Preoperative Considerations

Once a tracheotomy is planned, certain factors influence whether patients should have an open tracheotomy or a percutaneous dilatational tracheotomy, as first described by Ciaglia in 1985. Regardless of the tracheotomy method chosen, a patient’s overall medical condition must be optimized, body habitus assessed, and coagulation profile addressed. Other preoperative factors to consider include the urgency of the procedure (emergency vs. elective); need for general or local anesthesia, adult or pediatric patient, current status of the airway (intubated vs. nonintubated patient), availability of proper equipment, patient portability, surgeon’s experience (open vs. percutaneous technique), and capability of the institution to perform bedside procedures. This will determine which team performs the procedure and whether it will be done in the operating room or at the bedside in the intensive care unit.

External Anatomy

The patient is placed in the supine position. The surgeon might consider placing the neck into slight extension, but this should not be too far past the neutral position, so that the skin incision remains in line with the tracheal incision. A shoulder roll may be used in some patients to assist with positioning (Fig. 2-1).

The thyroid notch superiorly, cricoid cartilage, and suprasternal notch inferiorly can usually be palpated and should be marked (Fig. 2-1). If an awake tracheotomy is being performed, the skin is injected with 1% lidocaine with 1 : 100,000 epinephrine solution for hemostasis and anesthesia. According to surgeon preference, this injection may also be done for general anesthesia patients. A vertical or horizontal incision is made in the midline of the neck, about 2 cm above the sternal notch, and is carried down until the strap muscles are visible.