Inadvertent tracheal perforation during thyroidectomy

Introduction Top of page Introduction Patients and methods Results Discussion References Inadvertent tracheal perforation during thyroid surgery is extremely rare. Although there is an extensive body of literature relating to traumatic tracheal perforation, and to the management of tracheal invasion and resection in patients with thyroid cancer1, there are no published reports describing the management of inadvertent tracheal perforation during thyroid surgery. This paper examined the experience of two endocrine surgical units with inadvertent tracheal perforation. Jump to… Patients and methods Top of page Introduction Patients and methods Results Discussion References The study group comprised all patients who had thyroid surgery at Royal North Shore Hospital and the Liverpool Hospital, Sydney, Australia, from 1957 to 2002 and who were identified as having had inadvertent tracheal perforation. Data were obtained retrospectively from endocrine surgery databases maintained at both hospitals. Excluded were patients undergoing planned tracheal resection because of invasion by locally aggressive thyroid cancer. Patient demographics, indication for operation, operation performed, type of tracheal repair and outcome were evaluated. Jump to… Results Top of page Introduction Patients and methods Results Discussion References There were seven inadvertent tracheal perforations documented among 11 917 thyroid operations, an incidence of 0·06 per cent. The patients ranged in age from 28 to 79 years and all were women. All were primary procedures; there were no reoperations. In six patients the pathology was benign: four patients had a multinodular goitre, one had a benign Hurthle cell adenoma and one had Graves' disease. The final patient had an anaplastic tumour. Five patients had total thyroidectomy and two had unilateral lobectomy. In all patients the tracheal perforation was recognized and repaired at the first operation, under antibiotic cover. All perforations were located at the posterolateral surface of the trachea, close to the junction of the cartilaginous and membranous trachea, adjacent to the cricothyroid and the ligament of Berry. They were noted to be ‘small’ in the operative record. All perforations were repaired primarily using absorbable sutures; in two patients a buttress of strap muscle was included. The patient with an anaplastic thyroid carcinoma received a prophylactic tracheostomy at the time of the primary repair. Four patients had an uneventful recovery without additional intervention in relation to the tracheal injury. One patient was readmitted with subcutaneous emphysema that subsequently resolved with observation. Another patient developed bilateral tension pneumothorax that necessitated closed-tube thoracostomy and reoperation. In both these patients the perforation was noted to be small. One patient developed permanent hypoparathyroidism. There were no deaths or other long-term complications in this group. Jump to… Discussion Top of page Introduction Patients and methods Results Discussion References Tracheal perforation appears to be exceedingly rare; in the present series it occurred in less than one in every 1000 thyroid operations. For most thyroid surgeons the mean lifetime experience of such a complication is less than one patient, so it is unlikely that any individual will gather sufficient data to report the management of a series. Tracheal perforation is generally not considered a complication as such, but rather a technical occurrence during surgery that requires expeditious attention. Nevertheless, tracheal perforation, if encountered, needs to be managed appropriately. Although most patients recover uneventfully after primary repair, secondary complications such as subcutaneous emphysema, pneumothorax and wound infection may occur. The strength of this study was the ability to examine a very large series of well documented thyroid operations across two institutions. There were seven inadvertent tracheal perforations in over 11 000 thyroid operations, an incidence of 0·06 per cent. The perforation was recognized at the first operation in all patients. Generally these perforations occurred in the posterolateral trachea, either following attempted suture ligation of vessels in the region of the ligament of Berry or with the use of diathermy adjacent to the trachea. Once identified, all perforations were repaired primarily, some with a buttress of adjacent strap muscle. Patients had uniformly increased length of hospital stay but, with the exception of one patient, recovered with expectant management. Most perforations were recognized as they occurred, but smaller inadvertent injuries were identified at the conclusion of the procedure by filling the wound with saline and observing for small air leaks in the trachea. Once identified, the extent of the defect could be determined by careful dissection. The defect was repaired by reapproximating the tracheal edges, either with a single absorbable suture or with a catgut suture (in two early cases). Adjacent muscle was then used to buttress the repair in two cases. There are a number of published techniques for the repair of tracheal perforation2, 3, generally associated with otolaryngological or cardiothoracic procedures. Although there are no randomized studies to support use of any one repair, muscle flaps, fibrin glue, and thymus, pericardial and prosthetic patches have all been described4. The use of compressive dressings, drains, antitussives and prolonged ventilation has not been studied formally. Although tracheal perforation occurred in patients with both benign and malignant disease, benign disease was much more common in this study. There were no perforations in patients with well encapsulated lesions or well differentiated cancers. It appears that maintenance of normal dissection planes is more important than the presence of cancer. Multinodular goitre, which is characterized by repeated cycles of hyperplasia, degeneration and fibrosis, often contains dense fibrotic thyroid tissue that is contiguous with surrounding fibrous tissues such as the trachea. In a longstanding goitre it is frequently exceedingly difficult to define the plane between the two structures5. Importantly, upwards retraction of the thyroid in the region of the ligament of Berry may lead to distortion, and even overlapping, of adjacent tracheal rings, adding to difficulties in determining the plane of dissection (Fig.1).