Patient is supine with sandbags under shoulders to extend neck. This brings up to 50% of trachea superiorly above the sternal notch.
About 2cm above the sternal notch, a transverse incision 2-3cm long is made on the skin with a scalpel.
Haemostasis with diathermy is achieved before progressing to each next step.
Subcutaneous fat, platysma and superficial cervical fascia are separated in the midline and retracted in a transverse manner.
Anterior jugular veins may be encountered and are ligated with ties or coagulated with diathermy.
Underlying strap muscle layers (sternohyoid centrally and sternohyoid laterally) are divided longitudinally.
A West self-retraining retractor may be used to expose the pre-tracheal fascia under the muscles, which is also divided.
A dry surgical field with absolute haemostasis is required before proceeding to enter the trachea.
The 2nd to 4th tracheal rings are identified. The anaesthetist is asked to deflate the ETT cuff.
A 11-blade scalpel is used to cut an inverted-U cartilaginous flap with its base in the 4th ring and apex at the 2nd. Suction (using a small Frazier-type tip) is used to clear any blood out of the field.
The ET tube already in situ is visualised. It is withdrawn and held just proximally. An absorbable 2-0 suture is used to secure the flap to the subcutaneous tissue creating a window into the trachea.
The tracheostomy tube is inserted into the window, connected to the ventilator and the ETT removed completely.
The skin and subcutaneous incision is closed around the tracheostomy tube with vertical mattress sutures using 4-0 prolene.
The tube itself is secured around the patient’s neck using tape.