A guide to open surgical tracheostomy

Open tracheostomy procedure is one of the oldest described surgical interventions. It involves the creation of a stoma at the skin surface of the anterior neck leading to the trachea. There are multiple indications for such procedure. It can be used as a solution for upper airway obstruction of multiple aetiology, in cases of prolonged mechanical ventilation where there is the need to replace endotracheal intubation and for airway protection as part of another surgical procedure. In the preoperative phase, it is important to ensure adequate consent is present and that a preoperative check-list is followed, including reviewing investigations and familiarisation with available tracheostomy tubes. The operative technique should be performed in a logical systematic way. One should first ensure adequate surgical environment and proper patient positioning. Marking of anatomical landmarks is advised. Infiltration with local anaesthetic containing adrenaline solution is advocated. The surgical steps involved are followed stepwise. The skin incision is adequately placed, dissection through fascia and separation of strap muscles vertically with their lateral retraction performed. One should then identify trachea and deal with the thyroid isthmus. The correct site for the tracheotomy is identified and this is performed whilst liaising with the anaesthetist and scrub nurse. The chosen tracheostomy tube should be checked and inserted appropriately. There are some post procedure considerations and checks that should be followed including securing the tracheostomy tube. It is also imperative to recognise and deal with difficult anatomy scenarios. Various early and late complications may arise and appropriate knowledge is essential to avoid them. Early recognition will lead to better patient outcomes. Although there are many variations in performing a classical open surgical tracheostomy, these are all based on a standard technique composed of few fundamental steps, which if followed lead to the performance of a safe surgical procedure.