987), this is, to our knowledge, the first report of its clinical application. The flap has abundant vascularity as well as wide mobility, provides bulk to fill the dead space, and is easily elevated; in

160

Anterior Mediastinal Tracheostomv with a Latissimus dorsi Musculocutaneous Flan 161

Fig. 1

Fig. 3 Fig. 4

Figure l--Skin incisions and bone excisions. Figure 2-Circular defect in the skin island. Figure &Transposition of the trachea. Figure 6 Tracheocutaneous sutures with 3-O Nylon.

addition, primary closure is possible at the donor site. Furthermore, the appearance of the chest after reconstruction is better (which may prove particularly relevant to female patients) than the results of previously applied procedures (Fig. 5).

Fig. 5

Figme %-Anterior view 6 months after reconstruction of the anterior mediastinal tracheostomy.

Although our experience has been limited to one case, we believe that this method greatly facilitates the reliable creation of an anterior mediastinal tracheostomy.

Acknowledgement

The authors thank Dr Hidehiro Matsuura and Yumeji Takeichi, Department of Head and Neck Surgery, for support of this operation with their skilful techniques.

References

Comes, M. N., Kroll, S. ad Spear, S. L. (1987). Mediastinal tracheostomy. AnnaIs of Thoracic Surgery, 43,539.

Grille, H. C. (1966). Terminalor mural tracheostomy in the anterior mediastinum. Journal of Thoracic and Cardiovascular Surgery, 51, 422.

Orringer, M. B. and Sloan, H. (1979). Anterior mediastinal tracheostomy. Journal of Thoracic and Cardiovascular Surgery, 78, 850.

&son, G. A. and Coldmaa, M. E. (1981). Pectoral myocutaneous island flap for reconstruction of stomal recurrence. Archives of Otolaryngology, 107,446.

162 British Journal of Plastic Sureerv

Terz, J. J., Wagman, L. D., King, R. E., Brown, P., Neifeld, J. P. and Lawrence, W. Jr. (1980). Results of extended resection of tumor involving the cervical part of the trachea. Surgery Gynecology and Obstetrics, 151,491.

Waddell, W. R. and Cannon, B. (1959). A technique for subtotal excision of the trachea and establishment of a sternal tracheos- tomy. Annals of Surgery, 149, 1.

Withers, E. H., Davis, J. L. and Lynch, J. B. (1981). Anterior mediastinal tracheostomy with a pectoralis major musculocuta- neous flap. PIastic and Reconstructive Surgery, 67,38 1.

The Authors Masayuki Skinoda, MD, Section Head. Iwao Takagi, MD, Consultant Surgeon

Department of Thoracic Surgery, Aichi Cancer Center Hospital, l- 1 Kanokoden, Chikusa-ku, Nagoya 464, Japan.

Requests for reprints to Dr Shinoda.

Paper received 11 June 1991. Accepted 6 August 1991 after revision.