Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
The general indications for tracheostomy are 
prolonged orotracheal intubation and conditions in 
the upper airway that do not support a safe airway. 
These include tumors, severe soft tissue infections or 
trauma, and some surgical interventions.  
 
Some surgeons prefer to perform open 
tracheostomy through a small incision, hoping to 
maximize the cosmetic appearance of the resulting 
scar. We disagree: a tracheostomy scar never looks 
good after tube removal. The poor cosmetic 
appearance  is not due to the length of the incision, 
but to the tube passing through it. By using a slightly 
wider incision, the surgeon can safely achieve 
hemostasis and take measures to avoid excessive 
bleeding or tracheal stenosis, which we describe 
further below.  
 
Some patients with airway obstruction are 
able to maintain an airway while awake but 
orotracheal or nasotracheal intubation is impossible. 
One example is a patient presenting with a near-
obstructing laryngeal tumor who is still able to 
breathe, but with difficulty. These patients will 
require awake tracheostomy, a challenging but not 
impossible procedure.  This operation can be done 
exactly as described below, with frequent and 
copious injection of local anesthetic.  
 
Tracheostomy is never a suitable procedure 
for emergency airway access; cricothyroidotomy is 
much more appropriate in this situation. An obvious 
exception to this rule is an open neck injury with an 
exposed trachea, such as a “clothesline” injury. 
Cricothyroidotomy is described in a separate chapter.  
 
Tracheostomy proceeds in the following 
general steps:  
● Incision of the skin and superficial layer of the 
deep cervical fascia 
● Elevation of sub-fascial flaps 
● Division of the “strap” muscles at the midline 
● Dissection of the pretracheal fascia and exposure 
of the trachea 
● Preparation for entry into the airway 
● Incision of the trachea and placement of 
anchoring sutures 
● Insertion of the tracheostomy tube 
● Skin closure and securing the flange of the 
tracheostomy 
 
Steps: 
1. Excellent 
communication 
with 
anesthesia 
personnel is essential. The patient should already 
be intubated and anesthetized. For awake 
tracheostomy, the patient 
must be very 
cooperative and copious local anesthetic must be 
used. In this situation, “light” sedation should be 
avoided: the patient may become confused and 
uncooperative, resulting in loss of the airway.  
2. The patient’s neck is extended with a head ring 
and shoulder roll. Take care to make sure that the 
head is fully supported by the headring and the 
neck is not over-extended.  
 
When the patient is in position, with neck extended and 
supported by head ring and shoulder roll, push gently 
downwards on the forehead to be sure that it is the head ring, 
not the spinal column, that is supporting the head.  
 
3. A skin incision 4-5cm long is made one finger-
breadth above the suprasternal notch and carried 
down to the superficial layer of the deep cervical 
fascia. Laterally, this layer is continuous with the 
platysma, but here at the midline it is a fibrofatty 
layer.  
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
An incision 5cm long is made one fingerbreadth above the 
suprasternal notch and carried through the fibrofatty fascia 
layer underneath. 
 
4. The fascia is retracted anteriorly and the sub-
fascial plane is developed for 2cm in both a 
cranial and caudal direction. A self retaining 
(Weitlaner) retractor is placed horizontally to 
retract the skin and fascia. 
 
 
The plane deep to the superficial layer of the deep cervical 
fascia is dissected caudally and cranially (shown) until a 4cm 
wide space is cleared. Source: Eugenio Panieri and Johan 
Fagen-https://vula.uct.ac.za/access/content/group/ba5fb1bd-
be95-48e5-81be-586fbaeba29d/Thyroidectomy.pdf  
 
 
After flap elevation and retractor placement, the strap muscles 
are seen at the midline. 
 
5. The sternohyoid and sternothyroid muscles (the 
most medial of the “Strap muscles”) are 
separated where they meet at the midline. This 
dissection is extended cranially and caudally as 
far as the sub-fascial flaps have been raised. This 
will give a generous view of the trachea once it 
has been exposed. 
 
The sternothyroid and sternohyoid muscles meet at the midline 
just over the trachea: division at the midline allows the trachea 
to be reached in a relatively bloodless plane. 
 
6. Dissection continues in the plane between the 
“Strap” muscles, using a finger to palpate the 
trachea and dissect towards it.  
7. There will be a distinct layer of fat enveloped in 
fascia immediately anterior to the trachea. This 
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
fat can be resected or simply retracted out of the 
way, depending on its volume.  
 
The strap muscles have been divided and the pretracheal fat 
pad (Black arrow) is seen. Part of the right lobe of the thyroid 
gland (Blue arrow) is also seen. In this patient, the gland was 
not obstructing tracheostomy placement so it was left alone. 
Alternatively it can be dissected off the trachea and retracted, 
or a “wedge” of it can be resected, taking care not to 
approach the posterolateral aspect of the trachea. 
 
8. Clear the trachea for about 1/4 to 1/3 of its 
circumference. Do not go too far posterolaterally, 
both recurrent laryngeal nerves are vulnerable to 
injury here.  
 
The trachea has been cleared of pretracheal fat and the rings 
are clearly visible.  
 
9. If the middle lobe of the thyroid gland is blocking 
access to the trachea, try to retract it cranially. If 
this maneuver does not allow wide access to the 
trachea, resect the part of it that lies anterior to 
the trachea with electrocautery. Again, be careful 
not to go too far posterolaterally, as you do not 
know exactly where the recurrent laryngeal nerve 
is. 
10. In an obese patient, place a second Weitlaner 
retractor vertically, holding the Strap muscles 
and pretracheal fat that you have dissected out of 
the way.  
 
A second self-retaining retractor oriented vertically holds the 
dissected strap muscles out of the way and allows hands-free 
access to the dissected anterior ¼ of the trachea. The use of two 
self-retaining retractors is not essential for a thin patient, but is 
very useful for a muscular or obese patient.   
 
11. It is not necessary to dogmatically count tracheal 
rings, as long as you are well below the cricoid 
cartilage. Select a space on the trachea where the 
curved tracheostomy tube will pass from the 
trachea to the skin incision without tension or 
torsion.  
12. Prepare the equipment. Test the tracheostomy 
balloon and then be sure it is fully deflated. 
Familiarize yourself with the way that the inner 
cannula attaches to the tracheostomy. Then 
remove the inner cannula and place the obturator. 
Lubricate the tracheostomy tube with lubricating 
jelly or water, as the inside of the trachea will 
likely be desiccated and difficult to pass a tube 
into.  
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Test the balloon of the tracheostomy.  
 
 
Familiarize yourself with the way that the inner cannula 
connects to the tracheostomy. Once this is accomplished, 
remove the inner cannula and put the obturator in place. 
 
13. If you are performing awake tracheostomy, it is 
crucial that you inject the wall of the trachea prior 
to cutting it, to prevent the patient from coughing 
excessively.  
14. Inform anesthesia that you are about to enter the 
airway. Ask them to advance the endotracheal  
tube. This will help avoid cutting the balloon 
when you incise the trachea.  
15. Prepare the team for this, the crucial step of the 
operation. Be sure that the surgical field is well 
visualized and hemostasis is adequate. The 
assistant and scrub tech should be prepared with 
the two stay sutures of 2-0 Nylon, an 11 blade, 
the tracheostomy tube, a syringe to inflate the 
balloon, and a functioning suction device.  
16. Using the 11 blade, incise the space between two 
tracheal rings horizontally for a length of 10-
12mm. Then incise the ring inferior to this 
incision, on both sides of the incision. This 
creates an inverted “U” flap (also known as a 
Bjork flap.) We do not use the electrocautery on 
the trachea, and we do not use dilators or any 
other device that would tear the tracheal tissue. 
The cut edge will ooze blood, this is acceptable. 
Tearing or cauterizing the trachea theoretically 
increases the chance that it will heal with a 
stenosis.  
 
Make a horizontal incision in the space between tracheal rings 
about 1cm in length.  
 
 
At each lateral edge of the tracheal incision, make another 
incision caudally through the tracheal ring, making an inverted 
“U” or “trapdoor.”  
 
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
17. Pass the 2-0 Nylon sutures through each corner 
of your inverted “U” flap. These “stay stitches” 
will allow you to open the flap by pulling gently. 
Leave each suture long enough that it will lie on 
the chest, and secure it with a hemostat.  
 
Suture passed through one corner of the “trapdoor.” In this 
thin patient, maintaining both self-retaining retractors was not 
necessary. In a fat or very muscular patient, proper retraction 
is very valuable for performing this step quickly.  
 
18. While you are suturing the flap, the anesthetist 
deflates the cuff and withdraws the endotracheal 
tube until its tip is no longer visible. It is still in 
the trachea and can be advanced to below your 
tracheotomy and reinflated if, for some reason, 
you are not able to secure the airway.  
19. Hold the stay sutures in the non-dominant hand 
and gently pull them to open the tracheal flap. 
Insert the tip of the tracheostomy tube into the 
trachea. Before it is inserted all the way, have 
your assistant remove the vertically oriented 
Weitlaner retractor.  
 
Gentle traction on the sutures opens the “trapdoor.” The 
tracheostomy tip has been lubricated with jelly. The surgeon 
holds the tracheostomy like a syringe, with index and middle 
fingers on the flange and the thumb holding the obturator in 
place. It is introduced into the trachea, using a very gentle 
twisting motion if necessary.  
 
20. Advance the tracheostomy tube fully into place 
and inflate the cuff. Remove the obturator and 
insert the inner cannula, securing it in the way 
that you practiced in step 12. Have your assistant 
attach it to the ventilator tubing while you hold 
the tube secure. Ideally a short piece of sterile 
ventilator tubing is used for this step, but it is not 
essential. Confirm that the tube is within the 
trachea through end tidal CO2 or adequate tidal 
volumes.  
21. Remove the horizontally oriented Weitlaner 
retractor. 
22. Loosely close the skin under the tracheostomy 
flange with 2-0 Nylon, leaving space around the 
tube for re-insertion if this should be necessary. 
 
The flange is elevated away from the skin (ideally with an 
instrument, not a finger!) The skin is closed with one or two 
interrupted sutures on each side of the tube, leaving some space 
should reinsertion of the tracheostomy be necessary.  
 
23. Secure the flange to the skin using 2-0 Nylon and 
then with a tracheostomy tape. 
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The flange is secured to the skin with two sutures per side.  
 
The tracheostomy tape is cut into longer and shorter portions, 
a small longitudinal cut is made in the end of each one, and then 
each is passed through a side of the flange and secured.  
 
 
The tape is passed through the longitudinal cut that was 
previously made.  
 
The longer side of the tape is passed behind the neck and then 
the two pieces are tied together at the side of the neck.  
 
24. Tie the ends of the two stay sutures and tape them 
to the chest. This tape can be labeled with 
instructions as below:  
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The sutures are taped to the chest and labeled, “Pull Sutures to 
Re-Insert Tube.”  
 
Postoperative Care:  
● The patient should be nursed in a visible area 
of the ward with immediate access to suction 
and O2. Ensure availability of tracheostomy 
pack, appropriately sized suction catheters 
(i.e. no larger in diameter than half the 
diameter of the tracheostomy tube) and 
suction device.  
● Humidification of the air entering the 
tracheostomy is very important. Use a 
facemask if you do not have a dedicated 
tracheostomy humidifier.  
● Stoma area should be exposed, cleaned daily 
and as needed, and kept dry.  
● Suction as neededs using sterile technique 
ensuring not to advance the suction catheter 
any 
further 
than 
the 
length 
of 
the 
tracheostomy tube. Suction intermittently for 
10-15 seconds and reapply oxygen in 
between suctions to reoxygenate the patient.  
If 
thick 
secretions 
are 
encountered, 
nebulization with saline may loosen the 
secretion.  
 
Technique for suctioning tracheostomy tube. Take care to not 
pass the suction catheter beyond the tracheostomy tube itself. 
The proper placement of a split gauze under the tracheostomy 
device is also shown in this picture. Source: Doyle, G. R., 
McCutcheon, J. A. (2015). Clinical procedures for safer patient 
care. BCcampus. https://opentextbc.ca/clinicalskills/  
 
● Accumulation of thick secretions within the 
tube can lead to fatal obstruction of the 
airway. The best way to prevent this is to use 
a tracheostomy with a removable inner 
cannula, as shown in this chapter. Remove 
the inner cannula several times per day and 
clean it, completely removing any debris or 
impacted mucus with a brush. If a 
tracheostomy with a removable inner cannula 
is not available, it is important that the 
patient’s 
air 
is 
humidified 
and 
the 
tracheostomy is suctioned frequently as 
described above. After 5 days post surgery, 
remove the tracheostomy and clean the 
lumen frequently.  
 
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
With the inner cannula removed, the entire lumen can be 
cleaned with a brush or swab. Source: Doyle, G. R., 
McCutcheon, J. A. (2015). Clinical procedures for safer patient 
care. BCcampus. https://opentextbc.ca/clinicalskills/  
 
● Call the surgical team immediately if 
increased work of breathing, inability to pass 
suction catheter, bleeding, stridor or cyanosis 
is noted. The surgeon should immediately 
remove the tracheostomy of any patient who 
appears to have airway obstruction, as 
obstruction of the tube itself is the most likely 
diagnosis. Patient and relatives should be 
educated on cleaning and observation of 
stoma site. 
● The best way to prevent early mortality after 
tracheostomy placement is to educate the 
nursing staff. Put these patients in Intensive 
Care if you have such a facility, and train the 
nurses on the above principles.  
 
Pitfalls 
● Excessive bleeding can occur postoperatively 
due to incomplete hemostasis during the 
operation. Be meticulous, especially with large 
vessels such as the anterior jugular veins. A small 
amount of bleeding is acceptable, as you did not 
use diathermy on the trachea itself. Most often, 
packing gauze around the tube and inside the 
wound will stop bleeding and the need for 
reoperation is rare.  
 
Occasionally there will be veins running within the pretracheal 
fat pad. It is worthwhile to stop and individually ligate each one 
to prevent postoperative bleeding.  
 
● Dislodgement of the tube during the first 5 days 
after surgery can be catastrophic. Instruct the 
nursing staff on proper technique for reinserting 
the tube, including gently pulling on the stay 
sutures to open the “flap” in the trachea. 
● Blockage of the tube with secretions can be fatal. 
Humidify the air or oxygen that the patient 
breathes. Be sure that the inner cannula is 
removed and cleaned 2-3 times per day, more 
often if needed. We avoid tracheostomy tubes 
without a removable inner cannula because they 
cannot be cleaned without being removed, which 
is impossible in the first 5 days after operation.  
● Purulent discharge from the stoma is most likely 
not due to a surgical site infection, but rather to 
pneumonia or tracheitis. Remove the tube and 
inspect the area carefully; if there is necrotic 
tissue or an abscess here it will need to be 
debrided under general anesthesia.  
● Long term tracheal stomas can become blocked 
with excessive granulation tissue. This tissue can 
also become adherent to the tracheostomy tube 
and prevent its removal. Avoid this by instructing 
the patient with a long-term tracheostomy to have 
it changed every 4 weeks. If the tube is stuck and 
can not be easily removed, the patient will need 
debridement of the granulation tissue and 
tracheostomy tube change, which must be done 
under general anesthesia. 
● Tracheo-innominate fistula is a very feared but 
rare complication. Most cases of blood in the 
tracheostomy are some other process rather than 
a “herald bleed.” In a resource-limited setting this 
complication, when it truly occurs, is not likely 
survivable.  
● Tracheal stenosis can be prevented by avoiding 
over-inflation of any balloon in the trachea. Once 
it occurs, it is extremely difficult to treat. Make a 
habit of periodically checking that the balloon is 
not over-inflated on any intubated patient you 
care for. When a patient has tracheal stenosis, 
dilation of the trachea is unlikely to cause long-
term 
resolution; 
tracheal 
resection 
and 
reconstruction is usually needed.  
 
Tracheostomy 
Richard Davis and Joseph Nderitu 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
Joseph Nderitu MBBS 
AIC Kijabe Hospital  
Kenya 
 
 
 
 
