(BQ) Part 1 book An atlas of head and neck surgery has contents: Sectional radiographic anatomy and scanning, emergency procedures, basic considerations, diagnostic endoscopy, the sinuses and maxilla,... and other contents.
John M Lore, Jr., M.D Distinguished Member (Clinical Research) Medical Staff, Roswell Park Cancer Institute Professor Emeritus, School of Medicine, State University of New York at Buffalo Medical Director Emeritus, John M Lore, Jr., Head and Neck Center, Sisters of Charity Hospital Former Head, Department of Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital University Chief, Department of Otolaryngology, Buffalo Children's Hospital and Erie County Medical Center Consultant, Veterans Administration Medical Center Consultant, Roswell Park Cancer Institute Director of Surgery, Good Samaritan Hospital, Suffern, New York Jesus E Medina, M.D University Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology, of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma Illustrated by Robert Wabnitz Director Emeritus of Medical Illustration, University of Rochester and Medical Center, Rochester, Margaret Pence M.F.A in Medical Illustration, Rochester Institute of Technology Adjunct Professor, School of Fine Art, College of Imaging Arts and Sciences, Rochester, New York ELSEVIER SAUNDERS New York ELSEVIER SAUNDERS The Curtis Center 170 S Independence Mall W 300E Philadelphia, Pennsylvania 19106 AN ATLAS OF HEAD AND NECK SURGERY, FOURTH EDITION Copyright c 2005, Elsevier Inc All rights reserved ISBN 0·7216-7319-8 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia, PA, USA: Phone ( + 1)215 238 7869 fax: (+ 1) 215 238 2239 e-mail: healthpermissions@elsevier.com You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com) by selecting 'Customer Support' and then 'Obtaining Permissions.' NOTICE Surgery is an ever-changing field Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate Readers are advised to check the most current product infor- mation provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient Neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising from this publication Previous editions copyrighted 1988, 1973, 1962 Library of Congress Control Number: 2003114446 International Standard Book Number 0-7216-7319-8 Acquisitions Editor: Rebecca Schmidt Gaertner Developmental Editor: Arlene Chappelle Publishins Services Manager: Tina Rebane Senior Project Manager: Mary Anne Folcher Cover Designer and In/erior Design Coordinator: Ellen Zanolle Printed in China Last digit is the print number: CONTRIBUTORS AHMED ABDEHALlM, M.D ANGELA BONTEMPO, Clinical Assistant Professor of Diagnostic Radiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Neuroradiologist, Roswell Park Cancer Institute; Neuroradiologist, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York Advanced Techniques for CT in the Head and Neck (Chapter 1) President and CEO, Saint Vincent Health System, Erie, Pennsylvania A Comprehensive, Interdisciplinary Head and Neck Service (Chapter 3) F.A.C.H.E DANIEL BRODERICK, M.D Assistant Professor of Radiology, Mayo Clinic, Jacksonville, Florida Bone Imaging and Pathology (Chapter 3) RONALD A ALBERICO, M.D DANiEl SETTE CAMARA, M.D Associate Professor of Radiology and Assistant Clinical Professor of Neurosurgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Director of Neuroradiology and Head and Neck Imaging, Roswell Park Cancer Institute; Director of Pediatric Neuroradiology, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York Advanced Techniques for CT in the Head and Neck (Chapter 1) Clinical Associate Professor of Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Gastroenterology Service, Sisters of Charity Hospital, Buffalo, New York Percutaneous Endoscopic Gastrostomy (Chapter 21) JOSEPH M ANAIN, M.D Assistant Clinical Professor, Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chief, Division of Vascular Surgery, Sisters of Charity Hospital, Buffalo, New York Vascular Procedures (Chapter 22) DAVID M CASEY, D.D.S., M.S Clinical Professor, Department of Restorative Dentistry, State University of New York at Buffalo School of Dental Medicine; Head, Maxillofacial Prosthetic Section, John M Lore, Jr., M.D Head and Neck Center, Sisters of Charity Hospital; Maxillofacial Prosthodontist, Department of Dentistry, Maxillofacial Prosthetics, Roswell Park Cancer Institute, Buffalo, New York Dental and Prosthetic Considerations in Head and Neck Surgery (Chapter 3); Maxillofacial Prostheses (Chapter 3) SHIRLEY A ANAIN, M.D Assistant Clinical Professor, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Facial Paralysis (Chapter 7) GREGORY J CASTIGLIA, M.D Neurosurgeon, Buffalo Neurosurgical Group, Amherst, New York Supraorbital Approach to the Orbit and Paranasal Sinuses (Chapter 23) JOHN E ASIRWATHAM, M.D Clinical Associate Professor of Pathology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Department of Pathology, Sisters of Charity Hospital, Buffalo, New York Bone Imaging and Pathology (Chapter 3); Pathology of the Parathyroid Glands (Chapter 18) v CONTRIBUTORS NIEVA B CASTILLO, M.D Assistant Clinical Professor of Pathology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Associate Chief of Pathology, Department of Pathology, Sisters of Charity Hospital, Buffalo, New York Malignant Mixed Tumor (Chapter 17); Endocrine Surgery (Chapter 18); Vascular Procedures (Chapter 22) KANDALA CHARY, M.D Medical Oncology, Sisters of Charity Hospital, Buffalo, New York Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck (Chapter 3) SCOTT CHOLEWINSKI, M.D Director, Department of Magnetic Resonance Imaging, Sisters of Charity Hospital, Buffalo, New York CT and MRI (Chapter 1); Bone Imaging and Pathology (Chapter 3) KEITH F CLARK, M.D., Ph.D Clinical Professor, Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma Endoscopic Sinus Surgery (Chapter 5) ERNESTO A DIAZ-ORDAZ, M.D Assistant Professor of Otolaryngology and Assistant Professor of Communicative and Speech Disorders, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Acting Chair, Department of Otolaryngology, Sisters of Charity Hospital, Buffalo, New York Infratemporal Approach to the Skull Base (Chapter 23) ROBERT W DOLAN, M.D Surgeon, Department of Otolaryngology, Head and Neck Surgery, Lahey Clinic, Burlington, Massachusetts Microvascular Surgery (Chapter 24) MEGAN FARRELL,M.D Endocrinologist, John M Lore, Jr., M.D Head and Neck Center, Sisters of Charity Hospital, Buffalo, New York Endocrine Surgery (Chapter 18) DAVID F HAYES, M.D Assistant Clinical Professor of Radiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chair, Department of Diagnostic Imaging, Sisters of Charity Hospital, Buffalo, New York CT and MRI (Chapter 1); Ultrasound (Chapter 1) l NELSON HOPKINS, M.D Chief of Neurosurgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Vascular Procedures (Chapter 22) R LEE JENNINGS, M.D Assistant Clinical Professor of Surgery, University of Colorado Health Sciences Center School of Medicine; Colorado Surgical Oncology Associates, Denver, Colorado Preoperative and Postoperative Care (Chapter 3) CONSTANTINE P KARAKOUSIS, M.D., PH.D Professor of Surgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Millard Fillmore Hospital (Kaleida Health System), Buffalo, New York Malignant Melanoma (Chapter 3); Soft Tissue Sarcoma (Chapter 3) SOL KAUFMAN, Ph.D Research Assistant Professor of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Consultant, Biostatistics, Buffalo, New York Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck (Chapter 3) DOUGLAS W KLOTCH, M.D Surgeon in Private Practice, Tampa, Florida Fractures of Facial Bones (Chapter 13) ASHOK KOUL, M.D Clinical Assistant Professor of Pathology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Director of Pathology and Laboratory Medicine, Sisters of Charity Hospital, Buffalo, New York Commonly Used Terminology for Squamous Epithelium (Chapter 3) CONTRIBUTORS JOHN LAURIA, M.D DOUGLAS B MORELAND, M.D Professor and Chair Emeritus, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences and Sisters of Charity Hospital, Buffalo, New York Venous Air Embolism (Chapter 2); Malignant Hyperthermia (Chapter 2) Director, Buffalo Neurosurgery Group; Chief of Neurosurgery, Sisters of Charity Hospital; Co-Director, Gamma Knife Center, Roswell Park Cancer Institute, Buffalo, New York Endoscopic Endonasal Transsphenoidal Approach to the Pituitary Gland (Chapter 23) WILLIAM M MORRIS, M.D KEUN Y LEE, M.D Assistant Clinical Professor, Department of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Attending in Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital; Buffalo Otolaryngology Group, Buffalo, New York Posterior Neck Dissection (Chapter 16) Buffalo, New York Cardiopulmonary Resuscitation (Chapter2) WILLIAM R NElSON, M.D Clinical Professor Emeritus of Surgery, University of Colorado Health Sciences Center School of Medicine, Denver, Colorado Preoperative and Postoperative Care (Chapter 3) JOHN S LEWIS, M.D ROBERT J PERRY, M.D Associate Clinical Professor Emeritus of Otolaryngology, Columbia University College of Physicians and Surgeons, New York, New York Temporal Bone Resection (Chapter 23) Clinical Associate Professor of Surgery (Plastic), State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chief, Division of Plastic Surgery, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York Cleft Lip and Palate (Chapter 10) THOM R LOREE, M.D Chief, Department of Head and Neck Surgery, Roswell Park Cancer Institute, Buffalo, New York Management of Salivary Gland Tumors (Chapter 17) JOACHIM PREIN, M.D., D.M.D Senior Vice President, Medical Affairs, Sisters Healthcare System, Buffalo, New York A Comprehensive, Interdisciplinary Head and Neck Service (Chapter 3) Professor of Maxillofacial Surgery and Chair, Clinic for Reconstructive Surgery, Unit for Maxillofacial Surgery, University Clinics of Basel; Chair, European Maxillofacial Education Committee, Basel, Switzerland Compression Plating for Ireatment of Mandibular Fractures (Chapter 13) JESUS E MEDINA, M.D ALLEN M RICHMOND, Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma The Neck (Chapter 16) Clinical Instructor, Department of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; John M Lore, Jr., M.D Head and Neck Center, Sisters of Charity Hospital; Staff, Buffalo Hearing and Speech Center, Inc., Buffalo, New York Voice, Speech, and Swallowing Rehabilitation of the Head and Neck Patient (Chapter 3) A CHARLES MASSARO, M.D ROBERT S MILETICH, M.D., Ph.D Associate Professor of Clinical Nuclear Medicine, Department of Nuclear Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Staff Physician, Veterans Affairs Western New York Healthcare System, Buffalo, New York; Staff Physician, Dent Neurologic Institute, Amherst, New York Positron Emission Tomography (Chapter 1) PH.D ARTHUR J SCHAEFER, M.D.t Clinical Professor of Ophthalmology and Clinical Assistant Professor of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Blindness and Ophthalmic Complications of Surgery of the Head and Neck (Chapter 2) t Deceased CONTRIBUTORS DANIEL P SCHAEFER, M.D MONICA B SPAULDING, Director of Oculoplastic, Facial, Orbital, and Reconstructive Surgery; Clinical Professor of Ophthalmology; Clinical Assistant Professor of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Blindness and Ophthalmic Complications of Surgery of the Head and Neck (Chapter 2); Thyroid-Related Orbitopathy (Chapter 3); Supraorbital Approach to the Orbit and Paranasal Sinuses (Chapter 23) Associate Professor of Medicine and Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chief, Oncology Section, Veterans Affairs Western New York Healthcare System, Buffalo, New York The Place for Chemotherapy in Management of Squamous Cell Carcinoma of the Head and Neck (Chapter 3) DHIREN K SHAH, M.D Medical Director, Cancer Treatment Services; Assistant Clinical Professor, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Radiation Therapy for Laryngeal Cancer (Chapter 20) DONALD P SHEDD, M.D Professor Emeritus, Department of Head and Neck Surgery, Roswell Park Cancer Institute, Buffalo, New York Common Departures from Sound Management (Chapter 3) M.D MAUREEN SULLIVAN, D.D.S Chief, Department of Dentistry and Maxillofacial Prosthetics, Roswell Park Cancer Institute, Buffalo, New York Osseointegrated Implants in Head and Neck Reconstruction (Chapter 3) NAN SUNDQUIST, R.N Formerly Chief Nurse, Department of Otolaryngology, State University of New YQrk at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck (Chapter 3) IN MEMORIAM Dr John M Lore, Jr., passed away on January 12,2004 He continued active medical practice and cared for his patients until shortly before his death Dr Lore was world renowned as a head and neck surgeon After receiving his medical degree from New YorkUniversity, he completed residencies in both otolaryngology and general surgery He was the Chairman of the Department of Otolaryngology-Head and Neck Surgery at the State University of New York at Buffalo School of Medicine, 1966 to 1991 He later joined the Department of Head and Neck Surgery at Roswell Park Cancer Institute Dr Lore was one of the founders of the American Society of Head and Neck Surgery He was a past president of that society as well as of the Society of Head and Neck Surgeons He contributed to the early efforts to combine the two Head and Neck Societies He was also a founding member, and former chairman of the Joint Council for Advanced Training in Head and Neck Oncologic Surgery, which was instrumental in establishing the fellowship programs in advanced Head and Neck Surgical Oncology, accredited by the American Head and Neck Society During his long and distinguished career, Dr Lore received many honors and awards recognizing his many contributions to the specialty of Head and Neck Oncology He was passionate and tenacious in the practice of his profession; he was an early pioneer and champion of the use of adjuvant chemotherapy in the treatment of head and neck cancer Jack was equally passionate and tenacious in his many nonprofessional interests and pursuits He was an avid and accomplished skier, sailor, and photographer Professionally, his most enduring and cherished attribute was his compassion and his dedication to his patients When I first met Dr Lore, he was one of the leading members of our specialty I then became one of his collaborators and colleagues Eventually, came to know Jack as my friend He will be greatly missed An Atlas of Head and Neck Surgery, 4th edition, serves as a legacy and tribute to his memory Thom R Loree, M.D IX Recognition by The Board of Managers of St Vincent's Hospital, New York, New York, at the time of his death THE TRACHEA AND MEDIASTINUM Median Sternotomy, Total Thyroidectomy, With Superior Mediastinal Node and Radical Neck Dissection (Continued) (Fig 19-10) o The median sternotomy is closed by drilling small holes or using a sternal punch through and through with a ribbon retractor for protection of the underlying great vessels Malleable silver wire or stainless steel wire is first threaded outside-in through the left-sided hole The eyelet end of a curved needle is then passed outside-in through the right-sided hole, and the wire is inserted through the needle hole by using a clamp or needle holder The wire is pulled through the rightsided hole with the needle Another method is to use a pull-through fine wire on the right side, which forms a loop The heavy wire is passed through the loop and withdrawn P This technique is repeated as pictured for the remainder of the sternal approximation Some opera- tors not believe such through-and-through sutures are necessary They use periosteal and perichondrial sutures with supporting sutures through the fascia Q A tracheostomy is performed if indicated, and two drains are inserted, one in the cervical region and one in the mediastinum If a small portion of trachea is excised with the thyroid tumor, depending on its location, the resulting defect could serve as the site of the tracheostomy If a complete circumferential portion is excised, refer to the section on tracheal resection (see Fig 19-4) If the pleural cavity was entered, an intercostal tube with underwater drainage is mandatory (see Figs 2-3G to J and 2-4 to 2-6) If the upper respiratory or pharyngoesophageal tract was entered, it is best to insert tube drainage into the mediastinum because of the danger of fistula formation in the cervical region, which would then drain into the mediastinum Such tubes must not come in contact with any major vessel for fear of vessel erosion Catheters with negative pressure may be used in place of the cervical drain THE TRACHEA AND MEDIASTINUM o Q , ~/a~ FIGURE 19-10 Continued 01 THE TRACHEA AND MEDIASTINUM Mediastinal Dissection for Tracheostoma Recurrence (Sisson Procedure) (Fig 19-11) (After Sisson) (Harrison, 1977) Although tracheostoma recurrence was more common some years ago, currently the incidence appears to be decreasing This is most likely due to a number of factors, not the least of which are adequate tracheoesophageal dissection at the time of laryngectomy, the use of preoperative adjuvant chemotherapy aiding in the avoidance of tracheostomy associated with airway compromise secondary to laryngeal carcinoma, and emergency laryngectomy with airway resection The etiology of tracheostoma recurrence is a moot point This may be related to nodal disease in the tracheoesophageal and superior mediastinal areas, or it may be due to tracheostomy as an emergency or semi-emergency procedure associated with airway obstruction related to carcinoma of the larynx Initial steps of the surgical procedure of mediastinal dissection are directed to evaluate resectability; for example, involvement of the major arteries in the mediastinum would preclude resectability This step involves resection of the medial one third or medial one half of the clavicle on the side of major involvement by the neoplasm (see Fig 19-9) The costoclavicular ligament between the first rib and the clavicle is transected, and the medial one half or medial one third of the clavicle is excised This affords an excellent view and facilitates evaluation of the left common carotid artery and subclavian artery on the left side and the innominate artery with the right common carotid artery and the subclavian artery on the right side The thoracic esophagus (with an esophageal tube in place) and the extent of the disease inferiorly involving the trachea are evaluated The decision can then be made as to whether an ablative procedure is indicated, with a reasonable expectation of cure or palliation Preoperative CT scans and MRI and a pharyngoesophagram are helpful, but precise evaluation regarding resectability still depends on visualization and palpation of the superior mediastinum After tracheostoma recurrence, it is our admonition not to utilize preoperative radiation therapy but rather to use adjuvant preoperative chemotherapy Surgery after radiation therapy is not only difficult but increases the risk of postoperative hemorrhage and esophageal slough Sisson (personal communication) believes that if radiation therapy has failed to control the patient's disease, the surgeon should consider esophageal resection and replacement with a gastric pull-up procedure (see p 1200) when there is significant dissection around the esophagus This will obviate an esophageal slough Highpoints I Evaluate the extent of the neoplasm and clinically stage the types as to 1,2,3, and (see Fig 19-IIA) Insert esophageal feeding tube Perform wide resection of skin and soft tissue surrounding the sternal recurrence Depending on extent of disease, evaluate major arteries, esophagus, and trachea S Resect a portion of the clavicles with the manubrium sterni to the level of the second rib or lower, if required Preserve the major arteries: the innominate and its branches, the left common carotid, and the left subclavian The left brachiocephalic vein (innominate) may be sacrificed if absolutely necessary It is better to preserve this vessel, if at all possible Preserve the vagus nerves and the phrenic nerves, at least one of each Relocate the trachea lateral and caudad to the innominate artery if necessary to obtain additional length of the trachea Protect the innominate artery and the other vessels in contact with the trachea by invagination of a portion of a pectoralis major myocutaneous flap between the trachea and the vessels 10 Ensure adequate mediastinal drainage postoperatively, using very soft catheters to avoid erosion of vessels II Debulk the portion of the pectoralis major flap that surrounds the location of the new stoma, especially superiorly 12 Do not use any type of metal laryngectomy or tracheostomy tube because of the danger of pressure necrosis of the trachea from pulsations of the innominate artery or the aorta Use a small length of cut endotracheal tube if necessary Occasionally, no tube is necessary at all A The various types of stoma recurrence as outlined by Sisson (1969): (1) localized and usually presents as a discrete nodule in the superior aspect of the stoma The prognosis is very good if detected early; (2) indicates an esophageal involvement but no inferior involvement (prognosis for type is fair to good depending on the amount of esophagus involvement); (3) originates inferior to the tracheostoma and usually has direct extension into the mediastinum Prognosis is fair to poor (4) if there is an extension laterallyand often under either clavicleand may involve the great vessels and be nonresectable Prognosis is very poor THE TRACHEA AND MEDIASTINUM CLAVICLE A B FIGURE 19-11 B The skin incision (the solid line) extends at least to cm beyond the gross evidence of disease surrounding the stoma A large skin defect is of little concern, because a pectoralis major myocutaneous flap (the dotted line) will be utilized for reconstruction of the skin; the muscle portion of this flap will be used to protect the great vessels.If feasible, the periosteum over the sternum is left attached to the skin flaps If necessary,a contralateral pectoralis major flap could be used for only its muscle portion to further protect the innominate artery and also to reinforce a pharyngeal closure of the hypopharynx if a laryngectomy is performed Continued THE TRACHEA AND MEDIASTINUM Mediastinal Dissection for Tracheostoma Recurrence (Sisson Procedure) (Continued) retracted upward in a plane between the sternum and the periosteum, exposing the left and right brachiocephalic veins, the left and right internal jugular veins, the superior vena cava, and the arch of the aorta The right internal jugular vein is retracted laterally The locations of both subclavian veins are identified (Fig 19-11) (After Sisson) (Harrison, 1977) C Outline of the sternal resection is shown with one third to one half of the clavicles and the medial portion of the first and second ribs The level of transection of the sternum depends on the extent of the lesion (anatomically, the sternum is composed of three parts: manubrium, body, and the xiphoid process) The sternum is transected between the attachments of the second and third ribs The sternal Stryker saw is utilized to transect the ribs and sternum, whereas a Gigli saw is utilized to transect the clavicles (see Fig 19-9) Rib cutters can be used to transect the ribs and possibly the clavicles Malleable retractor is placed underneath the sternum for protection, as well as pleura and internal mammary arteries If the pleura are opened, repair is done with the lung inflated A chest tube is not usually necessary unless the lung itself is lacerated Care is taken relative to the thoracic duct D This illustration is viewed from below looking superiorly Caudal edge of the transected sternum is Continued The pectoralis major flap, which will be utilized to obliterate the defect, can be mobilized now or after the mediastinum dissection With a large flap, the lateral thoracic artery along with the pectoral branch of the thoracoacromial artery is preserved To free the lateral thoracic artery, a portion of the pectoralis minor may require transection on its lateral border The midline incision over the sternum for the mediastinum dissection is the medial border of the pectoralis major myocutaneous flap Complications • • • • Hemorrhage Mediastinitis Recurrence Slough of esophagus THE TRACHEA AND MEDIASTINUM c RT COMMON CAROTID A INT JUGULAR V RT SUBCLAVIAN A INNOMINATE A D LT RECURRENT SUPERIOR VENA CAVA' LT BRACHIOCEPHALIC AORTA FIGURE 19-11 Continued LARYNGEAL V N THE TRACHEA AND MEDIASTINUM Mediastinal Dissection for Tracheostoma Recurrence (Sisson Procedure) (Continued) (Fig 19-11) (After Sisson) (Harrison, 1977) E The mediastinal dissection consists of removing all of the lymph nodes, adipose tissue, and thymus gland remnants in the superior mediastinum In the illustration the left (innominate) brachiocephalic vein has been resected along with the mediastinal dissection This mayor may not be necessary The trachea has been relocated laterally and inferiorly to the innominate artery to gain additional length This maneuver depends on the extent of disease