Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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Hyoid bone

Anterior jugular vein

Cricoid cartilage

Trachea

Thyroid isthmus

Omohyoid muscle

Thyroid cartilage

Thyroid notch

Sternocleidomastoid

muscle

Thyroid gland

Sternohyoid muscle

Sternal notch

FIGURE 5 –1

STEP 1: SURGICAL ANATOMY

◆ The following landmarks are useful in performing a tracheotomy or cricothyroidotomy

(Figure 5-1):

◆ Hyoid bone

◆ Thyroid notch

◆ Cricoid cartilage

◆ Sternal notch

◆ The thyroid isthmus overlies the anterior trachea at the level of the ﬁ rst tracheal ring.

◆ See Figure 1-2 for demonstration of the relationship of the trachea to the thyroid gland,

esophagus, and great vessels in the neck.

CHAPTER

Tracheotomy

Anna M. Pou

66 Section I • Head and Neck and Endocrine Procedures

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications:

◆ Respiratory failure with ventilator dependence

◆ Airway obstruction: edema, trauma, tumor, hematoma

◆ Status of cervical spine:

◆ If status of cervical spine is in question, seek neurosurgical clearance before extending

the neck.

◆ In patients with a cervical spine injury, the neck remains in a neutral position and the

head and neck are stabilized with sandbags.

◆ If the patient has had a previous tracheotomy, the operative report is reviewed with atten-

tion to the level of the tracheotomy and the presence of anatomic abnormalities.

◆ A vertical, rather than horizontal, skin incision is useful in the following cases: (1) redo trache-

otomies, because it gives a larger area of exposure, which is helpful when dealing with scar

tissue; (2) in patients whose landmarks are not easily palpated; and (3) in infants and children.

◆ Local, awake tracheotomy should be considered in patients with laryngeal obstruction

(edema, tumor) who are not in acute airway distress and who are determined to be difﬁ cult

ﬁ ber-optic intubations.

◆ “High” tracheotomies are performed in patients with laryngeal carcinoma so that maximal

tracheal length can be preserved for stoma construction in the event a total laryngectomy is

required for treatment.

◆ The size of the tracheotomy tube is decided preoperatively (a size 6 cuffed tube is usually

placed in a woman, and a size 8 cuffed tube is usually placed in a man). An extended-

length tracheotomy tube may be necessary in patients with large necks and should be

available in the operating room before the tracheotomy is performed.

◆ The cuff of the tracheotomy tube is tested before use.

◆ The surgeon and anesthesiologist discuss the surgical plan preoperatively; the airway is

shared by both parties.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The patient is placed supine. The neck is extended using a shoulder roll and the head is

stabilized using a doughnut cushion.

◆ The anesthesiologist should be at the head of the table to maintain control of the airway.

◆ The surgical site is sterilely prepped with betadine and draped in such a manner that the

anesthesiologist has easy access in the event reintubation becomes necessary.

◆ Using a sterile marking pen, the surgeon outlines the previously mentioned landmarks on

the neck and a 2-cm horizontal skin incision 2 ﬁ ngerbreadths above the sternal notch

(Figure 5-2).

◆ The skin incision and subcutaneous tissues are injected with 1% lidocaine with

1:100,000 epinephrine.

◆ The skin incision is made using a no.10 scalpel blade and extends through the underlying

subcutaneous tissues (see Figure 5-2).

FIGURE 5 –2

Incision

Thyroid gland

CHAPTER 5 • Tracheotomy 67

68 Section I • Head and Neck and Endocrine Procedures

2. DISSECTION

◆ The superior and inferior skin ﬂ aps are retracted (Figure 5-3).

◆ A vertical incision is made in the midline fascia between the strap muscles. This is usually a

bloodless plane (see Figure 5-3).

◆ The strap muscles and, typically, the anterior jugular veins are retracted laterally

(see Figure 5-3).

◆ The dissection proceeds vertically in the midline through the pretracheal tissue and fat. The

lateral retractors are placed deeper in the wound as the dissection proceeds to a deeper level.

◆ The cricoid cartilage and thyroid isthmus are encountered (Figure 5-4).

Thyroid gland

Infrahyoid fascia

FIGURE 5 –3

Cricoid cartilage

Trachea

Thyroid gland

FIGURE 5 –4

CHAPTER 5 • Tracheotomy 69

Third tracheal ring

Thyroid isthmus

FIGURE 5 –5

◆ The isthmus is retracted superiorly using an Allis clamp (Figure 5-5, A).

◆ If the isthmus is difﬁ cult to retract, it is transected. A horizontal incision is made in the

anterior suspensory ligament of the thyroid, which is between the inferior edge of the

cricoid cartilage and the isthmus. A curved hemostat is used to dissect the thyroid isthmus

from the anterior surface of the trachea (Figure 5-5, B), and the thyroid isthmus is tran-

sected using electrocautery. Care is taken to not violate the anterior surface of the trachea or

to pass the hemostat deep to the cricoid cartilage.

◆ The pretracheal tissue is palpated in this area for a “high-riding” innominate artery before

the tracheotomy incision is made.

70 Section I • Head and Neck and Endocrine Procedures

◆ The anterior surface of the trachea is further cleaned; the tracheal fascia is incised vertically

in the midline and bluntly dissected laterally.

◆ A 2-mL injection of 4% lidocaine plain is given intraluminally. This is especially important

in awake patients to prevent coughing and anxiety while placing the tracheotomy tube.

◆ Before entering the airway, the surgeon notiﬁ es the anesthesiologist and the scrub nurse so

that the remainder of the procedure can proceed in a highly organized fashion. All neces-

sary instruments and the previously tested tracheotomy tube should be readily available

and placed in the order of need on the Mayo stand.

◆ The anesthesiologist untapes the endotracheal tube (ETT), holds it in place, and waits for

instructions from the surgeon. All extraneous noise in the room should cease.

◆ A horizontal incision (5 to 8 mm in length) is made directly above the tracheal ring of

choice (second, third, or fourth) using a no. 15 scalpel blade, taking care not to puncture

the cuff on the ETT (Figure 5-6, A).

◆ The incision continues in a manner necessary to remove an anterior portion of the ring

(Figure 5-6, B). An alternative method is to perform a broad, inferiorly based,

U-shaped

ﬂ ap extending the length of one tracheal ring (Figure 5-6, C).

CHAPTER 5 • Tracheotomy 71

Third tracheal ring

Tracheal ring flap

Thyroid gland

FIGURE 5 –6

72 Section I • Head and Neck and Endocrine Procedures

◆ The trachea is delivered into the wound and stabilized using the retractors already in place

or a cricoid hook (Figure 5-7). (The thyroid isthmus was removed in the ﬁ gure for

visualization of the underlying cricoid cartilage.)

◆ A 2-0 silk suture is placed through the inferior and superior tracheal rings, from outside to

inside the lumen. The needles are removed and the sutures are not cut; the ends are

brought out through the wound and can be used for retraction (Figure 5-8).

◆ The ETT is now withdrawn under direct visualization. The cuff is deﬂ ated and ventilation is

stopped. The surgeon instructs the anesthesiologist to slowly withdraw the ETT until the

tip is seen immediately above the tracheotomy incision and no farther.

Third

tracheal ring

FIGURE 5 –7

Superior

stay suture

Placing lower/

inferior stay suture

FIGURE 5 –8

CHAPTER 5 • Tracheotomy 73

◆ The surgeon places the tracheotomy tube (with obturator in place) into the airway under direct

visualization. The tube is introduced at a right angle and then turned inferiorly (Figure 5-9).

◆ Once the tube is in place, the obturator is removed, the inner cannula is placed, the cuff is

inﬂ ated, and the anesthesia circuit is hooked to the tracheotomy tube. The return of carbon

dioxide following ventilation is conﬁ rmed, and the chest is auscultated for the presence of

bilateral breath sounds. Conﬁ rmation is required before completely removing the ETT from

the airway.

◆ Tracheotomy ties are placed around the neck, and the ﬂ anges of the tracheotomy tube are also

sewn to the skin as an extra precaution to prevent accidental decannulation (Figure 5-10).

Tube in place

Stitch

FIGURE 5 –10

FIGURE 5 –9

Opening in trachea

Tube being introduced

74 Section I • Head and Neck and Endocrine Procedures

3. CLOSING

◆ Not applicable.

STEP 4: POSTOPERATIVE CARE

◆ The “stay sutures” are taped to the inferior and superior skin ﬂ aps, respectively. The pieces

of tape have “Do Not Remove” written on them so that these sutures can be used to retract

the trachea in the event of accidental decannulation.

◆ Postoperative orders should include the following:

◆ Tracheal suctioning every shift and as needed (prn). Patient may require tracheal

suctioning every hour in the immediate postoperative period. Preoxygenation with

100% oxygen may be necessary.

◆ Saline irrigation is used before suctioning to lubricate the trachea and suction catheter

and to thin secretions in selected patients (copious, thick secretions).

◆ The inner cannula must be changed/cleaned every shift and prn.

◆ Continual humidiﬁ cation via a tracheotomy collar to prevent mucous plug and obstruc-

tion of inner cannula with dried secretions.

◆ Gauze dressing is placed under the tracheotomy ﬂ ange to keep the area clean. Care is taken

not to dislodge the tube when changing this dressing.

◆ Regarding ventilator-dependent patients, the tracheotomy tubing is stabilized to prevent

subglottic and/or tracheal stenosis and accidental dislodgment of the tube.

◆ The cuff pressure should be minimal to prevent tracheal necrosis and resultant subglottic

and/or tracheal stenosis.

◆ Tracheotomy care is taught to the patient and his or her caregiver(s) as soon as possible.

◆ The “stay sutures” are removed on postoperative day 5.

◆ Speech pathology is consulted to address speech and swallowing problems associated with

tracheotomy.

STEP 5: PEARLS AND PITFALLS

◆ Complications include the following:

◆ Injury to the esophagus or great vessels intraoperatively. This is rare but can occur in

operative ﬁ elds ﬁ lled with scar tissue or tumor and in emergent cases.

◆ Pneumothorax