A Modified Open Method for Sutureless Tracheostomy

Personal Experience from 2008 to 2012

Chih-Hao Chen, MDDepartment 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 mmopen 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 Curvetime 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• Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, Schuller DE. Bedside tracheostomy in the intensive care

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• Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000 Nov;118(5):1412-8.

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• Reilly PM, Sing RF, Giberson FA, Anderson HL 3rd, Rotondo MF, Tinkoff GH, Schwab CW. Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Intensive Care Med 1997;23:859–864.

• Graham JS, Mulloy RH, Sutherland FR, Rose S. Percutaneous vs. open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;41:245–248. discussion 248–250.

• Friedman Y, Fildes J, Mizock B, Samuel J, Patel S, Appavu S, Roberts R. Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480–485.

• Crofts SL, Alzeer A, McGuire GP, Wong DT, Charles D. A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 1995;42:775–779.

• Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991;19:1018–1024.

• Griggs WM, Myburgh JA, Worthley LI. A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991;17:261–263.

The following is for young surgeons

• We do have enough resources of research.– Clinical research– Basic science

• We encourage innovations !

• We welcome new ideas !