Development Of Tracheal Surgery

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Development of Tracheal Surgery: A Historical Review. Part 1: Techniques of Tracheal Surgery
Hermes C. Grillo, MD
Division of General Thoracic Surgery, Massachusetts General Hospital and Department of Surgery, Harvard Medical School, Boston, Massachusetts

espite the antiquity of tracheostomy, tracheal surgery was the last anatomic subdivision of cardiothoracic surgery to develop. In 1950, Belsey [1] 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 [2, 3], 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 [4]: “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 [5]. By 1990, resection rates for tracheal tumors reached 63% for squamous carcinoma, 75% for adenoid cystic carcinoma, and 90% for other tumors [6]. 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 [7]. 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
Address reprint requests to Dr Grillo, Massachusetts General Hospital, Blake 1570, 55 Fruit St, Boston, MA 02114; e-mail: pguerriero@partners. org.


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.

Techniques of Tracheal Surgery Tracheostomy
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 [8 –11]. 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 [8]. 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 [8] identified Brasavola’s efforts as the first recorded successful tracheostomy, despite many ancient references to