Extensive Iatrogenic Tracheal Laceration Following Difficult Intubation in Elective Surgery: A Case Report

Abstract

Aims: Iatrogenic tracheal rupture is a rare but potentially life-threatening event. This report describes a complex case of extensive post-intubation tracheal injury (PITI) during elective surgery, focusing on diagnostic distractors like pneumoperitoneum and the critical need for early intervention. Presentation of Case: A 63-year-old female patient underwent elective abdominal surgery (ventral hernia repair and abdominoplasty). Intubation was technically challenging, requiring three attempts. Postoperatively, she developed progressive dyspnea and cervicothoracic subcutaneous emphysema at 72 hours. Initial CT imaging showed pneumomediastinum and subdiaphragmatic pneumoperitoneum, raising suspicion of hollow viscus perforation. After negative findings in exploratory laparoscopy and endoscopy, fiberoptic bronchoscopy identified a 3.5 cm longitudinal laceration in the posterior membranous trachea. Urgent surgical repair via anterior cervicotomy and protective tracheostomy were performed. Despite successful surgical closure, the patient developed mediastinitis and septic shock, eventually resulting in death. Discussion: PITI often presents with non-specific symptoms. The presence of pneumoperitoneum can act as a diagnostic distractor, leading to unnecessary abdominal exploration. Fiberoptic bronchoscopy remains the gold standard for defining the injury. Management is guided by the Cardillo classification, where lesions exceeding 2 cm or involving unstable patients usually mandate surgical intervention. Conclusion: PITI must be a priority differential diagnosis in any patient with postoperative emphysema. Early diagnostic bronchoscopy and structured preoperative airway assessment are critical for prevention and survival.