A tracheostomy is a medical procedure that establishes an artificial airway by creating an opening in the neck and into the trachea (windpipe). This procedure is performed to bypass an obstruction in the upper airway, to facilitate mechanical ventilation for an extended period, or to help with the removal of secretions. Precision in identifying the correct location for the cut is crucial due to the proximity of numerous delicate structures. This exploration will detail the general area of the incision and the procedures involved in creating and securing this alternative airway.
Identifying Key Anatomical Landmarks for Incision
The incision’s location is guided by several palpable structures in the neck, with the target area situated in the midline, just below the voice box. The thyroid cartilage, commonly known as the Adam’s apple, represents a superior boundary and is the largest cartilage of the larynx. Immediately below the thyroid cartilage is the cricoid cartilage, which is the only complete ring of cartilage in the airway.
The cricoid cartilage serves as a fundamental reference point, marking the transition between the larynx and the trachea. Most tracheostomies are placed approximately one to two centimeters below this structure, avoiding the first tracheal ring to reduce the potential for long-term complications like tracheal stenosis. The desired location for the opening is typically between the second and fourth tracheal rings, with the space between the second and third rings being the most common site.
Precise identification of these structures is necessary to avoid damaging surrounding tissues, including major blood vessels and nerves. The thyroid gland has an isthmus—a band of tissue—that often lies across the trachea and may need to be carefully divided or retracted to expose the tracheal rings. Furthermore, the innominate artery is a vessel that crosses the trachea lower in the neck, and a tracheostomy placed too low, below the third or fourth ring, increases the risk of this artery being damaged. Proper neck extension, often achieved by placing a roll under the patient’s shoulders, helps make the target area more accessible.
Distinguishing Between Primary Incision Techniques
The method used to create the opening in the trachea significantly influences the initial incision and subsequent steps. The two primary techniques are the surgical (open) tracheostomy and the percutaneous dilatational tracheostomy (PDT). A surgical tracheostomy is the traditional method, typically performed in an operating room with the benefit of direct visualization. The surgeon makes a larger skin incision, which can be vertical or horizontal, followed by careful dissection through the neck tissues to expose the trachea.
Once the tracheal rings are exposed, a precise cut is made, often creating a horizontal slit or a small window between the second and third tracheal rings. This technique provides the surgeon with the ability to see and avoid surrounding structures. It is the preferred choice for patients with complex neck anatomy or for those requiring concurrent neck surgery.
In contrast, percutaneous dilatational tracheostomy is a less invasive method frequently performed at the patient’s bedside in the intensive care unit (ICU). This technique begins with a smaller skin puncture or incision, after which a specialized guidewire is inserted into the trachea. Serial dilators are then passed over the guidewire to progressively stretch and widen the tract and the opening between the tracheal rings. This dilatational method is often quicker, results in less bleeding, and does not require the patient to be moved to an operating room.
Securing the Tracheostomy Tube and Stoma
The final phase of the procedure involves the placement and stabilization of the tracheostomy tube, or cannula, through the newly created opening. This opening, which connects the trachea to the skin surface, is called the stoma, and it represents the new pathway for air to enter and exit the lungs, bypassing the upper airway. The tracheostomy tube itself is a curved, hollow device that ensures the stoma remains patent and facilitates mechanical ventilation or secretion clearance.
Immediate stabilization is paramount to prevent the tube from becoming dislodged, especially in the first few days before the tract matures. The neck plate, or flange, of the tracheostomy tube rests against the skin and is secured using specialized tracheostomy ties or tape that wrap around the neck. These ties must be adjusted to be snug enough to prevent excessive movement but loose enough to allow one finger to fit comfortably underneath.
In many surgical procedures, “stay sutures” are also placed in the tracheal wall near the opening to assist with tube replacement if accidental dislodgement occurs post-operatively. These sutures are taped to the skin and can be gently pulled to widen the stoma, facilitating the reinsertion of the tube. Maintenance involves regular cleaning and assessment of the stoma and the surrounding skin to prevent infection or pressure injuries.