A Modified Open Method for Sutureless Tracheostomy Personal Experience from 2008 to 2012

1. A Modified Open Method for Sutureless TracheostomyPersonal Experience from 2008 to 2012 Chih-Hao Chen, MD Department of Thoracic Surgery Mackay Memorial Hospital 馬 偕 紀 念 醫 院 胸 腔 外 科 陳 治 豪 醫師

2. Brief Introduction • Tracheostomy is a common procedure and has a long history. • Conventional tracheostomy is a open methods for delicate dissection. • More delicate but time-consuming • More secure in control airway and ventilation • Recently, percutaneous puncture method become popular. ( similar to placement of a CVC ) • Quick due to dissect and place bluntly. • Bronchoscopic guide is useful but required more complicated • More likely to bleed • Require specialized tools

3. Complication of long-term placement of an oro-endotracheal tube: an example

4. Brief Introduction • At the time we attempted for such modified approach, percutaneous puncture methods is not a routine procedure in our institution. • Therefore the choice is limited. • And the economic burden existed ( not covered by insurance system ) • Not affordable for most conditions

5. A proposed modification • When we gained more and more experiences, we started to think if tiny wound is technically feasible by open method(s). • Theoretically, the smallest wound size is the size that allowed for secure passage of the tracheostomy tube. • Then, we began to try small incision and then utimately mini-wound for sutureless tracheostomy.

6. Materials and Methods • Study period : • 2008.07.01 ~ 2012.09.19 • Inclusion Criteria : • All case consulted for tracheostomy in our team • Exclusion Criteria : • Bedside emergency tracheostomy ( no clear records ) • Complex tracheal surgery • Traumatic tracheal injury • Operator : • Chih-Hao Chen • Single surgeon to avoid selection bias • Preference and experience • 259 patients ( not randomized ) • 156 case : conventional open tracheostomy • 103 case : modified sutureless tracheostomy

7. Materials and Methods • Steps of open method : • 1. positioning, preparing and disinfecting the operative field • 2. LA  a 1-3 cm wound was made horizontally (or vertically) • 3. open dissection of the pretracheal soft tissues by both electrical cautery and mini-retractors. • 4. In case of enlarged thyroid isthmus  separation/division • 4. confrim FiO2 below 40%. • 5. an inverted-U treacheal flap was created retracted ETT outwards • 6. A tracheostomy tube was placed into the trachea • 7. fascia /muscle/ skin were closed in layers.

8. An Example of Open Tracheostomy

9. Materials and Methods • Steps of such modified method : • Similar to that of conventional open method. • 1. positioning, preparing and disinfecting the operative field • 2. LA  a 4-5 mm wound was made vertically • 3. open dissection of the pretracheal soft tissues by both electrical cautery and mini-retractors. • 4. In case of enlarged thyroid isthmus, we retracted it upward. • 4. To confrim FiO2 below 40%. • 5. an inverted-U treacheal flap was created retracted ETT outwards • 6. a suction tube was placed to distal part of the trachea ( functioning as a guide-wire ) • 7. the tracheostomy tube was guided into the trachea

10. An example of such technique(1) • A patient with short neck and thick pre-tracheal soft tissues. • The trachea could not be identified by physical examination.

11. An example of such technique(2) • Anterior view of the operative field

12. An example of such technique(3)tiny skin incision – 4 mmopen dissection with retractor

14. An example of such technique(3) • Immediate postoperative view • The wound size is just fit with the size of tracheostomy tube. ( NO. 7 )

15. An example of such technique(4) • Immediate postoperative view • Although dissection was a bit difficult, such techniques still works. Suture was not required.

16. An example of such technique • Video presentation of a typical case

17. Brief results

18. Discussion • 1. Learning curve and technical refinement from the experience • 2. Comparison of open method, modified open and percutaneous puncture method. • 3. The significance of such modified open method.

19. Learning Curvetime v.s. caseFrom 30 minutes to 2.5 minutes

20. Comparison of 3 most popular procedures in tracheostomy

21. Previous literature showed… • perioperative complications • more common with the percutaneous technique (10% vs. 3%) • post-operative complications • Minor bleeding and wound infection • more common with the surgical technique • (10% vs. 7%), • serious complications • including death and serious cardiovascular events • higher in the percutaneous group • 0.33% vs. 0.06% • procedure-related complications • more frequently in the percutaneous group • Bleeding, T-E fistula, malposition or unexpected angulation.

22. Discussion • Thyroid isthmus : a problem for cutaneous puncture

23. The Significance • Such modified open method preserves the merits of delicate dissection in open method and attained sutureless benefits at the same time. • The cost is even lower than that of conventional open method. • No suture required ( skin and soft tissues ) • Quick turn-over rate in the operative room • Less burden for wound care • Not required to remove suture stiches when we renew the tube • Less likelihood of wound bleeding when compared to puncture method.

24. Discussion • Personal viewpoints : • Some meta-analysis showed comparable perioperative results in both groups. • Unavoidable bias : Surgery vs procedure ? Who perform the surgery / procedure ? surgeon vs physician vs anesthesiologist … Is bedside procedure better ? Or just acceptable ? Is non-anes. condition better / safer ? Or just acceptable ? Actually surgeons rarely report “bad results”. • Actual cost ? • (hidden costs covered by insurance) • Which one is more Cost-effective ?

25. Conclusion • The proposed modified open method may be a reasonable and plausible alternative appraoch in performing tracheostomy. • Long-term benefits may be followed for a longer period in the future.

26. References • Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, Schuller DE. Bedside tracheostomy in the intensive care unit: a prospective randomised trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope 2001;111:494–500. • Heikkinen M, Aarnio P, Hannukainen J. Percutaneous dilational tra- cheostomy or conventional surgical tracheostomy. Crit Care Med 2000;28:1399–1402. • Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000 Nov;118(5):1412-8. • Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999;27:1617–1625. • Gysin C, Dulguerov P, Guyot JP, Perneger TV, Abajo B, Chevrolet JC. Percutaneous vs. surgical tracheostomy: a double-blind randomized trial. Ann Surg 1999;230:708–714. • Porter JM, Ivatury RR. Preferred route of tracheostomy – percutaneous vs. open at the bedside: a randomised, prospective study in the surgical intensive care unit. Am Surg 1999;65:142–146. • Holdgaard HO, Pedersen J, Jensen RH, Outzen KE, Midtgaard T, Johansen LV, Moller J, Paaske PB. Percutaneous dilatational tracheostomy vs. conventional surgical tracheostomy. A clinical randomised study. Acta Anaesthesiol Scand 1998;42:545–550. • Reilly PM, Sing RF, Giberson FA, Anderson HL 3rd, Rotondo MF, Tinkoff GH, Schwab CW. Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Intensive Care Med 1997;23:859–864. • Graham JS, Mulloy RH, Sutherland FR, Rose S. Percutaneous vs. open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;41:245–248. discussion 248–250. • Friedman Y, Fildes J, Mizock B, Samuel J, Patel S, Appavu S, Roberts R. Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480–485. • Crofts SL, Alzeer A, McGuire GP, Wong DT, Charles D. A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 1995;42:775–779. • Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991;19:1018–1024. • Griggs WM, Myburgh JA, Worthley LI. A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991;17:261–263.

27. The following is for young surgeons • We do have enough resources of research. • Clinical research • Basic science • We encourage innovations ! • We welcome new ideas !