Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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

If the isthmus is difficult 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 transected 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.

Thyroid isthmus

Third tracheal ring

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 notifies the anesthesiologist and the scrub nurse so that the remainder of the procedure can proceed in a highly organized fashion. All necessary 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 flap extending the length of one tracheal ring (Figure 5-6, C).

B

Third tracheal ring

MC

A

Thyroid gland

Third tracheal ring

Tracheal ring flap

C

FIGURE 5–6

3. CLOSING

Not applicable.

STEP 4: POSTOPERATIVE CARE

The “stay sutures” are taped to the inferior and superior skin flaps, 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 humidification via a tracheotomy collar to prevent mucous plug and obstruction of inner cannula with dried secretions.

Gauze dressing is placed under the tracheotomy flange 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 fields filled with scar tissue or tumor and in emergent cases.

Pneumothorax

Bleeding: cut edge of thyroid or trachea (early); tracheo–innominate artery fistula (late)

Infection: tracheitis

Mucous plug

Accidental decannulation (may result in death)

Aspiration

In morbidly obese patients, pretracheal fat is excised to decrease the amount of subcutaneous tissue lying between the cervical skin incision and the tracheotomy. In rare patients, submental skin and fat must be excised before the tracheotomy to prevent obstruction of the tracheotomy tube postoperatively by soft tissue.

A saline-filled syringe with a small-gauge needle can be used to localize the trachea in a badly scarred neck (previous surgery, infection, radiation therapy, or a combination). The needle is placed in the presumed tracheal lumen and the plunger is withdrawn. The presence of air bubbles in the syringe confirms the location of the tracheal lumen.

If there is difficulty placing the tracheotomy tube, the anesthesiologist is instructed to advance the ETT and resume ventilation. The cuff of the ETT should be past the tracheotomy incision so that air does not escape from the wound.

If it is difficult to place the tracheotomy tube and the ETT cannot be advanced distal to the tracheotomy site, a small ETT (size 4 or 5) can be placed through the tracheotomy incision to ventilate the patient. Troubleshooting can then commence with the patient under stable conditions.

When a local awake tracheotomy is performed, the patient’s face is left undraped (a towel is placed over the chin) to allow the anesthesiologist access for mask ventilation and emergent intubation.

SELECTED REFERENCES

1. Myers EN: Tracheostomy. In Myers EN (ed): Operative Otolaryngology: Head and Neck Surgery. Philadelphia, Saunders, 1997, pp 575-585.

2. Morris WM: Cricothyroidotomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed. Philadelphia, Elsevier, 2005, pp 82-83.

3. Tracheostomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed. Philadelphia, Elsevier, 2005, pp 1015-1023.

4. McWhorter AJ: Tracheotomy: Timing and techniques. Curr Opin Otolaryngol Head Neck Surg 2003;11:473-479.

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-shaped cushion.

The anesthesiologist is positioned at the head of the table.

The patient’s neck is cleaned with betadine and draped in sterile fashion if patient is stable.

The landmarks in the neck are palpated and the skin overlying the cricothyroid (CT) membrane is marked using a sterile marking pen.

The skin and subcutaneous tissue is anesthetized with 1% lidocaine with 1:100,000 epinephrine.

The skin overlying the CT membrane is “put on stretch,” with the surgeon using the nondominant hand, and a horizontal skin incision is made using a no. 15 scalpel blade (Figure 6-2, A). A vertical, rather than horizontal skin incision, is useful in patients whose landmarks are not easily palpated due to trauma, hematoma, or obesity (Figure 6-2, B).

2.DISSECTION

Using an index finger, the surgeon palpates the CT membrane in the wound (Figure 6-2, C).