Ventilation-assisted functional visualization: a stepwise workflow for planned management of a preoperatively...

Area of Science:

• Surgical Oncology
• Thoracic Surgery
• Head and Neck Surgery

Background:

• Tracheal diverticula are often incidental findings on imaging.
• Their presence near the thyroid surgical field poses intraoperative challenges, especially concerning the recurrent laryngeal nerve (RLN) and central compartment dissection.
• Current methods rely on preoperative CT and intraoperative experience, lacking a standardized approach for localization and verification.

Purpose of the Study:

• To describe a stepwise surgical technique for thyroidectomy with a preoperatively identified cervical tracheal diverticulum.
• To present a workflow integrating CT-based risk stratification and a novel ventilation-assisted functional visualization maneuver for precise diverticulum localization.
• To confirm tracheal communication and verify integrity after diverticulectomy and repair.

Main Methods:

• Integration of preoperative contrast-enhanced CT for risk stratification.
• A ventilation-assisted functional visualization maneuver involving standardized endotracheal tube (ETT) repositioning within defined cuff-depth boundaries (D_cuff, D_cuff2).
• Stepwise dissection with emphasis on RLN identification, controlled diverticulectomy, and submerged air-leak testing for tracheal integrity verification.

Main Results:

• The described technique allows for functional localization of the tracheal diverticulum and confirmation of tracheal communication prior to definitive posterior dissection.
• The workflow facilitates safe dissection, protection of the RLN, and accurate diverticulectomy.
• Post-repair air-leak testing verifies the integrity of the tracheal wall.

Conclusions:

• This standardized intraoperative workflow enhances the safety and precision of thyroidectomy in patients with cervical tracheal diverticula.
• The ventilation-assisted visualization maneuver is effective for intraoperative localization and confirmation of tracheal integrity.
• The technique minimizes risks of diverticular rupture, contamination, and injury to adjacent structures like the RLN.