ABSTRACT

The thyroid gland isthmus is carefully undermined and elevated off the trachea. The isthmus is isolated, cross-clamped, divided using electrocautery and suture ligated with 2-0 silk. An intact thyroid isthmus could be irritated by the tracheostomy tube and cause postoperative bleeding. The remaining gland and soft tissue is cleaned off the pretracheal fascia from the level of the cricoid to the level of the fourth tracheal ring. Following meticulous hemostasis, the inferior aspect of the incision is palpated for the location of the innominate artery. The anesthesiologist is asked to deflate the endotracheal balloon and advance the endotracheal tube toward the right main stem bronchus before reinflating it. This technique avoids cuff injury from injection and incision and allows the airway to be sealed should bleeding occur. The trachea is anesthetized by transtracheal injection of lidocaine to reduce postoperative coughing. The cricoid is elevated superiorly with a hook to help control the tracheal incisions. The incision is centered over the third tracheal ring and can be an inverted U flap or H-or T-shaped depending on surgeon preference. The FiO2 should be <20% to reduce the risk of airway fire when entering the airway with electrocautery. Tracheal cartilage flaps are sutured to the skin or subcutaneous tissue with resorbable suture to facilitate emergent tube replacement if dislodged. Tracheal cartilage resection is generally reserved for permanent tracheotomy and contraindicated in temporary tracheotomy because cartilage loss may result in tracheal stenosis. Tracheal cartilages are separated with a tracheal spreader to facilitate tube placement. The anesthesiologist retracts the endotracheal tube to a level above the proximal opening. The tracheotomy tube with obturator is inserted. The obturator is removed, inner cannula inserted and balloon cuff inflated to the proper pressure. Wetting or lubricating the balloon cuff before insertion can help avoid puncture by calcified tracheal cartilage. Respiration is tested, and confirmed by carbon dioxide monitors. The tracheotomy tube is secured to the skin in the four quadrants using 2-0 silk sutures. Umbilical tape tracheotomy ties are then placed to prevent dislodgement of the tube by ventilator tubing. Skin may be left open to prevent subcutaneous emphysema and or pneumomediastinum. Post-operative chest x-ray is ordered to show the relationship of the tracheotomy tube to the carina, the status of the lung and mediastinum and tissue spaces in the neck.