Open repair
Cleft type: 3, 4, and other types that cannot be repaired endoscopically
Advantages:
Strongest repair
Excellent exposure
Disadvantages:
Invasive
Usually requires post-op ventilator support
May require tracheostomy
Relatively long hospitalization, including ICU care
Many serious and potentially fatal complications and risks exist
Open surgery through the neck or chest used to be the only way to repair a laryngeal cleft. Today, most clefts are now repaired using minimally-invasive endoscopic techniques. Despite advances, some clefts will still require an open technique through the neck or chest to achieve an adequate repair. In more mild clefts, every effort should be taken to avoid an open repair due to the many associated risks and complications. Open cleft repair is necessary in type 4 clefts, as well as some type 3s and those with limited exposure. An open repair may also be needed for other reasons such as repeat surgeries, TEF, and various syndromes.
Method
A laryngeal cleft is located in the organ’s posterior side, which faces the child’s backbone. There are various ways to expose the cleft in an open repair, but most surgeons now use the anterior approach from the front of the neck. This method helps to avoid nerve damage that can result when accessing from the side of the neck through a lateral approach. In deep type 4 clefts, access through the sternum may be necessary.
During an open repair, the surgeon creates an incision in the neck and carefully dissects the tissue to reach the front of the larynx and trachea. The front of the organ is opened up to expose the cleft in the back. The surgeon then uses various techniques to close the cleft with sutures. Usually the surgeon will place a bone membrane, taken from another part of the body, between the tissue to create a three-layer repair. After the cleft is sutured shut, the front of the larynx and trachea must also be closed, as well as the other tissues in the front of the neck.
Besides an ENT, open cleft repair often requires a cardiothoracic surgeon and may involve the use of a heart-lung bypass method such as ECMO. For technical reasons, surgeons commonly perform a two-stage repair, where they leave a residual type 1 or 2 cleft that can be fixed endoscopically at a later time. As with endoscopic suture repairs, surgeon techniques vary.
Animation showing an open repair of a type 4 laryngeal cleft. Video provided by Cincinnati Children's Hospital Medical Center.
Hospital stay
Due to the invasiveness of the surgery, patients are hospitalized for days to usually weeks. Most patients will be kept sedated on a ventilator in the ICU for at least several days to keep the body still and minimize complications. Many children requiring an open cleft repair will need to breathe through a tracheostomy tube for a period of time and possibly permanently.
An open repair is a complex surgery and requires a lot of planning and coordination among the surgical team and hospital. Patients need to be medically optimized before this surgery to increase the chances of success. There are many serious and potentially fatal complications that can occur.
Open repair one month after surgery.
Same repair eight months after surgery.