Development of tracheal surgery: a historical review. Part 1: techniques of tracheal surgery
2003; Elsevier BV; Volume: 75; Issue: 2 Linguagem: Inglês
10.1016/s0003-4975(02)04108-5
ISSN1552-6259
Autores Tópico(s)Head and Neck Surgical Oncology
ResumoDespite the antiquity of tracheostomy, tracheal surgery was the last anatomic subdivision of cardiothoracic surgery to develop. In 1950, Belsey [1Belsey R. Resection and reconstruction of the intrathoracic trachea.Br J Surg. 1950; 38: 200-205Crossref PubMed Google Scholar] observed that “The intrathoracic portion of the trachea is the last unpaired organ in the body to fall to the surgeon, and the successful solution of the problem of its reconstruction may mark the end of the ‘expansionist’ epoch in the development of surgery.” After the introduction of intratracheal anesthesia [2Dobell A.R.C. The origins of endotracheal ventilation.Ann Thorac Surg. 1994; 58: 578-584Abstract Full Text PDF PubMed Google Scholar, 3Mushin W.W. Rendell-Baker L. The origins of thoracic anaesthesia, Wood Library. Museum of Anesthesiology, Park Ridge, IL1991Google Scholar], enormous strides were made in pulmonary surgery in the 1930s, in esophageal surgery in the 1940s, and, after cardiopulmonary bypass became a reality, in cardiac surgery in the 1950s. In 1961, Richard Meade noted in A History of Thoracic Surgery[4Meade R.H. A history of thoracic surgery. Charles C Thomas, Springfield, IL1961Google Scholar]: “Carcinoma of the trachea is a rather rare lesion and when it is found it is usually found to be entirely inoperable. In rare instances the lesion is so localized that the involved trachea can be resected, and with mobilization the ends can be brought together. This is seldom true and one is faced with the problem of what to do after resection of the trachea.” The 1960s proved to be a decade when advance in tracheal surgery quickened [5Grillo H.C. Notes on the windpipe (Presidential address).Ann Thorac Surg. 1989; 47: 9-26Abstract Full Text PDF PubMed Google Scholar]. By 1990, resection rates for tracheal tumors reached 63% for squamous carcinoma, 75% for adenoid cystic carcinoma, and 90% for other tumors [6Grillo H.C. Mathisen D.J. Primary tracheal tumors treatment and results.Ann Thorac Surg. 1990; 49: 69-77Abstract Full Text PDF PubMed Scopus (0) Google Scholar]. The developments that led to such advances in 30 years between 1960 and 1990 deserve to be related in more detail than the page and a half devoted to airway surgery in another recent History of Thoracic Surgery[7Wagner R.B. Faber L.P. History of thoracic surgery.Chest Surg Clin N Am. 2000; 10: 1-226PubMed Google Scholar]. The following, not a comprehensive review of the literature on tracheal surgery, is a selective account of tracheal surgical development. Emphasis is on beginnings and early development of important concepts and procedures. Current references are not necessarily included, unless they report progress in fundamental aspects of tracheal surgery or significant evolution of techniques. For historical reasons, an author’s earlier publication may be cited rather than more complete later reports. Regrettably, omissions from this account are inevitable. This review is divided into two parts, the first of which traces the evolution of techniques of tracheal surgery. The second part records the acquisition of information about characteristics and treatment of specific diseases of the trachea. There is, of course, considerable overlap. Part 2, “Treatment of Tracheal Diseases,” will appear in the next issue of The Annals. References for both parts are numbered sequentially. See “Selected References” at the end of this article for further explanation. Even a brief history must note the ancient use of tracheostomy for a variety of indications. The story has been traced by a number of authors [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar, 9Nelson TG. Tracheotomy: a clinical and experimental study. Am Surg 1957;23:660–94, 750–84, 841–81Google Scholar, 10Frost E.A.M. Tracing the tracheostomy.Ann Otol. 1976; 85: 618-624Google Scholar, 11Eavey R.D. The evolution of tracheostomy.in: Myers E.N. Stool S.E. Johnson J.T. Tracheostomy. Churchill Livingstone, New York1985: 1-11Google Scholar]. Although Aretaeus and Galen remarked on the use of tracheostomy in the second and third centuries, the arteria aspera, the “rough artery,” as the trachea was known for generations, entered the surgical theater only slowly. The specific technique of Antyllus in the fourth century C.E. has been recorded [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar]. Fabricius of Aquapendente, who introduced the idea of a tracheostomy tube, warned of the danger of this intervention. Tracheostomy was regarded with fear and considered inappropriate by most. In 1546, Antonio Brasavola of Ferrara treated a pharyngeal abscess by tracheostomy after the patient had been refused by barber surgeons. In his thorough and excellent review, Goodall [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar] identified Brasavola’s efforts as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening. Severino used tracheostomy during an epidemic of diphtheria in Napoli in 1610, performing the procedure through a vertical incision recommended by Fabricius [12Castiglione A. A history of medicine. AA Knopf, New York1947Google Scholar]. In 1620 in Paris, Nicholas Habicot performed tracheostomy, which he termed “bronchotomy,” for 1 patient who had blood clots in the trachea and for another who attempted to foil a highwayman by swallowing a bag of gold coins, which then stuck in his esophagus and compressed the airway. Tracheostomy relieved the obstruction. We have no record of what happened to the bag of gold. Surprisingly contemporary tracheostomy devices are illustrated in 17th-century texts, including Habicot’s Question Chirurgicale, Sanctorius’ Commentaria in 1625, and by Julius Casserius in 1627 in Tabulae Anatomicae. Fienus of Louvain used the word tracheotomy in 1649, although this term was not used often for another century. Over the centuries, few reports of successful tracheostomy are found [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar]. A drowning victim was treated with tracheostomy by Detharding in 1714. De Garengot in 1720 described the division of the thyroid isthmus to accomplish tracheostomy, using a long vertical incision that extended almost from chin to sternum. He further argued that failure of tracheostomy was often due to its belated performance. Lorenz Heister in 1718 is said to have first used the word “tracheostomy.” Martin in 1730 described an inner cannula for the tracheostomy tube, a device suggested to him by a layman. Chovell in 1732 performed tracheostomy at the request of a patient who faced death by hanging. Unfortunately, this tactic did not save the accused. Goodall [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar] found reports of 28 successful tracheostomies carried out before 1825, when Bretonneau in Tours used tracheostomy with success in treating “croup.” His pupil, Trousseau, applied the technique in 1831 for the management of diphtheria, saving about 25% of 200 children in Paris who were dying from the disease. Tracheostomy changed little technically, although controversy continued about its indications, locations, and hazards [10Frost E.A.M. Tracing the tracheostomy.Ann Otol. 1976; 85: 618-624Google Scholar]. Chevalier Jackson [13Jackson C. High tracheotomy and other errors the chief causes of chronic laryngeal stenosis.Surg Gynecol Obstet. 1921; 32: 392-398Google Scholar] largely cast the procedure in its modern form, cautioning against high tracheostomy. He believed that “tracheotomy is the worst done of all operations” [14Jackson C. Tracheotomy.Laryngoscope. 1909; 19: 285-290Crossref Google Scholar]. Tracheostomy found application in general anesthesia, but was soon displaced by endotracheal intubation [15Macewen W. Clinical observations on the introduction of tracheal tubes by the mouth instead of performing tracheotomy or laryngotomy. BMJ 1880;2:122–4, 163–5Google Scholar]. As diphtheria waned tracheostomy was used in poliomyelitis, to prevent infection, in head and chest injuries, after major surgery, and to reduce dead space. The endotracheal tube largely replaced tracheostomy as a preferred method to establish an emergency airway. Later, tracheostomy vied with endotracheal intubation for management of secretions, and subsequently was used as a route for mechanical positive pressure ventilation. A high incidence of complications was recognized even before the frequent appearance of postintubation injuries [9Nelson TG. Tracheotomy: a clinical and experimental study. Am Surg 1957;23:660–94, 750–84, 841–81Google Scholar, 16Head J.M. Tracheostomy in the management of respiratory problems.N Engl J Med. 1961; 264: 587-591Crossref PubMed Google Scholar, 17Watts McK, J. Tracheostomy in modern practice.Br J Surg. 1963; 50: 954-975Crossref PubMed Google Scholar]. Plastic surgical closure of a persistent tracheostomy by a cutaneous inversion technique was described by Lawson and Grillo [18Lawson D.W. Grillo H.C. Closure of a persistent tracheal stoma.Surg Gynecol Obstet. 1970; 130: 995-996PubMed Google Scholar] in 1970. An ancient concern that cast a shadow on tracheal surgery into the 20th century was that cartilage healed poorly. Hippocrates [19Chadwick J, Mann WN. The medical works of Hippocrates [translation]. Oxford, UK: Blackwell, 1950:264Google Scholar] had cautioned that, “The most difficult fistulas are those which occur in the cartilaginous areas. …” In the second century C.E. Aretaeus pronounced that “The lips of the wound do not coalesce, for they are both cartilaginous and not of a nature to unite” [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar]. As late as 1990, Naef [20Naef A.P. The story of thoracic surgery. Milestones and pioneers. Hogrefe and Huber, Toronto, Canada1990Google Scholar] repeated that: “Tracheo-bronchial tissue, as compared with the stomach, intestine, or even skin, does not heal well… both the rigidity and the poor blood supply of the cartilaginous structure are definitely major handicaps.” Nonetheless, examples of early attempts and sometimes success in bronchial and tracheal repairs after trauma are recorded. Indeed, the Rigveda, a book of Hindu medicine dating from between 2000 and 1000 B.C.E., noted that the trachea can reunite “when the cervical cartilages are cut across, provided they are not entirely severed” [10Frost E.A.M. Tracing the tracheostomy.Ann Otol. 1976; 85: 618-624Google Scholar]. Ambroise Paré described suture of tracheal lacerations in the mid-1500s in 3 patients, the first from a sword wound and the latter 2 from knife wounds [21Paré A. In: Hamby WB, ed. The case reports and autopsy records of Ambrose Paré. Springfield, IL: Charles C Thomas, 1960:47–9Google Scholar]. The first survived despite a concomitant injury to the internal jugular vein. The second suffered division of both trachea and esophagus and died. We do not know the outcome of the third. Brasavola [8Goodall EW. The story of tracheostomy. Br J Child Dis 1934;31:167–76, 253–72Google Scholar] observed recovery after a suicide attempt cut five tracheal rings. Eventually, cumulative clinical experience in the 20th century established that the trachea healed firmly with suture repair after laceration [22Scott G.D. Extensive cut throat with complete laceration of trachea and esophagus.JAMA. 1928; 90: 689-690Crossref Google Scholar, 23Nach R.L. Rotyhman M. Injuries to the larynx and trachea.Surg Gynecol Obstet. 1943; 76: 614-622Google Scholar] or rupture [24Thompson J.V. Eaton E.R. Intrathoracic rupture of the trachea and major bronchi due to crushing injury.Thorac Surg. 1955; 29: 260-270Google Scholar, 25Baumann J. Verdoux P. Millner T. 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Experimental studies on the repair of wounds and defects of the trachea and bronchi.Dis Chest. 1950; 17: 426-441Crossref Google Scholar] in 1950 confirmed fibrous tissue repair of linear tracheal incisions in the laboratory, as Rob and Bateman [31Rob C.G. Bateman G.H. Reconstruction of the trachea and cervical esophagus.Br J Surg. 1949; 37: 202-205Crossref PubMed Google Scholar] did in 1949 in the clinic. Quinby and Morse [32Quinby W.C. Morse G.W. Experimental pneumonectomy; the application of data so obtained to the surgery of the human thorax.Boston Med Surg J. 1911; 165: 121-124Crossref Google Scholar] in 1911, for the first time experimentally, had highlighted the importance of peribronchial tissue in bronchial closure. Rienhoff and associates [33Rienhoff Jr, W.F. Gannon Jr, J. Sherman I. Closure of the bronchus following total pneumonectomy.Ann Surg. 1942; 116: 481-531Crossref PubMed Google Scholar] in 1942 made fundamental observations that bronchial healing after pneumonectomy was accomplished by new connective tissue that grew over the ends of the stump rather than by mucosal healing alone. Gluck and Zeller [34Glück T. Zeller A. Die prophylactische Resektion der trachea.Arch Klin Chir. 1881; 26: 427-436Google Scholar] in 1881 demonstrated healing after end-to-end tracheal anastomosis in dogs and believed the technique could be applied in humans. Colley [35Colley F. Die Resection der Trachea. Eine experimentelle Studie.Deutsche Ztschr Chir. 1895; 40: 150-162Crossref Scopus (3) Google Scholar] in 1895, to avoid stenosis, tried elliptical and bayonet anastomoses in dogs after resecting five rings. Primary anastomosis of the cervical trachea after limited resection for posttraumatic stenosis followed in 1886 by Küster [36Küster E. Über narbige Stenosen der Trachea.Zentralbl Chir. 1886; 13: 759-760Google Scholar], apparently the first in human. Bruns [37Bruns P. Resektion der Trachea bei primärem Tracheal krebs.Beitr Z Klin Chir. 1898; 21: 284-288Google Scholar] in 1898 performed an extended lateral excision of a papillary tumor in cervical trachea but managed the tracheal defect by packing and using a cannula. Complex methods for repair of cervical tracheal defects, with skin or fascia lata, were also explored in the early 20th century by Nowakowski [38Nowakowski K. Beitrag zur tracheoplastik.Arch klin Chir. 1909; 90: 847-861Google Scholar] in 1909, Levit [39Levit H. Deckung von Trachealdefecten durch eine freie Plastik aus der Fascia lata femoris.Arch klin Chir. 1912; 97: 686-699Google Scholar] in 1912 and by others. Eiselsberg [40Eiselsberg A. Zur Resektion und Naht der Trachea.Dtsch Med Wochenschr. 1896; 22: 343-344Crossref Google Scholar] successfully performed a second tracheal resection of 1.5 cm in 1 patient. Mathey and associates [41Mathey J. Binet J.P. Galey J.J. et al.Tracheal and tracheobronchial resections technique and results in 20 cases.J Thorac Cardiovasc Surg. 1966; 51: 1-13PubMed Google Scholar] commented in 1966: “This type of radical tracheal surgery was then forgotten for half a century.” The era of open thoracic surgery had arrived. By 1936, Churchill [42Churchill E.D. Lobectomy and pneumonectomy in bronchiectasis and cystic disease.J Thorac Surg. 1936; 6: 286-311Google Scholar] had refined the technique of lobectomy to achieve a 2.6% mortality rate. As interest in bronchial and tracheal surgery grew by the mid-20th century, laboratory experiments confirmed that healing followed end-to-end anastomosis of both bronchi and trachea, although sometimes with stenosis [29Jackson T.L. Lefkin P. Tuttle W. Hampton F. An experimental study in bronchial anastomosis.J Thorac Surg. 1949; 18: 630-642PubMed Google Scholar, 30Daniel Jr, R.A. Taliaferro R.M. Schaffarzick W.R. Experimental studies on the repair of wounds and defects of the trachea and bronchi.Dis Chest. 1950; 17: 426-441Crossref Google Scholar, 31Rob C.G. Bateman G.H. Reconstruction of the trachea and cervical esophagus.Br J Surg. 1949; 37: 202-205Crossref PubMed Google Scholar, 43Carter M.G. Strieder J.W. Resection of the trachea and bronchi an experimental study.J Thorac Surg. 1950; 20: 613-627PubMed Google Scholar, 44Ferguson D.J. Wild J.J. Wangensteen O.H. Experimental resection of the trachea.Surgery. 1950; 28: 597-619PubMed Google Scholar, 45Maisel B. Dingwall J.A. Primary suture of the divided cervical trachea.Surgery. 1950; 27: 726-729PubMed Google Scholar, 46Kiriluk L.B. Merendino K.A. An experimental evaluation in the dog of bronchial transplantation, bronchial, tracheal and tracheobronchial resection with reconstruction.Ann Surg. 1953; 137: 490-503Crossref PubMed Google Scholar]. Bronchial repair after trauma proved the feasibility of airway reconstruction. Sanger [47Sanger P.W. Evacuation hospital experience with war wounds and injuries of the chest.Ann Surg. 1945; 122: 147-162Crossref PubMed Google Scholar] described bronchial repair in patients during World War II. In 1949, Griffith [48Griffith J.L. Fracture of the bronchus.Thorax. 1949; 4: 105-109Crossref PubMed Google Scholar] resected a stricture and anastomosed the bronchus 3 months after rupture. Other late repairs of ruptured bronchi followed [49Weisel W. Jake R.J. Anastomosis of right bronchus to trachea forty-six days following complete bronchial rupture from external injury.Ann Surg. 1953; 137: 220-227Crossref PubMed Google Scholar]. Scannell [50Scannell J.G. Rupture of the bronchus following closed injury to the chest. Report of a case treated by immediate thoracotomy and repair.Ann Surg. 1951; 133: 127-130Crossref PubMed Google Scholar] first performed immediate repair of a bronchus ruptured during closed injury in 1951. Belcher [51Belcher J.R. Accidental section and successful resuture of a bronchus.Br J Surg. 1950; 38: 121-122Crossref PubMed Google Scholar] in 1950 and Mathey and Oustrieres [52Mathey J. Oustrieres G. End to end bronchial anastomosis after an accidental division of the main stem bronchus.Thorax. 1951; 6: 71Crossref PubMed Google Scholar] in 1951 reported reanastomosis of main bronchi after accidental division during surgery. Earlier cautious enlargement of bronchial stenosis by wire-supported dermal grafts [53Gebauer P.W. Plastic reconstruction of tuberculous bronchostenosis with dermal grafts.J Thorac Surg. 1950; 19: 604-628Google Scholar, 54Métras H. Grégorie M. Longepait H. Reconstruction plastique de deux cas de sténose bronchiques.Rev Tuberc Paris. 1952; 16: 54-59PubMed Google Scholar] were replaced by resection and reconstruction. The technique was applied to low-grade tumors [55D’Abreu A.L. Bronchial “adenoma” treated by local resection and reconstruction of the left main bronchus.Br J Surg. 1952; 39: 355-357Crossref PubMed Google Scholar, 56Price-Thomas C. Conservative resection of the bronchial tree.J R Coll Surg Edinb. 1955; 1: 169-186Google Scholar, 57Bikfalvi A. Dubecz S. Resection and anastomosis of the bronchus carried out in a case of benign tumor.J Thorac Surg. 1955; 29: 489-496Google Scholar] and to carcinoma [58Tuttle W. Discussion of Jackson TL, Lefkin P, Tuttle W, Hampton F. J Thorac Surg 1949;18:641Google Scholar, 59Paulson D.L. Shaw R.R. Bronchial anastomosis and bronchoplastic procedures in the interest of preservation of lung tissue.J Thorac Surg. 1955; 29: 238-259PubMed Google Scholar], as sleeve lobectomy evolved. Concurrent vascular sleeve resection was also pursued by Pichlmaier and Spelsberg [60Pichlmaier H, Spelsberg F. Organerhalten de Operation des Bronchuscarcinoms. Langenbecks Arch Chir 1971;328–221–34Google Scholar]. Main bronchial resection without removal of lung tissue was extensively described by Newton and associates [61Newton J.R. Grillo H.C. Mathisen D.J. Main bronchial sleeve resection with pulmonary conservation.Ann Thorac Surg. 1991; 52: 1272-1280Abstract Full Text PDF PubMed Google Scholar]. With retrospective wisdom, we may ask, “What were the barriers to application of the bronchoplastic and tracheal anastomotic techniques just noted to clinical tracheal resection and reconstruction?” One obstacle was the persistent suspicion that tracheal cartilage healed poorly. A more insistent concern was that only a limited segment of trachea could be removed and reanastomosis accomplished. Nowakowski [38Nowakowski K. Beitrag zur tracheoplastik.Arch klin Chir. 1909; 90: 847-861Google Scholar] in 1909 placed the limit of resection at 3 to 4 cm from cadaver studies. Colley [35Colley F. Die Resection der Trachea. Eine experimentelle Studie.Deutsche Ztschr Chir. 1895; 40: 150-162Crossref Scopus (3) Google Scholar] and Küster [36Küster E. Über narbige Stenosen der Trachea.Zentralbl Chir. 1886; 13: 759-760Google Scholar] reported resections of three rings and 2 to 4 cm, respectively. Rob and Bateman [31Rob C.G. Bateman G.H. Reconstruction of the trachea and cervical esophagus.Br J Surg. 1949; 37: 202-205Crossref PubMed Google Scholar], based on cadaver dissection, placed the limit at 2 cm. Belsey [1Belsey R. Resection and reconstruction of the intrathoracic trachea.Br J Surg. 1950; 38: 200-205Crossref PubMed Google Scholar] believed that three or four rings, about 2 cm, was the limit in humans. Cantrell and Folse [62Cantrell J.R. Folse J.R. The repair of circumferential defects of the trachea by direct anastomosis experimental evaluation.J Thorac Cardiovasc Surg. 1961; 42: 589-598PubMed Google Scholar] placed the limit at two rings if the patient was older than 80 years. Nicks [63Nicks R. Restoration and reconstruction of the trachea and main bronchi.J Thorac Surg. 1956; 32: 226-245PubMed Google Scholar] cited “1 inch or more” as a limit in the cervical trachea. These presumed limits led to devising complex methods of cervical tracheal reconstruction with available tissue flaps and transfers, and, further, to a century-long search for a means of tracheal replacement. This search ranged over foreign material in many forms, autogenous tissue constructions, tissue and foreign material complexes, fixed or “tanned” tissues, transplantation, and, recently, tissue engineering. Success has eluded investigators to date. The story of this frustrating pursuit and the reasons for overall failure thus far are detailed in a recent review [64Grillo HC. Tracheal replacement: a critical review. Ann Thorac Surg 2002;73:1995–2004Google Scholar]. An additional difficulty of reconstruction was maintenance of safe, continuous, stable ventilation throughout the procedure, especially for intrathoracic tracheal operations. The evolution of anesthetic techniques is discussed later. Finally, primary tumors of the trachea remained rare, as can be seen from earlier chronicles of their occurrence [65Culp O.S. Primary carcinoma of trachea.J Thorac Surg. 1938; 7: 471-487Google Scholar, 66Ellman P. Whittaker H. Primary carcinoma of the trachea.Thorax. 1947; 2: 151-161Crossref Google Scholar]. Stenoses from traumatic, iatrogenic, or inflammatory causes were not seen frequently before 1960. Thus, any single thoracic surgeon was not often challenged. Each case was largely dealt with in an ad hoc fashion. In the mid-20th century, a recrudescence of interest in tracheal surgery was marked by experiments in tracheal healing and replacement and by renewed clinical efforts. Earliest attempts at reconstruction of the cervical trachea were still most often by staged, complex repairs, typified by Crafoord and Eindgren’s [67Crafoord C. Eindgren A.G.G. Mucous and salivary gland tumors in bronchi and trachea formerly generally called bronchial adenoma.Acta Chir Scand. 1945; 92: 481-506Google Scholar] cutaneous reconstruction after tumor removal in 1945. Belsey [1Belsey R. Resection and reconstruction of the intrathoracic trachea.Br J Surg. 1950; 38: 200-205Crossref PubMed Google Scholar] seems first to have dared to remove intrathoracic tracheal tumors, but his repair was with wire-supported fascia, leaving a residual strip of mucosa for continuity and for epithelial regeneration. Clagett and associates [68Clagett O.T. Moersch H.J. Grindlay J.H. Intrathoracic tracheal tumors development of surgical technics for their removal.Ann Surg. 1952; 136: 520-532PubMed Google Scholar] and others followed, using polyethylene tubes or patches to repair the defects. Efforts to replace the trachea partially or circumferentially have been described in detail recently [64Grillo HC. Tracheal replacement: a critical review. Ann Thorac Surg 2002;73:1995–2004Google Scholar]. Despite continued concerns [68Clagett O.T. Moersch H.J. Grindlay J.H. Intrathoracic tracheal tumors development of surgical technics for their removal.Ann Surg. 1952; 136: 520-532PubMed Google Scholar] about the feasible length of tracheal resection and lingering doubts about cartilaginous healing, a number of successful resections and reconstructions with primary anastomosis were described in the 1950s and early 1960s, most often for shorter, benign lesions such as stricture. Conley [69Conley J.J. Reconstruction of the subglottic air passage.Ann Otol Rhinol Laryngol. 1953; 62: 477-495PubMed Google Scholar] successfully resected the second and third rings for scar in 1944, with end-to-end anastomosis. Kay [70Kay E.B. Tracheal resection and primary anastomosis.Ann Otol Rhinol Laryngol. 1951; 60: 864-870PubMed Google Scholar] removed four rings of proximal trachea for leiomyoma without event in 1951. Sweet [71Sweet R.H. Discussion.Ann Surg. 1952; 136: 530Google Scholar] in 1952 resected a cervical “cylindroma” with end-to-end anastomosis and questioned whether this procedure might be possible intrathoracically. Macmanus and McCormick [72MacManus J.E. McCormick R. Resection and anastomosis of the intrathoracic trachea for primary neoplasm.Ann Surg. 1954; 139: 350-354Crossref PubMed Google Scholar] in 1954 excised a three-ring segment for the same tumor, located about 2 cm above the carina, with end-to-end repair. An anastomotic leak was patched with fascia lata and a protective tracheostomy added. Forster and colleagues [73Forster E. Viville C. Moeller R. et al.Résection de la trachée. Suture bout a bout. Apropos de deux observations.Poumon Coeur. 1957; 13: 367PubMed Google Scholar, 74Forster E. Molé L. Fromes R. Sténose trachéale annulaire serrée après trachéotomie. Résection du segment sténosé. Anastomose bout a bout. Guérison.Mém Acad Chir. 1958; 84: 188-193PubMed Google Scholar] in 1957 and 1958 reported a series of three successful cervical and cervico-mediastinal tracheal resections with primary anastomosis of 1.5, 4, and 3 cm for tumor, posttraumatic stenosis, and postintubation stenosis. Other similar resections were reported by Binet and Aboulker [75Binet J.P. Aboulker P. Un cas de sténose trachéal apres trachéotomie. Résection–suture de la trachée. Guérison.Mém Acad Chir. 1961; 87: 39-42Google Scholar] and Miscall and colleagues [76Miscall L. McKittrick J.B. Giordano R.P. Nolan R.B. Stenosis of trachea. Resection and end-to-end anastomosis.Arch Surg. 1963; 87: 726-731Crossref PubMed Google Scholar]. Flavell [77Flavell G. Resection of tracheal stricture following tracheostomy with primary anastomosis.Proc Roy Soc Med. 1959; 52: 143-145PubMed Google Scholar] in 1959 had successfully corrected a postintubation stricture at the thoracic outlet by resection, but carried out the procedure from a difficult, transthoracic approach—an error to be repeated later by other surgeons. Mattes [78Mattes T.H. Resektionsmöglichkeiten bei Geschwûlsten des intrathorakalen Abschnittes der Trachea und ihre Kontinuitätswiederberstellung.Der Chirurg. 1958; 20: 32-36Google Scholar] performed a 4-cm transthoracic lower tracheal resection for cylindroma in 1958, wrapping the anastomosis with pleura. Indicative of revived interest in tracheal surgery were extensive reports in 1960 by Baumann and Forster [79Baumann J. Forster E. Chirurgie de la trachée.Poumon Coeur. 1960; 16: 5-119Google Scholar] of worldwide experiences in tracheal surgery. They pointed out that improvements in diagnosis (endoscopy) and technical and ventilatory methods had served to widen the field beyond tracheostomy and endoscopic treatment alone. Simultaneously, the potential for surgery of the thoracic trachea was exciting interest. These midcentury experiences in tracheal reconstruction, chiefly in the upper trachea and most often of limited extent, clarified that the basic techniques of tracheal anastomosis could achieve sound healing. The “2-cm rule,” which had served to inhibit advances in tracheal surgery, was now challenged by experimental studies reinvestigating the extent of trachea that could be removed and approximation achieved by anatomic tracheal mobilization, without use of prosthetic replacement. Clinical experiences, especially with intrathoracic and carinal lesions, contributed to widening the possibilities for more extended resection. Ferguson and associates [44Ferguson D.J. Wild J.J. Wangensteen O.H. Experimental resection of the trachea.Surgery. 1950; 28: 597-619PubMed Google Scholar] determined the extensibility of human trachea from cadavers to be 35% at 29 years and 17% at 76 years, with the most stretch reached with 200 grams (g) of tension. In living dogs, the majority of resectable lengt
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