Annals of the Royal College of Surgeons of England (I98I) vol.

63

INSTRUMENTS AND TECHNIQUES*

The advantages of stay sutures with tracheostomy

Summary The use of stay sutures in tracheostomy is proposed. They can be of help during the performance of the operation and can be of even greater benefit after it. If the tube is displaced from the trachea in the early postoperative period traction on these sutures permits rapid reintubation.
Introduction Stay sutures are used in a variety of operations in which cannulation is required because they provide stability while manipulations are performed. Typical examples are choledochotomy and venous cutdown. I wish to draw attention to their value during, and after, the perforinance of tracheostomy. This operation can be difficult, particularly when the trachea is calcified, highly mobile, or deeply placed. Stay sutures aid dissection and cannulation as well as playing a useful safety role after operation. If the tube is displaced in the early postoperative period (before an adequate track has formed), it can be very difficult to replace it because of soft tissue obscuring the stoma. The use of stay sutures greatly facilitates the replacement of a displaced tube.

chance of the sutures cutting out they should not be placed too near the midline and should be of braided material-for example, 3/0 silk or Dexon. (Braided sutures are less liable to cut through the soft tissue that lies between the tracheal rings, possibly owing to increased friction.) The sutures are now grasped by the surgeon and assistant and the trachea is drawn gently into the superficial part of the wound. Bulky retractors are removed and the trachea is firmly held for the subsequent incision and

intubation. Complete haemostasis is obtained and any bleeding from the needle holes is controlled by pressure with a swab held in artery forceps. A low-pressure Portex tube is selected and checked for any leak. A size 33 French-gauge tube (external diameter iI mm) is recommended for adults as the larger tubes produce greater trauma to the stoma and trachea (normal internal diameter is 12 mm) (i). The external diameter of the trachea is about 3 mm in the infant, and thereafter corresponds to the age in years (2). A light coating of lignocaine jelly is applied to the tube as this lubricates entry into the trachea and may reduce the cough reflex. rhe trachea is incised vertically in the median

Method
A secure airway is obtained with an endotracheal tube which is passed well down the trachea, thus ensuring that the tube cuff is below the proposed tracheostomy site. The

patient is careftully positioned with the neck in the midline and in moderate hyperextension. The operation proceeds in standard fashion until the trachea is exposed. The thyroid isthmus may be retracted, but it is better divided because this improves exposure and removes a major part of the soft tissue which obscures the stoma should the tube be displaced after operation. After the tracheal rings have been counted the stay sutures are inserted around the second and third rings using a half-circle tapercut needle (34 mm) (see figure). To reduce the Placing of stay sutures in trachea *Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor

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plane, dividing only those rings between the sutures - that is, the second and third - and great care being taken not to damage the posterior wall of the trachea (see figure). The tracheal incision should be tailored to allow a comfortable fit for the tube. Some lateral trimming of the edges of the opening may be required. Overtight fitting can cause horizontal splitting and pressure necrosis of the trachea adjacent to the tube and therefore increase the risk of stenosis. Alternatively excessive removal of normal tracheal tissue may similarly predispose to stenosis. If the cut edges bleed speedy intubation applies gentle pressure to the bleeding points and also reduces the risk of aspiration. At the moment of intubation the stay sutures fix the trachea, which can be elusive, and achieve excellent counteraction. An added benefit is to widen and slightly evert the tracheal opening. The tube is introduced as the endotracheal tube is removed. The operation is completed in the usual manner and the tube anchored to tapes passed around the neck. After the operation, as with all tracheostomy patients, regular checks are made that the tube is correctly positioned in the trachea. The stay sutures are removed on the fourth postoperative day.

Discussion Tracheostomy still has an important role to play in the management of upper airway obstruction and with prolonged mechanical ventilation, although endotracheal intubation should be used whenever possible. Many complications have been reported with tracheostomy and one of the most serious is tube displacement (34). If the tube is not rapidly replaced death can occur, especially if the upper airway is completely obstructed. Causes of displacement are: (i) When patients on ventilators are moved and the ventilator attachments are not (5). (2) Either poor midline positioning of the neck or unequal retraction of an apparently median tracheostomy which moves laterally after the operation. (3) T oo low an incision in the trachea which moves even lower when the neck is flexed at the end of the operation. (4) Failure to keep the tube-retaining tapes taut - for example, with subsiding oedema and surgical emphysema (3,6). Unfortunately displacement is not always recognised promptly, particularly when the tube dislocates into the pretracheal space. Various techniques have been devised to aid rapid reintubation. The most popular is the Bj6rk flap, whose original design was prompted by the death of a patient 'who suffocated when

the cannula slipped out and the inflated cuff compressed the trachea' (7). A tracheal flap based inferiorly is sutured to the skin of the inferior wound margin. This has the important advantage that displacement of the tube into the pretracheal space cannot occur and replacement is easy. It can be criticised in that a wide defect is created in the anterior tracheal wall and normal up-and-down movement of the trachea with respiration is prevented. This may lead to trauma and stenosis later (4,5). Also healing is delayed and tracheocutaneous fistula may be more common with this operation. Hewlett and Ranger have described a similar technique in which the lower margin of the 'window' tracheostomy is sutured to the skin (8). This suffers from the same defects as the Bjork operation. Both of the techniques described have been abandoned in children because of the high risk of tracheal stenosis and decannulation problems and the incision method is now universally used. Several authors have recommended the use of stay sutures in children (9,10). With adults, despite the larger size of the tracheal lumen stenosis is common. In a prospective study of 50 patients surviving after tracheostomy (many patients died before follow-up owing to underlying disease) some demonstrable narrowing of the trachea was present in all cases; Io patients had symptoms and 5 had disabling stenosis (i). Criticisms that have been levelled at the incision (or limited excision) technique are that tearing of the trachea between the cartilages can occur and that tube replacement is difficult (3). By the use of the smallest but adequate tracheostomy tube, excision of a minimal portion of the stoma margin, and stay sutures these hazards can be avoided.

Conclusions The advantages of the stay sutures are as follows: i) Blocked or displaced tubes can be rapidly replaced. If a replacement tube is not immediately available the airway can be maintained by traction on the sutures. 2) Exposure of the trachea at operation is improved. 3) Firm anchoring of the trachea at the moment of incision. 4) Reduced trauma associated with intubation. 5) Uniform tracheostomy technique for all ages.

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Adrian Burke
5 Wilson K. Respiratory units: intermittent positive pressure ventilation: tracheostomy. Proceedings of the Royal Society of Medicine I966;59: 29-36. 6 Pratt LW. Complications of tracheostomy. Eye, Ear, Nose and Throat Monthly I969;ii9: 102-I2. 7 Bjork VO. Partial resection of the only remaining lung with the aid of respirator treatment. J Thorac Cardiovasc Surg i960;39: 179-88. 8 Hewlett AB, Ranger D. Tracheostomy. Postgrad Med J I96I;37:18-21. 9 Johnson DG, Jones R. Surgical aspects of airway management in infants and children. Surg Clin North Am 1976;56:263-79. io Stool SE, Campbell JR, Johnson DG. Trach2ostomy in children: the use of plastic tubes. J Pediatr Surg I968;3:402-7.

I should like to thank Miss Catherine Anderson for the typing, Miss Jennifer Ryan for drawing the figure, and Mr Irwin Faris for reading the manuscript.

References
i Andrews MJ, Pearson FC. Incidence and pathogenesis of tracheal injury following cuffed-tube tracheostomy with assisted ventilation: analysis of a two year prospective study. Ann Surg 1971; I73: 249-63. 2 Warwick R, Williams PK, eds. Gray's Anatomy. 35th ed. Edinburgh: Longmans, 1973: I183. 3 Watts JMcK. Tracheostomy in modern practice. Br J Surg i962-63;50:954-75. 4 Stell PM. Tracheotomy and tracheostomy. In: Ransome J, Holden H, Bull TR, eds. Recent advances in otolaryngology. Edinburgh and London: Churchill Livingstone, 1973: 275-94.