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Tracheotomy template

last modified on: Thu, 03/07/2024 - 11:13

return to: Tracheotomy - Tracheostomy

Standardized template for tracheotomy dictation: (inferiorly based Bjork flap employing third tracheal ring)

Editors note: Every patient and therefore every procedure is unique. The following is therefore considered a guideline and not an absolute in directing management. HTH

Informed consent was reviewed. The patient was delivered to the OR and placed in the supine position. The table remained in place with the HOB elevated. Landmarks were palpated and marked including the: thyroid notch, cricoid, and suprasternal notch. Planned incision site was marked and injected with 1 cc of 1% lidocaine with 1:100,000 epinephrine. A number #15 blade was used to create a vertical incision extending 3 cm inferiorly from the lower border of the cricoid through dermis. Bovie dissection (with effort to avoid anterior jugular veins) was employed to remove fat overlying the strap muscles by grasping the fat with Allis clamps and lateral retraction of the skin edges with Tyrell retractors (double pronged delicates). The strap muscles were grasped with Allis clamps and pulled laterally to identify the midline with hemostat (with bovie) separation of the straps in the midline. The 'sweet spot' immediately below the cricoid and above the thyroid isthmus was identified by inspection and palpation and then opened with Bovie on cautery mode. With tips of a hemostat directed toward the trach, blunt dissection with the tips of the hemostat identifed the anterior tracheal wall. The hemostat was redirected inferiorly to separate the posterior aspect of the thyroid isthmus from the trachea. The hemostat (kelly clamp) was then used to clamp across the isthmus off the midline with a second hemostat placed opposite. Bovie cautery separated the isthmus and both edges were sutured with a 3-0 silk 'baseball stitch', and hemostasis was achieved. The anterior tracheal wall was further cleaned of overlying soft tissue with Kitners. The tracheal rings were identified. The anesthesiologist was requested to deflate the cuff of the ETT and advance the tip into the right mainstem. A small hemostat (with tips closed) was directed toward the trachea and pushed through the membranous ring (between 2nd and 3rd cartilaginous rings). The hemostat was then manipulated to direct a #15 blade to make a horizontal cut in the membranous trachea. Vertical lateral cuts were made on either side of the opening inferiorly through the third cartilaginous ring. The ET tube was pulled back out of the mainstem and cuff inflated with ventilation restored through the ETT.  An inferiorly based Bjork flap was created by suturing the third cartilaginous ring to the skin (one midline suture, two lateral). The endotracheal tube was partially removed, so that the tip was just superior to the tracheotomy site. The tracheostomy tube with obturator was then placed. The inner canula was placed, and placement of the tube was confirmed with CO2 return on the anesthesia monitor.