Tracheotomy

Classification and indications

Surgical access is classified depending on the level of tracheal ring incision relative to the thyroid isthmus:

• Upper: opening of rings above the isthmus.
• Middle: incision at the level of the isthmus (requires its division).
• Lower: incision below the isthmus.

The main goal of the intervention is to let air into the airways. Indications include:

1. Asphyxia (suffocation): occurs in edema of the vocal folds, laryngeal tumors, injuries, stenoses, or foreign body obstruction.
2. Mechanical ventilation (MV): when it is necessary to transfer the patient to prolonged artificial respiration.
3. Sanation: to clear the bronchi in case of impaired drainage function and depressed cough reflex.

Access and tissue handling (upper tracheotomy)

The patient is placed on their back strictly in the midline (in some cases, sitting). Elective operations are best performed under anesthesia (intubation), especially in children, as this ensures a smooth operation and prevents aspiration of blood. For local anesthesia, a 0.5% novocaine solution with adrenaline is used.

The incision is made along the midline from the middle of the thyroid cartilage downwards for 6–7 cm (or a transverse incision is made above the arch of the cricoid cartilage).

• The skin, subcutaneous tissue, and superficial fascia are successively incised.
• The linea alba of the neck (linea alba colli) is exposed, grasped with forceps, and incised.
• The muscles (mm. sternohyoidei) and median veins are retracted to the sides.

To reach the trachea, the isthmus of the thyroid gland must be displaced downwards. For this, the fixing fascial ligaments are incised along the lower edge of the cricoid cartilage (cartilago cricoidea).

Opening of the trachea and insertion of the cannula

Before opening the lumen, thorough hemostasis must be performed so that blood does not enter the airways.

1. The trachea is fixed with single-hook retractors, pulling it upwards and forwards.
2. With a scalpel (with an exposed blade of no more than 1 cm), 1–2 rings are incised, starting from the second. The direction of the incision is strictly from bottom to top (entry and exit of the blade).
3. To prevent necrosis of the cartilage tissue, the ends of the incised rings are excised, forming an oval window.
4. The edges are expanded with a clamp. The cannula flange is initially set in the sagittal plane, and as the tube is advanced, it is rotated into the frontal plane.
5. The wound is sutured in layers from the corners toward the tube: fascia and tissue with catgut, skin with silk.

Features of lower tracheotomy

The lower approach is more commonly used in pediatric practice. The surgeon stands to the left of the patient, and a longer cannula is required. The incision is made from the jugular notch to the cricoid cartilage. The second and third fascias of the neck are opened along a grooved probe.

Unlike upper tracheotomy, the thyroid isthmus is displaced upwards, after first incising the fascial bands holding it. Special care is required in the pretracheal space: the branches of the thyroid venous plexus must be ligated.

Common errors and complications

The operation requires high precision. Any deviation or technique violation leads to severe consequences:

• Deviation from the midline: risk of damage to the common carotid artery or internal jugular vein.
• Incision size errors: if the incision is smaller than the cannula, pressure will lead to cartilage necrosis. If it is larger, air will penetrate the tissues, causing subcutaneous emphysema.
• Superficial incision: if the mucosa is not incised, the cannula will enter the submucosal layer and block the lumen.
• Deep puncture: damage to the posterior wall of the trachea and the anterior wall of the esophagus.
• Specific risks of lower tracheotomy: injury to the lowest thyroid artery (a. thyroidea ima), brachiocephalic trunk, right subclavian artery (in anomalies), or aortic arch (in patients with a narrow chest).

باختصار: إجابات عن أسئلة حول الموضوع

أسئلة من المحاضرات والامتحانات

مواضيع أخرى للمراجعة في نفس السياق

• تقنية فغر الرغامى المتوسط وقواعد قطع البرزخ للغدة الدرقية.
• التشريح الطبقي للّفاقات العنقية عند إجراء المدخل السفلي.
• قواعد العناية المنتظمة بالأنبوب الداخلي للقنية (التنظيف، الغليان).
• متغيرات الشذوذات الوعائية في العنق والتي تشكل خطراً أثناء فغر الرغامى.

مواضيع أخرى في قسم «جراحات العنق»

تم إعداد المادة بواسطة أعضاء هيئة التدريس في WhiteCoat Pro وفقاً للمنهج الدراسي لكليات الطب. وهي ذات طابع تعليمي.