b. Patient Preparation. The patient is placed in dorsal recumbent position with
shoulders elevated. Generally, endotracheal anesthesia is used, and a pharyngeal
pack of moist gauze is inserted in the mouth.
c. Operative Procedure. Although the case may be scheduled as a local
excision, frequently lesions of the oral cavity require more extensive excision than
planned preoperatively. The setup should be designed to include the instruments for a
neck dissection, or to have them available. In most tumors of the oral cavity, a
tracheostomy is performed to assure an airway postoperatively.
1-38. ELECTIVE TRACHEOSTOMY
a. General. This procedure involves opening the trachea and inserting a
cannula through a midline incision in the neck, below the cricoid cartilage. It is used as
an emergency procedure to treat upper respiratory tract obstruction and as a
prophylactic measure in the presence of chronic lung disease in which an obstruction
could occur. A prophylactic tracheostomy is performed at the time of surgery, thus
providing for easy and frequent aspiration of the tracheobronchial tree and diminishing
the dead space that exists from the opening of the mouth down to the supraclavicular
region. The creation of a new clearance (tracheostomy) nearer to the functional areas
in the lung provides for greater volume of air for the patient with a partly destroyed lung.
Anesthesia may be maintained via a prophylactic tracheostomy.
b. Preparation of the Operating Room. The standard instruments and other
items needed are kept sterile in a pack, ready for immediate use. In addition, the
circulator is to have a cardiac arrest tray immediately available.
c. Preparation of the Patient. The patient is placed in a dorsal recumbent
position, with the shoulders raised by a folded sheet to hyperextend the neck and head.
The neck is cleansed and sterile drapes applied as for operations of the thyroid.
d. Operative Procedure.
(1) A vertical or transverse incision may be used. A vertical incision is made
in the midline from approximately the cricoid cartilage to the suprasternal notch. When
a transverse incision is made, it extends approximately one fingerbreadth above the
suprasternal notch parallel to it and from the anterior border of one sternocleidomastoid
muscle to the opposite side. Soft tissues and muscle are divided, and the isthmus of the
thyroid gland that joins both lobes of the gland in the midline over the trachea is
retracted in an upward direction with Cushing retractors, thus resulting in exposure of
the underlying tracheal rings, usually the third and fourth. In some cases, two curved
clamps may be inserted through this incision across the isthmus and the isthmus
transected. The transected ends of the isthmus are secured with chromic gut sutures.