Formal Tracheostomy

General remarks

When the patient is in immediate danger of death, and there is no time to do a formal tracheostomy

The isthmus of the thyroid gland may interfere with the approach towards the trachea. The anatomy can vary considerably however

When the isthmus of the thyroid is small, there is no need to divide it and can sometimes be retracted (by using a isthmus retraction hook). When it's large and interferes with your approach to his trachea, it needs to be divided

Avoid incising more than 40% of the circumference of the trachea, since this may lead to severe future stenosis

Percutaneous dilatational tracheostomy (PDT) is as safe and as effective as a formal (surgical) tracheostomy, without significant differences in early and late complications.

Step by step

1. Put a small pillow under the patient’s shoulders to extend the neck, this makes the larynx more prominent
2. Identify the landmarks (thyroid and cricoid cartilage) and make a transverse skin incision over the second tracheal ring. This is usually 2 cm below the border of the cricoid cartilage
3. Subcutaneous dissection towards the fascia (i.e. median fibrous raphe)
4. Vertically opening the raphe
5. Further dissection towards trachea
6. Isthmus of the thyroid can be retracted when small or divided when large and interfering with the dissection
7. Blunt dissection of the trachea
8. Identify second tracheal ring and place suture through it. Don't cut the needle yet
9. Create treachea flap and turn it downwards
10. Retract endotracheal tube
11. Insert cuffed tracheostomy tube
12. Inflate the cuff
13. Remove the obturator, and replace it by the inner tube
14. Connect the tube to respirator
15. Suture the trachea flap to the skin
16. Bring skin together on both sides with a suture
17. Place a gauze around the tube
18. Secure tube with a tape/band around patient's neck
19. Check cuff pressure

References	Isthmus retraction hook for open tracheostomy Technical note. Kovács AF. Int J Oral Maxillofac Surg. 2009 Jun 10 Comparison of percutaneous dilatational tracheostomy with surgical tracheostomy. Turkmen A et al et al. 2008 Jun;19(5):1055-67.