>> SO THE DAY OF SURGERY IS VERY STRESSFUL FOR THESE FAMILIES.
SOME OF THEM HAVE WAITED A YEAR, YEAR AND A HALF,
MAYBE TWO OR THREE YEARS, TO GET TO THIS POINT
OF SURGICAL RECONSTRUCTION.
IT'S A VERY BIG DAY IN THEIR LIVES.
>> AND EVERYONE'S GOAL IS TO MAKE SURE WE HAVE A CALM PATIENT
AND A CALM FAMILY.
>> CHILDREN FREQUENTLY GET A MEDICATION TO HELP THEM
IF THEY'RE FEELING ANXIOUS.
SO THAT THEY'RE VERY RELAXED.
IN FACT, A LOT OF THE KIDS LEAVE THEIR PARENTS GIGGLING,
WHICH IS VERY REASSURING FOR FAMILY TO SEE.
THE FAMILY GETS TO STAY WITH THE CHILD IN THE PREOPERATIVE AREA
RIGHT UP UNTIL THE MOMENT OF SURGERY.
>> WE HAVE A CHILD LIFE TEAM THAT ENGAGES THE CHILD TO MAKE
THE PROCESS OF COMING TO THE OPERATING ROOM A VERY
COMFORTABLE AND RELAXING PROCESS FOR OUR PATIENTS
AND FOR OUR PARENTS.
>> AS ANESTHESIOLOGISTS WE CONSIDER OURSELVES THE PRIMARY
MANAGERS OF THE AIRWAY.
DURING MANY OF THESE AIRWAY RECONSTRUCTION CASES,
WE HAVE TO SHARE THE AIRWAY WITH THE SURGEON.
>> SO THERE'S A TREMENDOUS CHOREOGRAPHY THAT GOES INTO
DESIGNING AN OPERATION AND PLANNING IT OUT.
>> WE HAVE SEVERAL ANESTHESIOLOGISTS WHO WORK
WITH THE AIRWAY PROGRAM.
>> AND I THINK ONE OF THE STRENGTHS OF OUR STAFF IS THAT
WE HAVE DEVELOPED A VERY OUTSTANDING WORKING RELATIONSHIP
WITH THE SURGEONS AND ARE ABLE TO SHARE THE AIRWAY EFFECTIVELY
BY COMMUNICATING THROUGHOUT THE PROCEDURE TO AVOID MANY PROBLEMS
THAT CAN OCCUR WHEN YOU'RE SHARING THE AIRWAY.
>> THERE REALLY ARE TWO BASIC APPROACHES TO RECONSTRUCTING
THE PEDIATRIC AIRWAY.
ONE IS KNOWN AS "LARYNGOTRACHEAL RECONSTRUCTION, OR LTR."
THE OTHER IS KNOWN AS "CRICOTRACHEAL RESECTION, OR CTR."
>> THE CHOICE BETWEEN LARYNGOTRACHEAL RECONSTRUCTION
AND CRICOTRACHEAL RESECTION DEPENDS ON THE DEGREE
OF STENOSIS, OR HOW SEVERE IS THE NARROWING,
AND HOW FAR AWAY FROM THE VOCAL CORDS THE NARROWING IS.
SUBGLOTTIC STENOSIS IS A LITTLE MORE COMMON IN CHILDREN BECAUSE
THE CRICOID CARTILAGE, WHICH IS THE NARROWEST PORTION OF OUR
AIRWAY, IS A SIGNET-SHAPED RING THAT SITS RIGHT BELOW THE VOCAL
CORDS, AND THAT AREA IS VULNERABLE TO INTUBATION TRAUMA.
SO THERE ARE MANY PREMATURE BABIES WHO ARE BORN WHO HAVE
TO HAVE A BREATHING TUBE IN PLACE FOR AN EXTENDED PERIOD OF TIME
THAT CAN CAUSE SOME NARROWING IN THAT AREA.
SO ACQUIRED SUBGLOTTIC STENOSIS IS A VERY COMMON REASON
WHY WE END UP PERFORMING LARYNGOTRACHEAL RECONSTRUCTION.
>> LARYNGOTRACHEAL RECONSTRUCTION, OR LTR,
INVOLVES RECONSTRUCTION USING CARTILAGE GRAFTS TO EXPAND
OR ENLARGE THE AIRWAY.
THESE CARTILAGE GRAFTS ARE BORROWED FROM THE RIB,
SO CARTILAGE CAN BE EASILY TRANSPLANTED FROM ONE PORTION
OF THE BODY TO THE OTHER AND WILL SURVIVE IN A REMARKABLE FASHION.
AND WHAT IT'S USED AS IS A SPACER, IN OTHER WORDS, IT ENLARGES
THE SIZE OF THE AIRWAY.
>> WE'RE GOING TO BE SPLITTING UP THE CRICOID CARTILAGE AND
THE TRACHEA IN THE MIDLINE AND THEN IMPORTING A PIECE OF RIB
CARTILAGE, OR IT COULD BE ANOTHER TYPE OF CARTILAGE,
BUT MOST COMMONLY A RIB CARTILAGE.
THE PIECE OF GRAFT IS SHAPED TO FIT THAT DEFECT AND THEN IT GETS
SNAPPED INTO THE AREA BETWEEN THOSE SPLIT ENDS OF THE CRICOID.
>> WE TAKE A VERY NARROWED AIRWAY, AND WE'LL TRANSECT THAT AIRWAY
IN ONE OR TWO POSITIONS AND PLACE ONE OF THESE SPACERS
IN THERE TO DRAMATICALLY ENLARGE THE SIZE OF THE AIRWAY.
>> THE CARTILAGE, ACTUALLY, HE SAID JUST WENT BEAUTIFULLY
INTO HER AIRWAY.
>> AND WHERE THEY HAD DONE THE GRAFT YOU COULD SEE THE NEW
TISSUE WAS GROWING AROUND THE GRAFT.
>> AND THE CARTILAGE IS NOW JUST GOING TO BECOME PART OF HER
AIRWAY, AND EVENTUALLY, WHEN YOU GO DOWN THERE WITH ANOTHER
SCOPE, YOU WON'T EVEN SEE IT.
>> NOW, THE OTHER POTENTIAL SURGERY WE MAY DO FOR THE MORE
ADVANCED CASES OF STENOSIS IS KNOWN AS
"CRICOTRACHEAL RESECTION," OR CTR.
>> THE CRICOTRACHEAL RESECTION IS WHEN YOU'RE ACTUALLY REMOVING
A DISEASED PORTION OF THE AIRWAY AND THEN RECONNECTING TWO
HEALTHY PORTIONS.
>> THAT INVOLVES CUTTING OUT THE SCARRED PORTION OF THE AIRWAY
OR THE LARYNX AND MOVING UP NORMAL TRACHEA TO REPLACE IT.
>> SO WE HAVE TO MAKE SURE BEFORE COMMITTING TO PERFORMING
A CRICOTRACHEAL RESECTION THAT WE HAVE ENOUGH SPACE BELOW
THE VOCAL CORDS TO ACCOMMODATE THAT SUTURING OF THE TRACHEA
TO THE VOICE BOX.
>> IT'S A MORE INVOLVED OPERATION,
WHICH IS NOT DONE AS COMMONLY AS LTR,
BUT IT CAN TREAT THE MOST SEVERE CASES OF SUBGLOTTIC STENOSIS
AND TRACHEAL STENOSIS WITH OUTSTANDING RESULTS.
>> THE OTHER TYPE OF RECONSTRUCTION FOR A TRACHEAL
STENOSIS THAT'S FURTHER DOWN IN OUR AIRWAY IS SOMETHING CALLED
A "SLIDE TRACHEOPLASTY," WHERE YOU DON'T REMOVE THE AREA
OF NARROWING, BUT YOU JUST CUT INTO IT AND THEN YOU SLIDE
THE TRACHEA SIDE BY SIDE AND CONNECT IT.
SO YOU MAKE IT SHORTER, BUT IT'S WIDER.
>> AN INCISION IS MADE IN THE BACK PORTION OF THE UPPER END
OF THE TRACHEA AND THE FRONT PORTION OF THE BOTTOM END,
AND THE TWO ENDS ARE SLID TOGETHER TO DOUBLE THE DIAMETER
OF THE AIRWAY BUT TO SHORTEN THE LENGTH.
AND THAT EFFECT GIVES YOU A MUCH WIDER AIRWAY AND IS A DIFFERENT
WAY TO DEAL WITH THE SAME TYPES OF PROBLEMS.
IT'S BETTER AND IMPROVED, IN A WAY, BECAUSE IT INVOLVES
LESS RESECTION, AND IT CAN EXPAND THE AIRWAY VERY EFFECTIVELY.