51.1 Introduction

Pediatric laryngotracheal stenosis involves a wide variety of pathologies caused by scar tissue formation in most cases but can also be a result of congenital anomalies. ^{1 – 3}

Various techniques for surgical management exist and will be discussed in other chapters.

Laryngotracheal reconstruction (LTR) is a procedure in which the thyroid, cricoid, and tracheal cartilages are split and the framework is expanded with various combinations of cartilage grafts and stents.

LTR has evolved to include a variety of techniques for expanding the laryngotracheal complex and stabilizing the resultant airway.

Different materials have been used in LTR over the years including short- and long-term stents, silastic sheaths, and auricular, thyroid, or costal cartilage grafts. ⁴

Cartilage interposition grafting for treatment of subglottic stenosis was pioneered by Fearon and Cotton in 1972, ⁵ and has since become the work horse for LTR. ^{6 – 9}

In this section, we wish to describe the surgical technique for costal cartilage graft harvest and discuss the postoperative care and possible complications of the procedure.

51.2 Indications and Contraindications

Costal cartilage grafting is indicated in patients with subglottic or tracheal stenosis who are planned for laryngotracheoplasty or LTR. ^{10 , 11} Contraindications include recent pulmonary infection and restrictive lung disease. Special consideration should be taken in children with prior cardiothoracic surgery as pleural adhesions may exist with resulting pleural tears during surgery.

51.3 Surgical Technique

To accurately describe surgical procedure it is imperative to include both stenotic site and donor site.

First, direct laryngoscopy and bronchoscopy under general anesthesia is performed, while maintaining spontaneous ventilation (▶ Fig. 51.1). After determining the location, degree, and length of stenosis, the patient is ventilated either through an existing tracheostomy tube or via an endotracheal tube.

The patient is then prepped and draped for the procedure at two separate sites.

Incisions are marked; horizontal neck incision in skin crease and costal cartilage donor site incision over the forth rib just lateral to the synchondrosis (▶ Fig. 51.2).

Surgical sites are injected with 1% lidocaine with 1:100,000 epinephrine.

The neck incision is made at the level of an existing tracheostomy tube or just below the cricoid. Subplatysmal flaps are elevated to expose the thyroid cartilage superiorly and the thyroid inferiorly. The trachea is exposed by dividing strap muscles at the midline raphe and 2–0 silk sutures are placed through strap musculature to facilitate exposure (▶ Fig. 51.3).

A thyroid isthmectomy is performed and the gland is separated from the trachea.

The trachea is entered using a #15 or #11 blade and stenotic segment is incised precisely in the midline (▶ Fig. 51.4), while a direct laryngoscopy is performed to re-evaluate the airway and location and adequacy of the vertical tracheolaryngeal incision. Adrenalin-soaked pledgets are placed along mucosal edges for hemostasis.

Next the length of cartilage graft necessary to repair stenosis is measured. At this point graft position and architecture is planned, determining whether anterior graft will suffice or posterior graft may also be needed.

The neck surgical site is covered and costal cartilage graft is harvested.

Right costal cartilages are preferred due to cardiac location. A 3- to 4-cm incision is made at the level of the fourth to fifth rib (▶ Fig. 51.5); the incision continues through skin, subcutaneous tissue, and fascial layers to the level of external oblique muscles. Costal cartilage is exposed while carefully preserving outer perichondrium (▶ Fig. 51.6). The bony-cartilaginous junctions are identified to evaluate graft potential length. A rectangular segment of cartilage exceeding the size of the measured stenosis is carefully separated with a periosteal elevator from the posterior wall of the rib, taking care not to penetrate the inner perichondrium and injure the pleura. In order to free the costal cartilage, a curved rib dissector is used (▶ Fig. 51.7). The rib cartilage is incised at the bony-cartilaginous junction and then dissected toward the sternum where another incision is performed after measuring and attaining adequate length (▶ Fig. 51.8).

The cartilage segment is then harvested and the donor site is evaluated for pleural competency by placing saline in the surgical wound and applying 40-cm positive-pressure ventilation while looking for bubbles.

Following meticulous hemostasis, the wound is closed in a layered fashion. No drain is needed.

The costal cartilage graft is then designed to fit the airway defect, usually carved in an elongated boat-shape and the edges are graded to avoid graft dislodgement (▶ Fig. 51.9 and ▶ Fig. 51.10).

Prior to graft placement the cartilage is placed in Cefazolin solution.

The graft is positioned in the anterior airway defect with perichondrium lining the airway. 4–0 PDS mattress sutures are first placed in graft circumference and then secured individually once the graft is in place (▶ Fig. 51.11). The ties should be performed on the tracheal/laryngeal cartilage and not on the graft. Usually the external surface of the graft will project above adjacent trachea.

If tracheotomy is present, tracheotomy site may be incised and fistula closed in layered fashion for one-stage repair followed by a leak test to verify adequacy of seal with an endotracheal tube left as stent for approximately 1 week. ^{1 , 2} If a two-stage repair is performed, either a T-tube is inserted in place of the tracheostomy tube or a stent is sutured at the level of the graft, to be later removed.

Surgical wound is closed in a layered fashion, with a Penrose catheter left as drain deep to the strap muscles.