Open tracheostomy

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anterior triangle of the neck

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    Situated between the anterior margin of the sternocleidomastoid muscle, the mandibula and the jugular fossa, the anterior cervical triangle in the vicinity of the hyoid bone comprises the suprahyoid and subhyoid muscles, vessels, nerves and the thyroid.

    Fascial layers

    The skin of the anterior triangle of the neck covers several fascial layers (all belonging to the cervical fascia) with distinctive features:

    • The superficial lamina invests all structures of the neck, except for the platysma, and separately invests the sternocleidomastoid muscle as well as the posterior aspect of the trapezius muscle (accessory nerve XI).
    • The medial pretracheal lamina invests the subhyoid muscles.
    • The deep prevertebral lamina courses outside the surgical field between the esophagus and spine.

    Just like the lateral vascular and nerve pedicle (carotid artery, internal jugular vein and vagus nerve), the trachea and thyroid / parathyroids also have their own organ fascias. With their three-dimensional configuration, the fascias invest compartments interspersed with spaces which extend into the mediastinum and thus represent potential routes of infection.

  • Florence-Nightingale-Krankenhaus

    Dr. Corinna Ludwig

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  • Florence-Nightingale-Krankenhaus

    Dr. Corinna Ludwig

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  • Skin incision

    142-4

    Transverse skin incision, about 3 cm, long, inferior to the thyroid cartilage and about 1-2 finger widths superior to the jugular fossa. Take down the skin and platysma to the superficial cervical fascia.

  • Tracheal access

    142-5

    After transverse transection of the superficial cervical fascia incise the pretracheal lamina in the midline and dissect down. After splitting the strap muscles expose the anterior tracheal wall at the level of the 3rd and 4th cartilage ring with two retractors; the thyroid isthmus may have to be pulled craniad.

    Note: Excise the thyroid isthmus if it continues to block the anterior tracheal wall, and suture-ligate its transection margins to both lobes of the thyroid.

  • Tracheal fenestration

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    If possible, fenestrate the trachea between the second and third cartilage ring. In doing so, incise the annular ligament of the trachea the full width of the anterior tracheal wall. At both sides of the tracheal wall, cut through the second and third cartilage ring and the annular tracheal ligament with scissors. This creates a fenestration with inferior base.

    Note: Before incising the trachea, it must be verified that the cuff of the translaryngeal tube is outside the surgical field. If this is not the case, the tube should be advanced further, thereby protecting the cuff from damage. 

  • Transcutaneous fixation of the fenestration

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    After careful hemostasis, the tracheostomy is epithelialized by suturing the skin to the margin of the tracheal fenestration. First, suture the skin in the inferior part of the wound to the folded-back fenestration and then suture the mobilized margin of the skin to the trachea (in both cases interrupted horizontal mattress sutures 4/0, monofilament, delayed absorption).

  • Inserting and connecting the tracheostomy tube

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    The anesthesiologist deflates the cuff of the translaryngeal tube and pulls it back under direct vision. After suctioning the tracheal secretions insert a size 9 tracheostomy tube through the tracheostomy. Once the cuff has been inflated the tube is connected with the ventilator.

  • Outer fixation

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    After correct ventilation, has been verified, the tracheostomy tube is secured with a collar around the patient’s neck.

  • Florence-Nightingale-Krankenhaus

    Dr. Corinna Ludwig

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  • Intraoperative complications

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  • Postoperative complications

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  • Praxis für Chirurgie & Gefäßchirurgie

    Dr. Helmut Nigbur

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  • References on this topic

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  • Meta-analyses and prospective trials

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  • literature search

    Literature search under: http://www.pubmed.com