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Renee L. MakowskiMadigan Healthcare SystemEmail: renee.makowski@us.army.mil Phone: 253-968-1420

Objective:1. Describe a minimally invasive hybrid tracheostomy technique that combines the advantages of open and percutaneous techniques. 2. Compare the safety of hybrid tracheostomy to a historical cohort of open tracheostomy

Methods:We developed a rapid, highly efficacious technique of hybrid tracheostomy (HT) that combines the advantages of standard (ST) and percutaneous (PT) techniques. The procedure has been used for the last 5 years and 173 cases at a tertiary referral academic medical center. This poster will describe that technique, and present an outcome study along with a historical cohort comparison that demonstrates the efficacy of the procedure.

Results:There were no intraoperative complications in the HT or ST groups. The typical procedure duration for resident surgeons ranged from 4-7 minutes. There appears to be no significant difference between the post-operative rates of bleeding, infection, or accidental decannulation between the two HT and ST. The HT uses an incision similar to the percutaneous procedure, but provided open view of the airway to ensure safety. It was significantly more rapid that the percutaneous technique, and bronchoscopy was not required. It also appeared to be more rapid than ST.

Conclusion:HT appears to be more rapid than either PT or ST. It provides the excellent airway control and visualization of ST, while being similarly or less invasive than PT. In our experience, there were no significant complications with either technique.

Minimally Invasive Open Tracheostomy: A Safe, Effective CompromiseCPT Renee L Makowski, MD1; Kristen S Moe, MD, FACS2

1Madigan Healthcare System, Tacoma, WA, 2University of Washington School of Medicine, Seattle, WA

• HT is a minimally invasive approach to surgical tracheostomy• It relies on maximal exposure of the tracheal anatomy as in ST, with

minimal tissue disruption as favored in PT• Anatomically, the trachea deviates away from the skin as it descends

through the neck, into the thorax• HT dissection is high in the neck immediately below the cricoid, and

delivers the trachea to the skin surface for easier visualization and access

Surgical Steps1. 1.5 cm horizontal skin incision approximately 1 cm below the cricoid

cartilage (Figure 1)2. Minimal core lipectomy (Figure 2)3. Cricoid hook is placed for superior airway control and traction

elevates the superior trachea toward the skin4. After limited dissection to the trachea (avoidance of thyroid is more

likely as the incision is high in the neck), a horizontal incision is made between the tracheal rings and gently dilated (Figure 3)

5. A Senn retractor is placed into the inferior aspect of the tracheal incision and traction delivers the trachea toward the skin as it would otherwise descend deeply into the neck (Figure 4)

6. Traction above and below the tracheal stoma allows direct visualization into the stoma through a small soft tissue window for accurate tracheostomy tube placement (Figure 5)

• HT made up the majority (68%) of the patients; there was no statistically significant difference in patient age per group

• No statistically significant difference in intra-operative or post-operative complications in ST versus HT

• Surgical time was significantly less in the HT compared to the ST group

Considerations

• Available surgical times were taken from the circulating nurses’ record on cases that included only tracheostomy, and no other procedures (i.e, direct laryngoscopy and biopsy, fracture repair, carcinomaresection and reconstruction, etc); this record was not always available

• Operative details relied entirely on the operative reports which vary in the amount of detail

• Training level of the primary surgeon was not recorded

• Based on the increasing use of the EMR during the study period, earlier patients had less documentation in the chart, such as otolaryngology daily notes, and therefore minor complications may not have been listed in the summaries that were reviewed

• Retrospective review of a single surgeon’s experience in a tertiary, referral academic medical center from February 2005 through February 2011

• Patients were identified by procedure code “31600,” “trach” or “tracheostomy”

• Operative reports were reviewed to confirm indications, technique and intra-operative complications

• Post-operative data was taken from the electronic medical record (EMR) which included rounding notes by otolaryngology, respiratory therapy, nursing, intensive care and discharge/interim summarieswhen applicable

• Complications were reviewed until active tracheostomy care was complete, either at tracheostomy tube change or suture removal, usually between post-operative days 5-7

• Complications included any intra-operative problems, post-operative bleeding, infection and accidental decannulation

• Patients were excluded for inadequate available data, age < 18 years, emergent or revision surgery

• HT is a safe tracheostomy technique which combines the benefits of surgical exposure and minimized dissection

• There is no statistically significant difference in the safety of HT compared to ST

• HT is a faster technique when compared to ST

• Tracheostomy is an extremely common procedure among otolaryngologists with numerous indications and expanding techniques

• Historically, tracheostomy is an open surgical procedure in the operating room

• Popularization of percutaneous, bedside tracheostomy began with Ciaglia in 1985

• Numerous studies and meta-analyses have compared the safety and cost-effectiveness of open surgical (ST) versus percutaneous tracheostomy (PT)

• Overall major complication rates are rarely significantly different1,2

• PT tends to have a lower rate of stomal infection2,3

• Bleeding rates intra-operatively and post-operatively vary2,3

• PT is usually shorter than ST4,5

• Decreased bleeding and infection in PT likely results from decreased soft tissue dissection

• ST offers direct visualization to decrease risk of false passage, posterior wall injuries and easy access in the event of complications

• HT provides the benefit of decreased soft tissue dissection to limit infection and bleeding, but allows a surgical view to best access the necessary anatomy

• The safety of HT has not been compared to ST

INTRODUCTION

METHODS

1. Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgicaltracheostomy: a meta-analysis. Critical Care Medicine 1999; 27(8).

2. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational traceostomy versussurgical tracheostomy in critically ill patients: a systemic review andmeta-analysis. Critical Care 2006;10(2):1-13.

3. Higgins KM, Punthakee X. Meta-analysis comparison of open versuspercutaneous tracheostomy. Laryngoscope 2007; 17(3):447-54. Kost KM. Endoscopic percutaneous dilatational tracheotomy: aprospectiveevaluation of 500 consecutive cases. Laryngoscope 2005; 115: 1-30.

4. Cheng E, Fee WE. Dilatational versus standard tracheostomy: a meta-analysis. Ann Otol Rhinol Laryngol. Sep 2000;109(9):803-7.

5. Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospectivetrials comparing percutaneous and surgical tracheostomy in critically illpatients. Clinical Investigations in Critical Care 2000; 118(5):1412-18.

CONCLUSIONS

DISCUSSIONMETHODS

REFERENCES

Table 1. Complication rates.

Figure 1. Planned incision 1 cm below cricoid. Figure 2. Core lipectomy through 1.5 cm incision.

ABSTRACT

CONTACT

• 173 tracheostomy patients• 35 excluded; 138 patients included• 44 patients underwent ST between Feb 2005 – June 2007• 94 patients underwent HT between June 2007 – Feb 2011

• Average age 52 years old (50.4 in ST, 53 in HT), p=0.45• Indications were most commonly for ventilator dependence, facial

trauma or airway obstruction/carcinoma• Average surgical time was 22.4 minutes (26.9 ST, 20.2 HT),

p=0.0027• Otolaryngology resident HT time from skin incision to confirmed end

tidal carbon dioxide was 4-7 minutes in recent procedures

Complications (see Table 1)• Intra-operative complications: 1 ST, 3 HT (p=1, Fisher exact); all

were >1 attempt to pass tube and obtain end-tidal carbon dioxide• Post-operative bleeding: 1 ST, 3 HT (p=1, Fisher exact); treated with

conservative intervention, 1 HT required electrocautery• Post-operative infection: 0 ST, 2 HT (p=1, Fisher exact); 1 developed

after exposure to post-operative emesis, 1 only local wound care• Post-operative accidental decannulation: 1 ST, 1 HT (p=0.54, Fisher

exact)• Overall complications: 3 ST (6.8%), 9 HT (9.6%) (p=0.75 Fisher

exact)

RESULTS

Figure 5. Completed tracheostomy.

Figure 3. Gentle tracheal dilation.

The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or as reflecting the views of the Department of Defense.

Complication ST HT

Intra-operative 1 3

Post-operative

Bleeding 1 3

Infection 0 2

Accidental decannulation 1 1

Total 3 9

Figure 4. Traction of the trachea toward the skin with superior and inferior control.