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Trachea and Subglottis Operative Notes Modified

last modified on: Mon, 03/25/2024 - 13:57

The sample dictations below are not intended to be used as templates. They are variations on procedures and should not substitute for the surgeon's own dictation. They are provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences. Click on the large blue title of the procedure to move to the actual protocol.

Case Example Percutaneous Tracheotomy

Modified/edited Operative Note:

Securing the airway: The patient was brought into the main OR by Anesthesia and placed in a supine padded position with the head positioned toward anesthesia. Due to concerns about potential airway difficulties, the neck was injected with 1% lidocaine with 1:100,000 epinephrine (10 cc) to the upper trachea and cricoid in preparation for possible urgent tracheotomy or cricothyrotomy. Additionally, the bovie monopolar cautery was connected and tested after placement of a grounding pad. Instrumentation for tracheotomy were opened and identified as adequate for possible urgent surgery. The patient then underwent mask ventilation followed by an effort by anesthesia to intubate using MAC blade showing only a grade 4 view. Mask anesthesia was resumed with the Otolaryngology evaluating the airway with a Dedo laryngoscope and suspended (employing a Lewy suspension placed on a pillow over the chest) with fulcrum laryngoscopy permitting intubation with a 5-0 MLT endotracheal tube through the laryngoscope. Ventilation was reestablished and confirmed with return of CO2 identified on the monitor. There were no desaturations. The superior attachment to the ET tube was removed and the end of the ETT grasped with straight forceps. The cuff of the endotracheal tube was deflated and the ETT was advanced (pushing it into the right mainstem with the straight forceps through the Dedo laryngoscope) as the Dedo scope was withdrawn. The tube was then digitally palpated intraorally at its exit from the tip of the Dedo laryngoscopy. It was secured in this position by by trapping it with digital pressure against the tongue as the straight forceps were released and the Dedo laryngoscope was removed. The ETT was then repositioned as it was pulled back to ~ 23 cm marking with the cuff reinflated auscultation of the lungs revealed bilateral breath sounds and it was secured with tape to the corner of the mouth.

Performing the Percutaneous Tracheotomy: The patient was rotated, 90 degrees, and repositioned. The Lindholm laryngoscope was inserted with poor visualization of the glottis. Next, the Dedo laryngoscope was inserted with good visualization of the vocal cords employing suspension laryngoscopy with the Lewy apparatus. The percutaneous tracheotomy was done with the patient in suspension. The neck was prepped and draped in a sterile fashion. 1% lidocaine with epinephrine had previously been injected into the tracheostomy site. A long 0 degree Storz telescope was used to image the glottic larynx, subglottis and upper trachea. Next the percutaneous kit was opened. A stab incision was initiated through the skin and through some subcutaneous tissue. Next a series of hemostats were used to dilate the skin and subcutaneous tissue. The introducer was then inserted through the anterior tracheal wall and visualized with the 0 degree scope. Next, a series of dilators were used to dilate the tracheostomy opening. After the opening had been appropriately dilated, a #6 percutaneous Shiley trach was inserted. The cuff was then removed from the ET tube and that was removed from the airway. The cuff was inflated on the tracheostomy tube and connected to the ventilator. The tracheostomy tube was then secured with 3-0 nylon and trach straps. Patient was taken out of suspension and returned to anesthesia.

Pediatric Tracheotomy

Modified Operative Note:

Informed consent for tracheotomy with microdirect laryngoscopy on their infant child was reviewed with the parents. The patient was then transferred to the OR and placed in the supine position. A time out was performed. The patient was mask ventilated with ease. Landmarks were palpated and marked in the neck including the cricoid and suprasternal notch. A vertical line was drawn at midline on overlying the trachea. Planned incision site was then marked and injected with 0.5 cc of 0.5% lidocaine with 1:100,000 epinephrine. A number #15 blade was used to create a vertical incision approximately 1 cm above suprasternal notch, extending 1.5 cm in length. Dissection was carried out at midline through subcutaneous tissues with the use of hemostats. The strap muscles were identified, and divided by blunt dissection through the median raphe and retracted laterally with sen retractors. The thyroid was then encountered and was carefully elevated from the trachea with hemostats. It was then divided at the isthmus using electrocautery.  The anterior tracheal wall was identified, and the overlying soft tissue was cleared using Kitners. Numbers 1-4 tracheal rings were identified, and the ET tube was advanced. Prolene sutures were placed in a vertical fashion bilaterally in the lateral portion of the trachea. A cricoid hook was then placed beneath the cricoid cartilage to stabilize and elevate the trachea. A number 11 blade was used to create a vertical incision through the second and third tracheal rings at midline. A tracheal spreader was used to open the incision and prepare it for the tracheotomy tube. Hemostasis was achieved with bipolar cautery. The stay sutures were used to elevate the trachea, and retract it laterally to prepare for receiving the tracheotomy tube. The endotracheal tube was partially removed, so that the tip was just superior to the tracheotomy site. A 3.5 pediatric cuffed Shiley tracheostomy tube was then placed. Placement of the tube was confirmed with CO2 return on the anesthesia monitor. The tracheal hook was carefully removed in addition to the sen retractors. The fiberoptic scope was used to ensure appropriate positioning with the tip of the trachea demonstrated an appropriate distance from the carina. The tracheotomy tube was then secured in place with 2-0 silk sutures placed at each corner to the underlying skin. A tracheal tie was also placed in addition to a drain sponge. The procedure was complete and the patient was returned to anesthesia in good condition.