Robotic Assisted Repair of Large Iatrogenic Tracheal Laceration with ECMO Support

Postintubation tracheal laceration (PITL) remains a challenging and rare, yet persistent, problem around the world. It has increased in incidence, previously about 0.005 percent to currently almost 0.48 percent, related to the epidemic of SARS-CoV-2 (1,2). Although bronchoscopic management with tube placement might be effective in some cases, for some patients with ventilatory issues and clinical instability, surgical repair emerges as the definitive treatment. This video describes the use of a robotic platform combined with veno-venous ECMO as an excellent option to avoid major surgical trauma and improve surgical results in a severe PITL.

The Patient

The patient in this case is an eighty-three-year-old women who is obese and has hypertension, and a palliative performance scale (PPS) score of 90 percent (3). The patient was diagnosed with COVID-19 by RT-PCR test. After ten days from the onset of symptoms, she had respiratory failure requiring orotracheal intubation and mechanical ventilatory support. She developed subcutaneous emphysema, initially cervical but with rapid progression to universal distribution with tension, and had ventilatory instability. Bronchoscopic findings confirmed the presence of PITL. She was transferred to the hospital where the surgery was eventually performed. Endoscopic evaluation showed a 6 cm transmural lesion of the posterior wall of the trachea, grade IIIA of Cardillo (4), from the middle third of the trachea to the left main bronchus. No tracheoesophageal fistula was observed.|

Next, a multidisciplinary board discussed the case. Because of the complex tracheal laceration, high ventilatory parameters, progressive and massive subcutaneous emphysema, formerly functional capacity, and age-related frailty, it was decided to perform a minimally invasive robotic assisted thoracoscopic surgery (RATS) with the support of extracorporeal membrane oxygenation (ECMO) therapy.

The Surgery

The patient was submitted to a veno-venous ECMO. Cannulas were inserted in the groin bilaterally because of subcutaneous emphysema—the right femoral vein for drainage and the left vein for return. After twelve hours of stability with improvement in blood gases, the RATS repair of the trachea was performed using the Da Vinci Xi® surgical platform with four 8 mm ports for the robotic arms and one 15 mm port for the assistant using a right-side approach.

The surgery began by opening the mediastinal pleura, then dissecting and stapling the azygos vein for better exposure of the entire posterior wall of the trachea and carina. After clearing small mediastinal collections, esophagus isolation, and correct identification of the entire lesion with bronchoscopy assistance, the repair was performed with running suture with 3.0 Stratafix® on the trachea and interrupted suture with 4.0 PDS® on the left main bronchus. There were no complications and no air leak in this process. The use of CO2 to keep the pneumothorax during the procedure with open airways was safe and did not cause hypercapnia. Because of the underlying cause and the intubation time, a percutaneous guided tracheostomy was performed at the same time. Owing to satisfactory ventilation parameters and good autonomy, ECMO was withdrawn at the end of the surgical procedure.

The patient had a gradual and favorable recovery with intensive clinical care, antibiotics, and progressive respiratory improvement. Her tracheostomy site was decannulated thirty-six days after surgery, and she was discharged home on the forty-seventh day.

Conclusion

PITL is a rare condition that requires individualized decision making. Obesity, old age, and female sex are the most important risk factors (5,6). There is some consensus for surgical repair in grade IIIA lacerations with progressive emphysema and respiratory failure. The decision to move forward with a surgical approach depends on the location and extent of the lesion, usually with large thoracotomies to access the entire trachea. However, this is associated with major surgical trauma, and ventilation during the surgery requires intermittent apnea, which is challenging. Endobronchial repair can also be performed but demands technical skills, intermittent apnea, and adequate instruments (7). 

Therefore, ECMO support and the robotic platform allow surgeons to safely maintain oxygenation during the procedure and perform a minimally invasive, complete, and safe tracheal reconstruction (8,9). This ensures all the benefits of RATS, such as less postoperative pain, pneumonia, and atelectasis, along with all the reduced perioperative changes in acute phase of immunological and hormonal responses (10–12).

References

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