A Modified Open Method for Sutureless Tracheostomy
Personal Experience from 2008 to 2012
Chih-Hao Chen, MD
Department of Thoracic Surgery
Mackay Memorial Hospital
馬 偕 紀 念 醫 院
胸 腔 外 科
陳 治 豪 醫師
Brief Introduction
• Tracheostomy is a common procedure and has a long
history.
• Conventional tracheostomy is a open methods for
delicate dissection.
– More delicate but time-consuming
– More secure in control airway and ventilation
• Recently, percutaneous puncture method become
popular. ( similar to placement of a CVC )
– Quick due to dissect and place bluntly.
• Bronchoscopic guide is useful but required more complicated
– More likely to bleed
– Require specialized tools
Complication of long-term placement of
an oro-endotracheal tube: an example
Brief Introduction
• At the time we attempted for such modified
approach, percutaneous puncture methods is
not a routine procedure in our institution.
– Therefore the choice is limited.
• And the economic burden existed ( not
covered by insurance system )
– Not affordable for most conditions
A proposed modification
• When we gained more and more experiences, we
started to think if tiny wound is technically feasible
by open method(s).
• Theoretically, the smallest wound size is the size that
allowed for secure passage of the tracheostomy tube.
• Then, we began to try small incision and then
utimately mini-wound for sutureless tracheostomy.
Materials and Methods
• Study period :
– 2008.07.01 ~ 2012.09.19
• Inclusion Criteria :
– All case consulted for tracheostomy in our team
• Exclusion Criteria :
– Bedside emergency tracheostomy ( no clear records )
– Complex tracheal surgery
– Traumatic tracheal injury
• Operator :
– Chih-Hao Chen
• Single surgeon to avoid selection bias
– Preference and experience
• 259 patients ( not randomized )
– 156 case : conventional open tracheostomy
– 103 case : modified sutureless tracheostomy
Materials and Methods
• Steps of open method :
– 1. positioning, preparing and disinfecting the operative field
– 2. LA  a 1-3 cm wound was made horizontally (or vertically)
– 3. open dissection of the pretracheal soft tissues by both
electrical cautery and mini-retractors.
– 4. In case of enlarged thyroid isthmus  separation/division
– 4. confrim FiO2 below 40%.
– 5. an inverted-U treacheal flap was created retracted ETT
outwards
– 6. A tracheostomy tube was placed into the trachea
– 7. fascia /muscle/ skin were closed in layers.
An Example of Open Tracheostomy
Materials and Methods
• Steps of such modified method :
– Similar to that of conventional open method.
– 1. positioning, preparing and disinfecting the operative field
– 2. LA  a 4-5 mm wound was made vertically
– 3. open dissection of the pretracheal soft tissues by both electrical
cautery and mini-retractors.
– 4. In case of enlarged thyroid isthmus, we retracted it upward.
– 4. To confrim FiO2 below 40%.
– 5. an inverted-U treacheal flap was created retracted ETT outwards
– 6. a suction tube was placed to distal part of the trachea ( functioning as
a guide-wire )
– 7. the tracheostomy tube was guided into the trachea
An example of such technique(1)
• A patient with short neck and thick pre-tracheal soft tissues.
• The trachea could not be identified by physical examination.
An example of such technique(2)
• Anterior view of the operative field
An example of such technique(3)
tiny skin incision – 4 mm
open dissection with retractor
An example of such technique(3)
• Immediate postoperative view
• The wound size is just fit with the size of tracheostomy tube.
( NO. 7 )
An example of such technique(4)
• Immediate postoperative view
• Although dissection was a bit difficult, such techniques still
works. Suture was not required.
An example of such technique
• Video presentation of a typical case
Brief results
Discussion
• 1. Learning curve and technical refinement from the
experience
• 2. Comparison of open method, modified open and
percutaneous puncture method.
• 3. The significance of such modified open method.
Learning Curve
time v.s. case
From 30 minutes to 2.5 minutes
Comparison of 3 most popular procedures in tracheostomy
Previous literature showed…
• perioperative complications
– more common with the percutaneous technique (10% vs. 3%)
• post-operative complications
– Minor bleeding and wound infection
– more common with the surgical technique
• (10% vs. 7%),
• serious complications
– including death and serious cardiovascular events
• higher in the percutaneous group
• 0.33% vs. 0.06%
• procedure-related complications
– more frequently in the percutaneous group
• Bleeding, T-E fistula, malposition or unexpected angulation.
Discussion
• Thyroid isthmus : a problem for cutaneous
puncture
The Significance
• Such modified open method preserves the merits of
delicate dissection in open method and attained
sutureless benefits at the same time.
• The cost is even lower than that of conventional open
method.
–
–
–
–
No suture required ( skin and soft tissues )
Quick turn-over rate in the operative room
Less burden for wound care
Not required to remove suture stiches when we renew the
tube
• Less likelihood of wound bleeding when compared to
puncture method.
Discussion
• Personal viewpoints :
– Some meta-analysis showed comparable perioperative results in both
groups.
– Unavoidable bias :
Surgery vs procedure ?
Who perform the surgery / procedure ?
surgeon vs physician vs anesthesiologist …
Is bedside procedure better ? Or just acceptable ?
Is non-anes. condition better / safer ? Or just acceptable ?
Actually surgeons rarely report “bad results”.
– Actual cost ?
– (hidden costs covered by insurance)
• Which one is more Cost-effective ?
Conclusion
• The proposed modified open method may be a
reasonable and plausible alternative
appraoch in performing tracheostomy.
• Long-term benefits may be followed for a
longer period in the future.
References
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The following is for young surgeons
• We do have enough resources of research.
– Clinical research
– Basic science
• We encourage innovations !
• We welcome new ideas !