In a conversation with Dr. Schega, the editors of the Leading Medicine Guide learned more specifically about the treatment of diseases and injuries of the windpipe—tracheal surgery.
Tracheal surgery is a highly specialized field of surgery that focuses on treating diseases, injuries, and malformations of the windpipe (trachea). Because the trachea plays a central role in the respiratory system, accurate diagnosis and treatment are essential for issues such as narrowing, tumors, or injuries. Tracheal surgical procedures range from tumor removal to reconstruction for tracheal stenosis and traumatic damage. Thanks to modern minimally invasive techniques, these operations can often be performed more gently today, with faster recovery.
Common reasons for tracheal surgical treatment include narrowing of the trachea (tracheal stenosis), which can result from inflammation, surgery, injury, or prolonged mechanical ventilation and can make breathing difficult. Another cause is tracheomalacia, in which the tracheal walls collapse and narrow the airway. Tumors—both benign and malignant—as well as congenital or acquired malformations may also make surgery necessary.
“The trachea can be affected by a wide range of conditions and injuries that require treatment. Particularly common are the consequences of prolonged mechanical ventilation: many patients—young or old—receive intensive care after accidents or in cases of severe heart and lung disease and are ventilated for extended periods. In these cases, not only an endotracheal tube but also a tracheostomy cannula is often used, placed either percutaneously by anesthesiologists or surgically—temporarily or sometimes permanently. When a patient recovers, the cannula can be removed. Often, however, scarring or narrowing (stenosis) has developed that impairs breathing. In such cases, specialized procedures are needed: the narrowed segment is removed and the healthy ends of the trachea are sewn back together (anastomosis). Most commonly, these narrowings occur in the neck region directly below the larynx, and less often in deeper sections as a consequence of intubation”, Dr. Schega explains, continuing:
“A special feature of Treuenbrietzen is the cross-site weaning center (where patients are reconditioned to breathe normally again), which is operated jointly with the Beelitz-Heilstätten rehabilitation clinic. There, patients are prepared after severe neurological illness or accidents. In close cooperation, the teams decide when surgery makes sense and how the trachea can be made ‘airway-patent’ again—whether through resection, dilation, or the use of new tracheostomy cannulas. Such operations require a well-coordinated team: ENT specialists, thoracic surgeons, anesthesiologists, and intensive care physicians work closely together. Above all, a reliable oxygen supply during the procedure is critical. Logistics are supported by a well-networked system: patients can be referred from other hospitals, such as Charité Berlin, to Treuenbrietzen. Findings are often shared digitally in advance—including CT or MRI images—so specialists can decide early on whether treatment is possible and what it should look like. The most rewarding moments are when a patient who previously could barely breathe can breathe freely again after a successful operation—without a cannula, without obstruction”.
The development of minimally invasive techniques has significantly changed tracheal surgery and offers numerous advantages for both patients and treating physicians. These modern methods have revolutionized the way tracheal diseases are treated by focusing on smaller incisions, less physical stress, and faster healing.
Larynx, trachea, and bronchial system._Patrick J. Lynch, medical illustrator, CC BY 2.5
“In the past, procedures on the trachea were performed very differently; today, many are minimally invasive or at least done through smaller incisions. Of course, we always have to tailor the incisions to the individual: if the narrowing is in the neck region, a small approach is sufficient, but sometimes the breastbone has to be partially or completely opened—or we operate from the side, depending on where exactly the narrowing is located. After all, the trachea is 10 to 12 centimeters long, consists of 22 to 24 cartilaginous rings, and divides behind the sternum into the two main bronchi. The major advance in recent years is modern oxygenation during surgery. Today we can work with jet ventilation—it’s like a fine catheter that is advanced through the opened trachea into the lung and delivers oxygen at high frequencies and controlled pressure. This allows us to ventilate both lungs or just the lower trachea. We also monitor gas exchange with transcutaneous CO₂ measurement on the skin. That gives us valuable time to calmly sew an anastomosis—that is, reconnect the edges of the trachea—or, if needed, even reconstruct a new bifurcation. Of course, you always need Plan B and Plan C: if jet ventilation doesn’t work, we can place a tube through the surgical field and selectively ventilate one lung until the connection is restored. The key is perfect preparation: anesthesia, surgery, and nursing have to function as a well-coordinated team; every move has to be spot on. This ‘crisis resource management’ ensures that no time is lost in an emergency. The great advantage of a specialized center is routine. In Treuenbrietzen, we perform around 100 tracheobronchoplastic procedures per year, putting us at the top nationwide in Germany in both volume and quality of care. In addition to consequences of ventilation or injuries, we also treat rare tracheal tumors, whether benign or malignant. This allows us to cover the entire spectrum of modern tracheal surgery”, Dr. Schega emphasizes.
Treatment for tracheal diseases depends on the underlying cause: milder narrowings (e.g., in tracheal stenosis or tracheomalacia) can be treated minimally invasively with stents or balloon dilation. In more severe cases, open surgery is necessary, for example to remove or reconstruct sections of the trachea. For tumors, partial tracheal resection (partial trachectomy) may be considered; malformations or injuries often require reconstruction. In advanced disease, such as lung cancer with tracheal involvement, a combination of surgery, radiation therapy, and chemotherapy is typically used.
Tracheomalacia._AI-generated
Tracheal surgery plays a crucial role in treating tumors of the trachea, as these tumors can both block the airway and pose a potential risk to surrounding structures such as the lungs, esophagus, and blood vessels.
Tracheal tumors are relatively rare but can be either benign or malignant, with the latter generally requiring more aggressive and comprehensive treatment. Surgical treatment aims to remove the tumor mass, secure the airway, and minimize complications.
“When it comes to tumors in the trachea, the question of causes often arises. In principle, there are both genetic factors and known risk factors, and it is clear that smoking plays a decisive role. In lung cancer, the link to smoking has been well studied, and tracheal cancer shows a similar correlation: statistically, about nine out of ten male cancer patients are chronic smokers. For women, it’s about seven out of ten, which still means that their risk is also significantly increased by avoidable factors. Smoking is considered the most important preventive factor in reducing the risk of developing such a tumor. This close connection also explains the frequency of tracheal cancer among smokers. However, there are also benign tumors, such as papillomas, which can likewise obstruct the airway. The problem is that these benign tumors are sometimes underestimated: one might assume it’s just chronic bronchitis, especially when narrowings occur that are treated with bronchodilators or antibiotics. But the true cause may be a tumor that can quickly obstruct the airway and severely impair breathing. In such cases, time is a critical factor. If someone notices changes in their breathing, increased coughing, and the condition persists for weeks, they should definitely see a specialist. Often, the underlying tumor disease is not recognized at first. That’s why the recommendation is: if a cough persists for two to three weeks, an evaluation should be performed. This usually includes imaging such as an X-ray or CT scan as well as bronchoscopy to clarify the exact cause”, Dr. Schega says.
Tumors diagnosed early have significantly better prospects for treatment because they often have not yet grown into surrounding tissues.
Dr. Schega comments: “This is where so-called sublobar resection is used—a minimally invasive operation in which only the affected segment of the lung is removed. The lung consists of 19 segments arranged in five lobes, so this type of operation allows only the diseased segment to be removed. This preserves the remaining lung and maintains the patient’s respiratory function as much as possible. In treating patients with lung or tumor diseases, the operative technique is generally similar. Both procedures require careful removal of the disease in an inflammation-free, scar-free environment to avoid recurrence and strictures. Frozen-section microscopy is often used to ensure during surgery that clear, tumor-free margins have been achieved. As for the duration of such an operation, it can take about two to three hours with an experienced team. Especially in patients who have been intubated long term and have a tracheostomy cannula, the anatomy is often significantly altered and scarred. That makes the operation more complex and requires precise technique, particularly when addressing stenoses below the larynx, for example at the roof of the cannula. The narrowed area is carefully removed, an end-to-end anastomosis is performed, and oxygenation is ensured. A current trend is the use of neuromonitoring during surgery to precisely monitor nerve function, especially the recurrent laryngeal nerve. This protects the voice and helps avoid nerve injury. To support nerve integrity and the best possible postoperative function, this technique is also used for complex procedures on the trachea or in the thoracic region. The nerves are continuously monitored using special electrodes and sensors to ensure they remain well perfused during the operation—a measure that significantly improves long-term outcomes”.
If a patient already has carotid stenosis (narrowing of the carotid artery), for example treated with a stent, this generally does not fundamentally affect the performance of airway surgery.
“Experienced colleagues have several options for choosing the optimal approach. If blood flow in the neck area has been adequately restored, for example through interventional or surgical procedures, there is usually nothing to prevent surgery. However, thorough preparation is important, particularly with regard to vocal cord function and the airway, to avoid complications. Before surgery, existing swallowing disorders or feeding methods should also be taken into account. Many patients on long-term ventilation with a tracheostomy cannula receive nutrition via gastrostomy, which makes speech therapy and swallowing training necessary. A comprehensive assessment of these factors is essential so the patient can breathe and swallow independently again after the procedure and aspiration can be avoided. This is important because aspiration can worsen lung function and, in the worst case, make re-tracheostomy necessary—which we want to prevent whenever possible. Especially in young injured patients who require long rehabilitation periods, it becomes clear how important interdisciplinary collaboration in specialized centers is. In addition to the surgeon, anesthesia, thoracic surgeons, and other specialists are involved. This collaboration under one roof is key to success, similar to society and family: together, better results can be achieved. In tracheal and laryngeal surgery, the various disciplines must be coordinated optimally to consistently achieve the best outcome. Particularly important is close coordination between anesthesia and thoracic surgeons, because the trachea extends into the chest and connects with the lungs. Careful preparation is half the battle, because well-planned anastomoses heal better. If respiratory performance is limited before surgery, there is a risk that the patient will need to be re-tracheostomized after the procedure. That’s why a comprehensive assessment should be performed in advance—similar to planning a tumor operation, where the chart is reviewed together with the anesthesiologist to minimize all risks and ensure treatment success”, Dr. Schega explains.
The practical and organizational approach to weaning (the gradual withdrawal of mechanical ventilation) at the Center for Business, Education, and Health (BWB) is well structured. It provides interdisciplinary care for patients who require specialized medical support. It combines medical treatment, rehabilitation, and educational programs to optimally prepare patients to return to everyday life.
“Cases are discussed regularly via video or telephone conferences. In these conversations, the professionals involved clarify how preparation for removing the tracheostomy cannula is progressing and whether the prerequisites for weaning are met. During the process—for example, when withdrawing the cannula or placing a placeholder—it is checked whether there is a narrowing in the airway or whether soft tissues have collapsed. These local issues are identified in the conference, as are the patient’s existing comorbidities, such as kidney insufficiency, circulatory disorders, or cardiac problems like coronary artery disease or valve defects. When all factors align, it becomes possible to wean the patient successfully and remove the tracheostomy cannula. This joint approach is then implemented as planned. Afterward, if rehabilitation is necessary, follow-up treatment continues with the patient in an improved condition. Patients are optimally prepared for independent living, supported by an interdisciplinary team. The period from planning to implementation generally takes one to two weeks. The team receives inquiries from other facilities, such as outpatient or inpatient ventilation centers, and maintains ongoing exchange. Often, even in advance—for example through bronchoscopic examinations—there are indications of relevant problems such as tracheal narrowing, which plays an important role in the further approach. A central challenge remains the essential function of airflow, because breathing is vital. Therefore, careful planning and preparation are crucial to minimize risks and ensure the success of the weaning process”, Dr. Schega emphasizes.
In addition to the usual surgical risks, these procedures involve several special risks and complications that must be considered.
Dr. Schega explains: “The risk of vocal cord weakness, particularly bilateral vocal cord weakness, must be kept low—something we have observed only once in the past 20 years. Such risks can be minimized through very delicate surgical technique, often supported by the use of neuromonitoring to safeguard nerve function during surgery. Still, a certain degree of aggressiveness is sometimes necessary, for example to remove scar tissue again. Especially with complex changes in the tracheal area, such as extensive narrowings, mobilization or transposition of parts of the trachea is required to gain length and restore a functional airway. The trachea itself is an organ that, to date, can hardly be fully replaced by plastics or other substitute materials. Research is exploring approaches such as tissue engineering, in which the patient’s own cells are cultured to replicate the functions of the tracheal mucosa. But these methods are still experimental, because functioning innervation and blood supply are required”, and he elaborates on the goal of normal breathing for the patient:
“For patients with chronic airway problems that are not accident-related or caused by intubation, the question is whether they can benefit long term from such an operation. If a mechanical narrowing in the trachea is the cause of shortness of breath, removing that narrowing can significantly improve breathing. The prerequisite, however, is that the lungs themselves still have adequate capacity. That’s why respiratory and cardiology performance is thoroughly evaluated before such procedures. The goal is to restore normal airway configuration, but a purely mechanical improvement does not always lead to spontaneous breathing; in some cases, support via a mask or a ventilator remains necessary, for example in sleep apnea or respiratory insufficiency”.
Beelitz-Heilstätten – From Spa Town to a New City
On the edge of the Brandenburg Fläming region—yet always with a direct rail connection to Berlin—the Beelitz-Heilstätten were established more than 100 years ago as one of Europe’s largest pulmonary sanatoriums. In the 1920s and 1930s, more than 2,000 tuberculosis patients were treated here at the same time. The complex was state-of-the-art for its era: spacious buildings, its own heating and power plant, underground corridors, and expansive green grounds provided ideal conditions for the then-common fresh-air therapy. After 1945, the Soviet army used the site until its withdrawal in the 1990s. After closure, the buildings fell into disrepair; vandalism and vacancy shaped the area. Only the commitment of historian Irene Krause, who collected and documented the history and offered guided tours, sparked renewed interest. Today, the site is one of the largest construction projects in the Berlin-Brandenburg region: historic buildings have been extensively restored and converted into apartments, complemented by a new neighborhood with a school, daycare center, and medical office building. In this way, a place once dedicated to healing is reinventing itself as a vibrant area to live and thrive.
The Johanniter Hospital Treuenbrietzen has been certified by the German Society for Thoracic Surgery (DGT) as a Center of Excellence in the state of Brandenburg and is also recognized as a Lung Cancer Center by the German Cancer Society. Modern operating rooms, specialized techniques, and a 14-bed intensive care unit enable high-performance thoracic surgery. Thanks to the close integration of specialized pulmonary and thoracic-surgical diagnostics and therapy, the hospital is considered an important thoracic surgery and pulmonary competence center in Brandenburg and beyond.
The goal is for the patient to be able to breathe freely again._AI-generated
“In Treuenbrietzen, we want to drive the development of new technologies, particularly the introduction of robotic surgery, similar to what some other centers in Germany are already doing. We are pursuing this goal with a clear patient-centered focus. In doing so, we are increasingly relying on minimally invasive procedures that can be performed without intubation and general anesthesia. That means that, in suitable patients, we can now perform lung surgery—for example for benign findings or other indications—under analgesic sedation without an endotracheal tube (sedation with calming and pain medications). We can selectively numb nerve structures, such as the vagus nerve, to facilitate breathing and minimize the risk of injury to the central airways. With this technique, we can perform both smaller and larger lung operations in the same safe setting, which clearly distinguishes Treuenbrietzen. Thoracic surgery has existed in Treuenbrietzen for 22 years. Previously a specialized, conservative clinic, it moved from Beelitz-Heilstätten to Treuenbrietzen and was built up there with me—an experienced thoracic surgeon and a native of Treuenbrietzen—along with a dedicated team. Our range of services is broad—from septic surgery for pleural infections, to metastasis surgery using state-of-the-art laser and photothermal energy, to sublobar anatomic resection for early lung tumors requiring segmental resections. We also treat thoracic trauma using modern titanium systems to stabilize the chest wall so patients can quickly return to their normal work and leisure activities. Another key strength is our network beyond Brandenburg. We support patients from neighboring hospitals in places such as Brandenburg, Frankfurt, and elsewhere. If acute thoracic conditions arise there that require immediate care and transfer to Treuenbrietzen is not possible, we provide assistance on site. This promotes close collaboration within Brandenburg and reflects the modern approach of working in a more team-oriented and interdisciplinary way in Germany. We also value exchange with international colleagues and regularly participate in global symposia to actively bring back and implement the latest developments in thoracic surgery”, Dr. Schega says, and with that we conclude our conversation.
Thank you very much, Dr. Schega, for this almost historical insight into thoracic surgery—and especially into tracheal surgery!
- Head of the Department of Thoracic Surgery at Johanniter Hospital Treuenbrietzen; a recognized specialist in diseases of the chest and lungs.
- Exceptionally well-trained surgeon with extensive experience in open, minimally invasive, and video-assisted thoracic surgery.
- Particular expertise in gentle, modern procedures such as video-assisted thoracoscopic interventions, laser metastasis surgery, and reconstructive techniques.
- Broad spectrum of care: from inflammatory diseases and chest wall malformations to complex lung cancers and pulmonary emphysema.
- Closely integrated into a certified lung cancer and thoracic center; works interdisciplinarily to develop individualized, cutting-edge treatment concepts.
