Classification and indications
Surgical access is classified according to the level of incision of the tracheal rings relative to the thyroid isthmus:
- Upper: opening of the 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 restore airflow to the respiratory tract. Indications include:
- Asphyxia (suffocation): occurs due to edema of the vocal folds, laryngeal tumors, injuries, stenoses, or foreign body obstruction.
- Mechanical ventilation (MV): when there is a need to transfer the patient to prolonged artificial ventilation.
- Sanation: to clear the bronchi in case of impaired drainage function and suppressed cough reflex.
Access and tissue dissection (upper tracheotomy)
The patient is placed in a supine position strictly along the midline (in some cases, sitting). Elective surgeries are best performed under general anesthesia (intubation), especially in children, as this ensures a smooth procedure 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 down by 6–7 cm (alternatively, 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 laterally.
To reach the trachea, the isthmus of the thyroid gland must be displaced inferiorly. For this purpose, the fixing fascial ligaments are incised along the lower edge of the cricoid cartilage (cartilago cricoidea).
Opening the trachea and inserting the cannula
Before opening the lumen, thorough hemostasis must be performed to prevent blood from entering the airway.
- The trachea is fixed with single-hook retractors, pulling it upward and anteriorly.
- Using a scalpel (with an exposed blade no longer than 1 cm), 1–2 rings are incised, starting from the second. The direction of the incision is strictly from bottom to top (puncture and exit).
- To prevent cartilage necrosis, the ends of the incised rings are excised, forming an oval window.
- The edges are widened with a clamp. The flange of the cannula is initially set in the sagittal plane, and as the tube is advanced, it is rotated into the frontal plane.
- The wound is closed in layers from the angles toward the tube: fascia and subcutaneous 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 layers of the cervical fascia are incised along a grooved director.
Unlike upper tracheotomy, the thyroid isthmus is displaced upward after preliminarily incising the fascial bands holding it. Particular caution is required in the pretracheal space: branches of the thyroid venous plexus must be ligated.
Common errors and complications
The surgery requires high precision. Any deviation or technique violation leads to severe consequences:
- Midline displacement: risk of injury 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: injury to the posterior wall of the trachea and the anterior wall of the esophagus.
- Specific risks of lower tracheotomy: injury to the inferior thyroid artery (a. thyroidea ima), brachiocephalic trunk, right subclavian artery (in case of anomalies), or aortic arch (in patients with a narrow chest).
Briefly: answers to topical questions
At the level of which cartilage rings is the tracheal lumen opened during upper, middle, and lower tracheotomies?
In an upper tracheotomy, 1–2 tracheal rings are incised, starting from the 2nd. In a middle tracheotomy, the area covered by the thyroid isthmus is opened. In a lower tracheotomy, the tracheal rings located below the isthmus are incised. The exact ring numbers for middle and lower tracheotomies are not specified in the sources.
Which neck muscles, located below the hyoid bone, must be retracted laterally to expose the thyroid gland and trachea?
To access the trachea, the sources indicate the following infrahyoid muscles, between the edges of which the tissue incision/separation is performed:
- in upper tracheotomy, tissues are incised strictly along the midline between the edges of the sternohyoid muscles (mm. sternohyoidei);
- in lower tracheotomy, the 2nd and 3rd fasciae are opened strictly between the edges of the sternothyroid muscles (mm. sternothyroidei).
During thyroid resection, the 2nd and 3rd cervical fasciae are incised longitudinally along the midline between the sternohyoid and sternothyroid muscles.
What special surgical instruments are included in the tracheotomy kit?
The specialized tracheotomy kit includes the following instruments:
- Tracheostomy cannula — inserted into the tracheal lumen to ensure breathing.
- Sharp single-tooth hook — used to fixate the trachea and larynx.
- Tracheal dilator — used to widen the incision before cannula insertion.
- Auxiliary instruments.
What specific patient positioning on the operating table is necessary to bring the trachea as anteriorly as possible?
During a tracheotomy, the patient is placed in a strictly midline supine position. Depending on the patient's condition, the surgery can also be performed in a sitting position. Sources do not mention a specific body position intended solely to bring the trachea maximally anterior (it is only noted that the trachea itself is pulled upward and anteriorly using sharp single-tooth hooks).
According to Shevkunenko's classification, which cervical fasciae are sequentially dissected along the midline during an inferior tracheotomy?
During an inferior tracheotomy, the cervical fasciae are sequentially dissected along the midline as follows:
- Superficial cervical fascia (fascia I) — dissected in the first incision along with the skin and subcutaneous tissue.
- Superficial layer of the deep cervical fascia (fascia II) and pretracheal layer of the deep cervical fascia (fascia III) — opened along a grooved director strictly between the medial borders of the sternothyroid muscles.
Class and exam questions
Why is anesthesia not performed in cases of severe asphyxia?
In emergency situations, every second counts. Wasting time on administering and waiting for anesthetics to take effect can cost the patient's life.
Why is it necessary to wrap the scalpel with gauze?
This is a makeshift guard. Only 1 cm of the blade is left exposed to prevent accidentally piercing the posterior tracheal wall and esophagus during a sudden movement or cough of the patient.
How to properly insert a tracheostomy cannula?
First, its flange is positioned in the sagittal plane (along the incision). As it is advanced, the cannula is rotated 90 degrees into the frontal plane so that the tube follows the anatomical axis of the airway.
How does cannula withdrawal (decannulation) occur?
The patient is trained before the tube is finally removed. The cannula opening is periodically occluded so the person gradually adapts to breathing through the natural airways.
What else to study on this topic
- Technique of middle tracheotomy and rules for transecting the thyroid isthmus.
- Layer-by-layer topographic anatomy of cervical fasciae during the inferior approach.
- Rules for regular care of the inner cannula tube (cleaning, boiling).
- Variants of cervical vascular anomalies that pose a hazard during tracheotomy.
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