Robotic Repair of Intraoperative Tracheal Injury

The authors present the case of a 62-year-old female who underwent a right lower lobectomy for stage 1B adenocarcinoma. During the procedure, an injury to the membranous trachea caused by the endotracheal tube (ETT) balloon was identified. At the conclusion of the surgery, a moderate amount of blood was noted to be emanating from the endotracheal tube. The authors switched to a single-lumen endotracheal tube for bronchoscopy, and after clearing the blood clots, they observed continued bleeding from the upper airway. This was unusual, as after lung resection, one would typically expect bleeding distally rather than proximally. 
 
To improve visualization of the airway, the authors switched to a laryngeal mask airway, which allowed them to identify the tracheal injury. Then, the authors reverted to a single-lumen endotracheal tube, positioning the tip just above the carina, and used an EZ blocker to ventilate the patient. The decision was made to re-dock the surgical robot to repair the tracheal injury. Upon examination, the endotracheal tube balloon was found protruding from the tracheal defect. To avoid inadvertent puncture, the balloon was deflated, and the authors avoided inflating it between stitches to prevent disrupting the repair. 
 
Suturing was performed without positive pressure ventilation, using breath holds with a cigar placed over the defect to increase positive end-expiratory pressure (PEEP). The tracheal defect was repaired in an interrupted fashion with full-thickness bites ensuring mucosa-to-mucosa approximation. Meticulous dissection around the trachea was crucial to preserve its blood supply because the trachea lacks a direct blood supply. A bronchoscopy performed five days post-surgery revealed a well-healed tracheal repair. 
 
A key point in this case is the challenge of airway management during tracheal repair. Maintaining ventilation is particularly difficult. In this instance, the authors used a single-lumen tube with EZ blockers to maintain ventilation, but the balloon was within the operative field. Consequently, the authors had to perform the repair with the balloon deflated and without adequate positive pressure. In retrospect, using a smaller endotracheal tube to intubate the left mainstem for single lung ventilation would have improved ventilation. However, the authors deemed extubating and re-intubating the patient was too high risk in this particular case. 

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