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return to: Trachea Surgical Protocols

PROCEDURE

1. Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is injected into the surgical site and lidocaine (4% lidocaine) is sprayed into the trachea via the fistula.
2. The patient is prepped and draped in a normal sterile fashion after placement in a semi recumbent position.
3. Using a #15 blade, an elliptical incision is made. The incision begins at the border of the cutaneous/mucosal junction at the most lateral aspect of the fistula. As the incision is carried superiorly and inferiorly, it curves medially to create the elliptical shape. At the same time, it travels more superficial resulting in the superior and inferior ends of the ellipse within the skin and not at the cutaneous/mucosal junction as the lateral portion
4. The skin is slightly undermined using the blade. Hemostasis is achieved with the bipolar cautery.
5. Skin is closed in one layer using a series of vertical mattress sutures. These sutures incorporate a portion of the deep tissue to obliterate potential dead space. The skin is loosely approximated to prevent water tight closure. There is small air leak to prevent formation of subcutaneous emphysema.
6. Patient can be discharged home after close observation for approximately 1 hour to assure no subcutaneous emphysema has developed. One week of antibiotics such as Augmentin is recommended.

Area surrounding the fistula is 'freshened' to remove scar

 
4-0 nylon vertical mattress sutures are placed to oppose the raw edges, leaving
egress for air escape to prevent subcutaneous emphysema

Two or three sutures usually suffice. The sutures are removed 7 to 10 days later.

Closure of tracheo-cutaneous fistula

Closure of tracheal fistula is 31820. The description of the code is "Surgical closure tracheotomy or fistula: without plastic repair."

References

Khaja SF, Fletcher AM, and Hoffman HT: Local repair of persistent tracheocutaneous fistulas. Ann Otol Rhinol Laryngol. 2011 Sep;120(9):622-6

Management of Tracheocutaneous Fistula; Berenholz et al. Arch Otolaryngol Head Neck Surg. 1992;118(8):869-871.