Possible complications from tracheal release maneuvers include each of the following EXCEPT

A. carotid artery disruption
B. cervical esophageal injury
C. left atrial injury
D. phrenic nerve injury
E. postoperative aspiration


Answer A

Tracheal release maneuvers are utilized to reduce tension on tracheal reconstruction suture lines. Release maneuvers include mild chin flexion, dissection of the pretracheal plane, laryngeal release, and a hilar release. Simple mild chin flexion usually allows about 4 cm of trachea to be resected. Dissection of the pretracheal plane as if for mediastinoscopy increases the mobility of the trachea, especially the most distal segment. The risks are minimal and are similar to mediastinoscopy. 

Laryngeal release (suprahyoid), described by Montgomery, involves dividing the suprahyoid laryngeal suspensory attachments to gain length in the cervical trachea. About 2.5 cm of additional length is gained by such a release. Laryngeal dysfunction resulting in aspiration is sometimes reported, especially in elderly patients.

Whether accessed by cervical incision or right thoracotomy, the lateral attachments of the trachea must be left intact, but the plane between the esophagus and the membranous trachea is relatively avascular. Following division of the trachea, this plane can be cautiously mobilized for a short distance, but gross injury or induced postoperative esophageal dysfunction can occur. 

Carotid artery injury, like recurrent nerve injury, is avoided by restricting lateral dissection during tracheal operations. While catastrophic carotid complications can occur from retraction or resection of tracheal pathology, the carotid arteries are remote from the dissection fields for tracheal release.

Hilar release entails dividing the pulmonary ligament, opening the pericardium in a U-shaped fashion around the hilum and sometimes dissecting the superior pulmonary vein and pulmonary artery to loosen all fibrous attachments to the hilum to gain mobility. Injuries to the pulmonary vessels, the phrenic nerve, or either atrium are possible but should be rare. 


Heitmiller RF. Tracheal release maneuvers. Chest Surg Clin N Am 1996;6:675-82.
Tracheal release procedures are specialized surgical techniques designed to permit low tension end-to-end primary reconstruction after tracheal sleeve resection. Therefore, an understanding of the principles and techniques of these tracheal release maneuvers is essential in order to perform tracheal surgery safely. The release procedures include dissection of the pretracheal plane, cervical flexion, and laryngeal and hilar release. Dissection of the pretracheal plane and cervical flexion are the most commonly employed techniques.