Surgical tracheostomy is frequently used to wean intensive care patients off mechanical ventilation, or electively in operations on the head and neck. Although a tracheostomy facilitates a safe airway, displacement or accidental decannulation of the tube can potentially be fatal. When it does occur, swift reintubation of the trachea is critical. This, however, can be extremely difficult in patients who have had post-radical ablative operations for cancer of the head and neck, or those with difficult anatomy (short neck or obesity).
Various techniques such as the Björk flap and stay sutures have been described to aid rapid reintubation, but they are associated with complications. We report a modified approach for suspension of the trachea in surgical tracheostomies. To our knowledge, this is the first description of this modification in the literature.
The tracheostomy is made through a horizontal skin incision. In obese patients the excision of supraplatysmal fat will remove the excess adipose tissue that will compromise visualisation of the trachea in the event of decannulation ( Fig. 1 ).
Subsequent dissection down to the anterior tracheal wall, including division of the thyroid isthmus, is performed in a standard way ( Fig. 2 ). We favour the creation of a tracheal window as opposed to a Björk flap, as it avoids the potential risk of tearing or being obstructed by the flap collapsing backwards. Once the window is made in the trachea, its inferior edge is sutured to the skin. It is important to pass the suture around the whole inferior tracheal ring to achieve stable suspension and avoid cheese-wiring of the suture ( Figs. 3 and 4 ). Additional stay sutures can be placed on the lateral edges of the tracheal window and stitched to the skin.
