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Tracheotomy (Bjork)
Preoperative Considerations
Consent:
- Explain need to establish alternate airway
- Descibe steps if awake trach is planned
- Describe inability to talk afterwards
- Bleeding, infection
- Scar formation
- Tracheal stenosis
- Accidental decannulation
- Pneumothorax/pneumomediastinum
- Injury to esophagus, recurrent laryngeal, major vessels, tracheocutaneous fistula
Anesthesia/Positioning:
- Supine
- Shoulder roll with neck extension
- When approaching the trachea, anesthesia team must be instructed to decrease FiO2 to less than 30% to minimize risk of airway fire
Other:
- Ensure armored ETT vs Shiley cuffed trach is available with backups. Communicate with anesthesia about the size
- Ensure that all cuffs are checked for leak prior to insertion
Armamentarium:
- Local anesthesia
- Monopolar/bipolar
- Colorado tip
- Debakey x2
- Tonsil or hemostat
- Army/Navy x 2
- Kittner "Peanut"
- Tracheal hook
- #15 blade
- Heavy mayo scissor
- Needle driver
- 2-0 Vicryl (Bjork Flap)
- 2-0 Prolene (stay sutures)
- Tracheal dilator
- Metal yankhauer suction
- 2-0 Silk suture (to secure Shiley trach or armored tube)
- Lubricating jelly
- Mastisol
- Steri strips
- Shiley trach in multiple sizes, check for cuff patency
- Armored tube in multiple sizes, check for cuff patency
- Surgicell
Technique
- Sterile marking pen is used to mark midline, inferior aspect of cricoid cartilage (straight line), and sternal notch (V)
- In this case, the clavicles were also marked to assist in orientation for secondary reconstruction procedure to be performed after tracheotomy
- Local anesthesia with vasoconstrictor is injected in subcutaneous layer at anticipated site of incision
- A 3-4cm incision through skin and subcutaneous tissue is created approximately halfway between the inferior aspect of the cricoid cartilage and the sternal notch
- Subcutaneous fat can be removed to aid in visualization
- Once through subcutaneous tissue and platysma, a vertical incision is created through the superficial layer of deep cervical fascia
- Dissection then proceeds bluntly until the midline raphe of the strap muscles is identified
- The strap muscles are then divided at the midline in the avascular raphe to reveal the trachea below
- Pre-tracheal fascia is cleaned off the trachea with a Kittner and hemostasis is ensured before proceeding to tracheal incision
- If necessary, a cricoid hook is used in in the inferior aspect of the cricoid cartilage to bring tracheal rings 2-3 into view
- A Bjork flap is then created by making an "Inverted-U" shaped flap through tracheal rings 2-3
- The base of this flap should be approximately one third of the tracheal diameter
- Stay sutures are first passed through skin and then passed through the Bjork flap closer to its free edge
- Sutures must be passed close enough to the free edge of the Bjork flap that they will effectively retract it, but not so close to the edge that they pull through
- Suture is then once again passed through the Bjork flap in the opposite direction
- Finally, suture is then passed once more through the skin
- Suture is pulled taught to hold Bjork flap open
- In this case, an armored ETT was then placed into the trachea to allow for easier access to the neck without potential obstruction from tracheostomy tube flange or anesthesia circuit
- ETT will be exchanged for tracheostomy tube at the end of the case
- Once the ETT is placed to an appropriate depth, the stay suture is tied at the skin
- The ETT is then secured to the chest wall for the duration of the case
- Stay suture ends are secured with steri strips and Surgicel is packed around tracheotomy to aid in hemostasis
Postoperative Considerations
Immediate:
- Postop CXR
Follow Up:
- Decide decannulation timeline early and downsize accordingly
Operative Note
Surgeon(s): ***
Assistant Surgeon(s): ***
Preoperative Diagnosis: ***
Postoperative Diagnosis: Same
Procedure(s): ***
Anesthesia: General
Implants: None
Specimen:***
Drains: None
Fluids: See anesthesia record
EBL: Minimal
Complications: None
Counts: Correct x2
Indications: ***
Findings: As expected
Procedure in Detail:
The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail. The patient was transferred to the operating room by the anesthesia team. The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures. A time-out was performed and the procedure began.
number #15 blade was used to create a horizontal incision extending 3 cm inferiorly from the lower border of the cricoid through dermis. Bovie dissection (with effort to avoid anterior jugular veins) was employed to remove fat overlying the strap muscles by grasping the fat with Allis clamps and lateral retraction of the skin edges. The strap muscles were grasped with Allis clamps and pulled laterally to identify the midline with hemostat (with bovie) separation of the straps in the midline. Below the cricoid and above the thyroid isthmus was identified by inspection and palpation and then opened with Bovie cautery. With tips of a hemostat directed toward the trach, blunt dissection with the tips of the hemostat identifed the anterior tracheal wall. The hemostat was redirected inferiorly to separate the posterior aspect of the thyroid isthmus from the trachea. The hemostat (kelly clamp) was then used to clamp across the isthmus off the midline with a second hemostat placed opposite. Bovie cautery separated the isthmus. The anterior tracheal wall was further cleaned of overlying soft tissue with Kitners. The tracheal rings were identified. The anesthesiologist was requested to deflate the cuff of the ETT. A small hemostat (with tips closed) was directed toward the trachea and pushed through the membranous ring (between 2nd and 3rd cartilaginous rings). The hemostat was then manipulated to direct a #15 blade to make a horizontal cut in the membranous trachea. Vertical lateral cuts were made on either side of the opening inferiorly through the third cartilaginous ring. An inferiorly based Bjork flap was created by suturing the third cartilaginous ring to the skin (one midline suture). The endotracheal tube was partially removed, so that the tip was just superior to the tracheotomy site. The tracheostomy tube with obturator was then placed. The inner canula was placed, and placement of the tube was confirmed with CO2 return on the anesthesia monitor. Endotracheal tube removed. Mastisol and steri-strips used to secure stay suture to skin.
The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.
Coding
- 31600
