Percutaneous Tracheostomy and Open Standard Surgical Tracheostomy

A tracheostomy procedure involves the creation of a communicating tract between the trachea and the overlying skin of the neck. There are multiple indications for such a procedure to be carried out, the main being to provide an airway in cases of upper airway obstruction. At present, there are two main types of tracheostomy techniques. The most common is the open standard surgical tracheostomy, but the percutaneous dilational tracheostomy technique has gained popularity, especially in the intensive care setting. Multiple considerations need to be evaluated prior to deciding which technique to use. The main patient factors to consider include neck anatomy and bleeding tendencies. Factors not related to the patient include equipment availability and logistics. In low-risk patients, the percutaneous dilational method may provide certain advantages, but the open surgical tracheostomy remains the gold standard when multiple high risk factors are present. In the preoperative phase, it is important to ensure adequate consent and to follow a preoperative checklist, including review of all investigations and familiarisation with the medical equipment available. Both techniques involve sequential steps that should be performed in a logical, systematic way. Patient positioning is to be optimised. The open standard surgical tracheostomy technique involves performing an adequate skin incision, dissection through fascia, vertical separation of strap muscles, and identification of the thyroid isthmus and trachea. Various surgical techniques can be used to enter the trachea. The percutaneous dilational tracheostomy technique involves the identification of the cricoid cartilage by palpation and the insertion of a needle or trocar through a small, appropriately placed neck incision, into the midline of the tracheal wall. A guide-wire is inserted, and the tract is dilated until the size can accommodate the tracheostomy tube. Postoperative checklists are essential in both techniques for early identification of postoperative complications, and it is imperative to ensure the delivery of adequate tracheostomy care. Both open standard surgical tracheostomy and percutaneous dilational tracheostomy techniques have advantages and disadvantages, but both play an important role in this airway management niche. The techniques complement each other, and it is important that they are both available in the hospital setting to ensure the ideal management of such patients.