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

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