OR / Prep · Otolaryngology, Head & Neck · open
You’re scrubbing into
Surgical tracheostomy
Why are we operating?
A controlled front door into the trachea below an obstruction the mouth cannot bypass, or for the ventilated patient whose tube has outstayed the larynx's welcome.
Indication: Upper airway obstruction, prolonged ventilation, airway protection; elective and controlled wherever possible.
Read the imaging first
Practice before you scrub
The airway reads first
Three days of sore throat, now fever, trismus and a muffled voice. CT neck with contrast. (Fictional educational case.)
- Deep neck sepsis is drained in theatre with the airway secured first: the drainage is the easy half of the operation.
- Stridor, voice change and trismus grade the threat better than the scan alone: trajectory, not appearance, sets the tempo.
The operation in 4 steps
01Position and landmarks
Neck extended, and the midline landmarks are drawn: thyroid notch, cricoid, sternal notch; the incision sits between cricoid and sternal notch.
Why: The airway is a midline structure with great vessels either side; the operation stays safe by staying midline, and the landmarks are what define midline when the anatomy is deep or distorted.
02Dissection and the thyroid isthmus
Strap muscles are separated in the midline raphe; the thyroid isthmus crossing the trachea is retracted or divided between ties.
Why: The isthmus sits directly over the target rings in most necks; dealt with deliberately it is a step, torn in haste it is a bloodbath over the airway.
03The tracheal window
The trachea is opened at the second to fourth rings, as a window or flap, with stay sutures placed either side.
Why: Too high risks the cricoid and future stenosis; too low invites the brachiocephalic trunk. The stay sutures are the safety system: if the tube displaces before the track matures, they pull the trachea back to the surface.
04Tube insertion and confirmation
The tube is inserted under vision, the cuff inflated, ventilation confirmed with capnography, and the tube secured; the first change is deferred until the track matures.
Why: End-tidal CO2 is the proof the tube is in the airway, not near it. Securing and documenting the stay sutures completes the safety system this operation is built around.
Anatomy you need
The larynx and the tracheal rings below it: the operation enters between the second and fourth.
What can go wrong
Watch it done
Surgical tracheostomy procedure
The open tracheostomy in under three minutes: strap muscles, isthmus, the window and the tube.
Source: Medscape · Watch on YouTube
Conceptual teaching for learners preparing to observe and assist under supervision, not operative instructions. Five minutes from now you should know why this operation exists, what its shape is, and which structures it is designed not to injure.