气管切开术（图文演示）

10. Tracheal incision

[点击按纽展开更多->收起->回放]

The incision in the trachea should not be started before the surgeon has prepared the correctly-sized tracheostomy cannula, suction tubing for the trachea, and the connecting tube to the anesthetic machine.

[点击按纽展开更多->收起->回放]

After deflating the cuff of the endotracheal tube, the anesthesiologist pulls it back until the tip is at the level of the second or third tracheal ring. The trachea is suctioned clean. The surgeon checks the tracheostomy cuff for proper expansion and leakage by inflating it under water.

• Choosing the incision

[点击按纽展开更多->收起->回放]

A horizontal incision between the second and third or between the third and fourth tracheal rings is one of the two most commonly used incisions.

[点击按纽展开更多->收起->回放]

A midline vertical incision, between the second and third or between the third and fourth tracheal rings, is the other commonly used incision.
To facilitate the introduction of the tracheostomy tube, the vertical incision may be enlarged by making a small transverse incision between the rings, creating a cruciate opening.

• Other incisions

[点击按纽展开更多->收起->回放]

Other types of incisions are used less often, as they are more invasive and carry a greater risk of post-tracheostomy stenosis. They have the advantage, however, of creating a larger opening for introducing and changing the tracheostomy tube:

[点击按纽展开更多->收起->回放]

- an H-shaped or inverted U-shaped incision with formation of a tracheal flap.

[点击按纽展开更多->收起->回放]

- an H-shaped or inverted U-shaped incision with formation of a tracheal flap.

[点击按纽展开更多->收起->回放]

- an H-shaped or inverted U-shaped incision with formation of a tracheal flap.

[点击按纽展开更多->收起->回放]

- an incision with removal of part of the tracheal wall, creating a window.

[点击按纽展开更多->收起->回放]

At the moment of incision, beware of the following:
- do not damage the posterior wall of the trachea, which is in direct contact with the esophagus;
- do not incise the first tracheal ring, as there is a high risk of late subglottic stenosis;
- do not incise below the fourth tracheal ring, for the following reasons: it is difficult to create the tracheostomy, as the trachea is situated deep in the neck at this level. In addition, the tube tends to slide out when the neck returns to an anatomical position and the tracheal opening is at the level of the manubrium. Changing the tube later is very difficult, and selective intubation of one or the other main bronchi is possible. Furthermore, erosion of the brachio-cephalic trunk may occur.

11. Inserting the cannula

[点击按纽展开更多->收起->回放]

Before introducing the tracheostomy tube, 2 non-absorbable sutures are placed in the rings above and below the tracheal opening. Traction on these sutures will facilitate changing of the tube until a tract has formed. The sutures must therefore exit through the incision. This precaution is especially recommended for obese patients or those with a short neck, but should perhaps be employed in all cases.

[点击按纽展开更多->收起->回放]

After verifying that the cuff is completely deflated, the cannula is introduced into the trachea. A 2- or 3-bladed retractor can be used to keep the orifice open. If traction sutures were inserted beforehand, the traction on the 2 sutures may be sufficient.
During the insertion of the cannula, the surgeon should take care not to invaginate the wall of the trachea or tear the balloon of the cannula. The tube, cuff, and the tip of the trocar should be lubricated to ease the insertion into the trachea.

[点击按纽展开更多->收起->回放]

The trocar is removed, the cuff is inflated, and the cannula is connected to the anesthetic machine by a flexible tube. Thereafter ventilation through the cannula is started. The anesthesiologist will verify by auscultation over the chest that the tracheostomy tube is in the right position. Only then can the endotracheal tube be removed.

[点击按纽展开更多->收起->回放]

The surgeon determines the “minimal occluding volume” (MOV), which is the minimum amount of air that must be injected into the balloon to obtain airtightness at a pressure of 25 to 30 cm H2O. One should listen for an air leak, although a small leak is preferable to a balloon that is inflated too much.

12. Closure

[点击按纽展开更多->收起->回放]

Only the skin is sutured.
The suture should not be too tight because:
- surgical emphysema may develop,
- it will be difficult to replace the tube if it slips out.

[点击按纽展开更多->收起->回放]

The cannula is fixed by passing a band around the back of the neck and fixing it to the 2 wings of the cannula.
For extra safety, the 2 wings can also be fixed to the skin with non-absorbable sutures. This reduces the risk of tube dislodgement in the immediate postoperative period, especially in confused, uncooperative patients.

[点击按纽展开更多->收起->回放]

A thin gauze coated with an antiseptic is slid around the margins of the cannula to protect the skin.