Open Airway Cases

Hartnick CJ, Hansen MC, Gallagher TQ (eds): Pediatric Airway Surgery. Adv Otorhinolaryngol. Basel, Karger, 2012, vol 73, pp 39–41

Costal Cartilage Harvest

Thomas Q. Gallaghera ⭈ Christopher J. Hartnickb
aLCDR,MC, USN, Department of Otolaryngology, Naval Medical Center Portsmouth, Portsmouth, Va., bDepartment of Otology and
Laryngology, Massachusetts Eye & Ear Infirmary, Boston, Mass., USA

Abstract Indications
Cartilage interposition grafting for treatment of sub-
glottic stenosis was pioneered by Fearon and Cot- Subglottis stenosis requiring cartilage augmen-
ton in 1972. Costal cartilage is the preferred source for tation.
graft material in most cases. In this section, the authors
highlight the surgical technique for cartilage graft
harvest with discussion of surgical pearls necessary for Contraindications
success.
• Age less than 1 year – rib cartilage may be too
Relevant Anatomy small to carve adequately for an insert graft
• Osteogenesis imperfecta
• Structures divided during dissection (super-
ficial to deep):
– Skin and subcutaneous fat Anesthesia Considerations
– Muscle fibers of the pectoralis major muscle,
rectus abdominus muscle and external oblique Communication with your anesthesia provider
muscle regarding the chance of pneumothorax with this
◆ Depending on which rib harvested and age/ procedure.
muscle development of patient
– Perichondrium of cartilaginous rib
Preparation

The views expressed in this article are those of the authors and
do not necessarily reflect the official policy or position of the • A 4-cm incision is marked out of the desired
Department of the Navy, Department of Defense, or the United rib. Injection with 1% lidocaine with 1:100,000
States Government.
Thomas Q. Gallagher is a military service member. This work
epinephrine is utilized.
was prepared as part of his official duties. Title 17 .S.C. 105 • Rib selection is based on obtaining the most
provides that ‘Copyright protection under this title is not avail-
able for any work of the United States Government.’ Title 17
flat and straight piece of cartilage that can be
U.S.C. 101 defines a United States Government work as a work obtained. This usually is the 5th or 6th rib.
prepared by a military service member or employee of the
United States Government as part of that person’s official
• Gender is important to consider with making
duties. incision. Placement of the incision in the
Fig. 1. Muscular layer is exposed.
mammary crease is considered for female
patients.
• If the need for autogenous cartilage is known
prior to surgery, the harvest is performed prior
to opening the airway in order to maintain
sterile technique for the chest wound
Procedure
• Sharp dissection through the skin is carried
into the subcutaneous fat
• Blunt dissection over the selected rib is
performed with a hemostat and electro-
cautery
• Palpation of the desired rib is done throughout
the procedure in order to avoid erroneous
dissection
• Muscle fibers are divided with electrocautery
(fig. 1; online suppl. video 1)
• The rib is exposed with the use of blunt
dissection from peanut sponges (fig. 2). Self-
retaining retractors are utilized.
• The rib is examined to ensure sufficient length
(>2 cm) and shape. The bony-cartilaginous
junctions are identified.
40
Fig. 2. Perichondrium of rib is exposed.
• The inferior and superior edges of the rib are
cauterized to help reduce bleeding
• Along the inferior and superior edges, the
perichondrium is sharply incised
• Subperichondrial dissection with a Cottle
elevator is initiated through these incisions.
The dissection is then continued with a Freer
elevator. Care is taken to make contact with the
undersurface of the rib the entire time.
• Once the inferior and superior subperi-
chondrial dissections are complete, the lateral
bony-cartilaginous junction (blue in color) is
identified (fig. 3)
• The lateral rib is incised sharply over the
Freer
• The remainder of the posterior rib dissection
is completed under direct vision. This is
accomplished with the surgeon in the seated
position.
• The medial incision is made once ensuring at
least 2 cm of cartilage is harvested
• Again, this is done over the Freer to avoid
injury to the structures below
• Once removed, the rib is placed on the back
table in saline solution
• The wound is filled with sterile saline solution,
and a Valsalva maneuver to 30 cm water
Gallagher · Hartnick
 • The rubber band drain is usually removed on
postoperative day 1 or 2

Pearls

• The patient’s gender is kept in mind when

Fig. 3. The rib is exposed and the ‘blue line’ is identified
with the needle. This is the bony-cartilaginous junction.
pressure is performed to ensure the thoracic
cavity was not violated
• The wound is checked for hemostasis and
closed in a layered fashion over a rubber
band drain using absorbable braided suture.
Approximation of the muscular layer is
necessary.
marking the incision
• The size and shape of the rib are more important
than which rib number
• Use of electrocautery on the inferior and
superior edges of the rib prior to sharply
incising will help reduce nuisance bleeding
• During subperichondrial dissection with the
Freer, contact with the posterior surface of the
rib is essential in order to prevent entry into
the thoracic cavity
• Identification of the ‘blue line’ laterally prior to
dividing the rib will help to obtain the largest
graft possible
• The surgeon in the seated position will facilitate
dissection of the posterior perichondrium of
the rib

Postoperative Care

• A portable chest X-ray is obtained in the

recovery room or intensive care unit to ensure
there is no pneumothorax

Christopher J. Hartnick, MD
Professor, Department of Otology and Laryngology
Chief, Division of Pediatric Otolaryngology
Director, Pediatric Airway, Voice and Swallowing Center
Chief Quality Officer
Massachusetts Eye and Ear Infirmary, Harvard Medical School
243 Charles Street
Boston, MA 02116 (USA)
E-Mail christopher_hartnick@meei.harvard.edu

Costal Cartilage Harvest 41