Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-28T06:03:08.630Z Has data issue: false hasContentIssue false
  • English
  • Français

Surgical tracheostomy in morbidly obese patients: technical considerations and a two-flap technique for access

Published online by Cambridge University Press:  30 January 2012

S G Khoo  and
N Rajaretnam
S G Khoo*
Affiliation:
Department of Otolaryngology – Head and Neck Surgery, Mater University Hospital, Dublin, Ireland
N Rajaretnam
Affiliation:
Department of Otolaryngology – Head and Neck Surgery, Mater University Hospital, Dublin, Ireland
*
Address for correspondence: Mr S G Khoo, St Joseph's Ward, Mater University Hospital, Dublin 7, Ireland E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

In an era in which percutaneous tracheostomies are frequently performed in ‘suitable’ necks, more technically complex cases are referred to the otolaryngologist. We describe the surgical technique used and close cooperation required in securing the airway of a morbidly obese patient.

Case report:

A 52-year-old, morbidly obese man with significant comorbidities was referred for surgical tracheostomy following spinal fractures. This was complicated by a previous percutaneous dilatational tracheostomy scar. Tension-free skin advancement was not possible with a deeply plunging trachea; a vertical skin incision was dropped inferiorly to the sternum for access. A size 8 Shiley XLT Proximal Extension cuffed tracheostomy tube was inserted successfully.

Conclusion:

We describe safe airway surgery in a morbidly obese man, and outline requirements including the use of a specially designed operating table, the need for an elongated proximal limb tracheostomy tube, and the use of a distal two-flap technique for access to a deeply plunging trachea.

Keywords

Otorhinolaryngological Surgical ProceduresTracheostomyObesity, Morbid
Type
Clinical Records
Information
The Journal of Laryngology & Otology , Volume 126 , Issue 4 , April 2012 , pp. 435 - 438
Copyright
Copyright © JLO (1984) Limited 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Presented at the Royal Academy of Medicine in Ireland – Otolaryngology Section, 4th January 2011, Royal College of Physicians in Ireland, Dublin, Ireland

References

1El Solh, AA, Jaafar, W.A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients. Crit Care 2007;11:R3CrossRefGoogle ScholarPubMed
2McCormick, T, Venn, R.Recently published papers: tracheostomy: why rather than when? Obesity: does it matter? And stroke: diagnosis, thrombosis and prognosis. Crit Care 2007;11:127CrossRefGoogle ScholarPubMed
3Byhahn, C, Lischke, V, Meininger, D, Halbig, S, Westphal, K.Peri-operative complications during percutaneous tracheostomy in obese patients. Anaesthesia 2005;60:12–15CrossRefGoogle ScholarPubMed
4Plummer, AL, Gracey, DR.Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest 1989;96:178–80CrossRefGoogle ScholarPubMed
5Rehm, CG, Wanek, SM, Gagnon, EB, Pearson, SK, Mullins, RJ.Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy. Crit Care 2002;6:531–5CrossRefGoogle ScholarPubMed
6Rossi, M, De Monti, M, Sonnino, D, Giacometti, B.The use of fiberoptic bronchoscopy during percutaneous dilatational tracheostomy with laryngeal mask. Diagn Ther Endosc 1997;4:13–18CrossRefGoogle ScholarPubMed
7Rajajee, V, Fletcher, JJ, Rochlen, LR, Jacobs, TL.Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study. Crit Care 2011;15:R67CrossRefGoogle ScholarPubMed
8Mansharamani, NG, Koziel, H, Garland, R, LoCicero, J 3rd, Critchlow, J, Ernst, A.Safety of bedside percutaneous dilatational tracheostomy in obese patients in the ICU. Chest 2000;117:1426–9CrossRefGoogle ScholarPubMed
9Sustic, A, Krstulovic, B, Eskinja, N, Zelic, M, Ledic, D, Turina, D.Surgical tracheostomy versus percutaneous dilational tracheostomy in patients with anterior cervical spine fixation: preliminary report. Spine 2002;27:1942–5CrossRefGoogle ScholarPubMed
10Meyer, M, Critchlow, J, Mansharamani, N, Angel, LF, Garland, R, Ernst, A.Repeat bedside percutaneous dilational tracheostomy is a safe procedure. Crit Care Med 2002;30:986–8CrossRefGoogle ScholarPubMed
11Heyrosa, MG, Melniczek, DM, Rovito, P, Nicholas, GG.Percutaneous tracheostomy: a safe procedure in the morbidly obese. J Am Coll Surg 2006;202:618–22CrossRefGoogle ScholarPubMed
12Lim, PV, Raman, R.Adjustable length tracheostomy tube for the morbidly obese and thick neck patient: a prototype. Otolaryngol Head Neck Surg 2001;124:56–7CrossRefGoogle ScholarPubMed
13Romero, CM, Cornejo, RA, Ruiz, MH, Galvez, LR, Llanos, OP, Tobar, EA et al. Fiberoptic bronchoscopy-assisted percutaneous tracheostomy is safe in obese critically ill patients: a prospective and comparative study. J Crit Care 2009;24:494–500CrossRefGoogle ScholarPubMed
14Dossett, LA, Heffernan, D, Lightfoot, M, Collier, B, Diaz, JJ, Sawyer, RG et al. Obesity and pulmonary complications in critically injured adults. Chest 2008;134:974–80CrossRefGoogle ScholarPubMed
15Darrat, I, Yaremchuk, K.Early mortality rate of morbidly obese patients after tracheotomy. Laryngoscope 2008;118:2125–8CrossRefGoogle ScholarPubMed
16Blankenship, DR, Kulbersh, BD, Gourin, CG, Blanchard, AR, Terris, DJ.High-risk tracheostomy: exploring the limits of the percutaneous tracheostomy. Laryngoscope 2005;115:987–9CrossRefGoogle ScholarPubMed
17Biderman, P, Weinbroum, AA, Rafaeli, Y, Raz, E, Porat, E, Wiesel, O et al. Retrosternal percutaneous tracheostomy: an approach for predictably impossible classic tracheostomy. Crit Care Res Pract 2010;290:397270 Epub 2010 Apr. 7Google Scholar
18Gross, ND, Cohen, JI, Andersen, PE, Wax, MK.‘Defatting’ tracheotomy in morbidly obese patients. Laryngoscope 2002;112:1940–4CrossRefGoogle ScholarPubMed
19Shimizu, T, Mizutani, T, Takahashi, S, Hoshi, T, Tanaka, M.New use of a laryngectomy tube for management of mechanical ventilation in patients with anatomical abnormalities. Br J Anaesth 2008;100:728–9CrossRefGoogle ScholarPubMed
20Szeto, C, Kost, K, Hanley, JA, Roy, A, Christou, N.A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese. Otolaryngol Head Neck Surg 2010;143:223–9CrossRefGoogle ScholarPubMed
21Price, DG.Techniques of tracheostomy for intensive care unit patients. Anaesthesia 1983;38:902–4CrossRefGoogle ScholarPubMed
22Greisz, H.Techniques of tracheostomy for intensive care patients. Anaesthesia 1984;39:295–6CrossRefGoogle ScholarPubMed
23Orringer, MB.Endotracheal intubation and tracheostomy: indications, techniques, and complications. Surg Clin North Am 1980;60:1447–64CrossRefGoogle ScholarPubMed
24Tommerup, B, Borgeskov, S.Endoscopic evaluation at follow-up after Bjork tracheostoma. Scand J Thorac Cardiovasc Surg 1983;17:181–4CrossRefGoogle ScholarPubMed
25Eliashar, R, Goldfarb, A, Gross, M, Sichel, JY.A permanent tube-free tracheostomy in a morbidly obese patient with severe obstructive sleep apnea syndrome. Isr Med Assoc J 2002;4:1156–7Google Scholar