S. Vijayasekaran 1,2, R.R.E. Uwiera 3, A.L. Smith 1, H. Herbert 1, T.C. Uwiera 4,5*
1 Department of Otolaryngology, Perth Children’s Hospital, Perth, WA, Australia; 2 Department of Surgery, University of Western Australia, Perth, WA, Australia; 3 Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, AB, Canada; 4 Pediatric Surgery, Stollery Children’s Hospital, Edmonton, AB, Canada; 5 Department of Surgery, University of Alberta, Edmonton, AB, Canada

* Corresponding author

S. Vijayasekaran

email: Shyan.Vijayasekaran@health.wa.gov.au

R.R.E Uwiera

email: richard.uwiera@ualberta.ca

A.L. Smith

email: ls_lele@hotmail.com

H. Herbert

email: Hayley.Herbert@health.wa.gov.au

T.C. Uwiera

email: tuwiera@ualberta.ca

Abstract:
Procedure: This video demonstrates the operative method of pediatric tracheostomy with maturation sutures of the tracheocutaneous fistula tract. Introduction: Pediatric tracheostomy provides an alternate airway. Indications: This procedure is done to alleviate upper airway obstruction, facilitate prolonged mechanical ventilation, or pulmonary toilet. Contraindications: There are no absolute contraindications to this procedure, however, like any procedure, it has recognized possible risks. Conclusion: Pediatric tracheostomy with maturation sutures provides an alternate airway to bypass obstruction, facilitate long term ventilation, or pulmonary toilet.

Introduction
Tracheostomy, the surgical creation of an airway in the neck, was reported in both Hindu and Egyptian scripts dating back to 1500BC (1, 2). In 1620, Habicot reported successful tracheostomies in four patients (2, 3) while modern medical publications recording tracheostomies emerged by 1649 (2). In 1808, Caron documented the first successful tracheostomy to treat pediatric infectious airway obstruction (4).
Tracheostomy became a more recognized procedure in the twentieth century. Chevalier Jackson published the basis of modern tracheostomy in 1909 (2) outlining surgical indications, surgical techniques and appropriate post-operative care. This surgical procedure has been a tool used since World War II to bypass airway obstruction, to promote ventilation, and to facilitate pulmonary toilet (2). As technology improved, advances in endotracheal tube design permit longer duration of intubation (5) and may preclude the need for tracheostomy, particularly in pediatric patients. While pediatric tracheostomies rates have trended downward in the last 50 years (5), it is estimated that over 4 800 children undergo tracheostomy annually in the United States (6). Recently, indications for surgery are shifting from alleviating airway obstruction to facilitating long term ventilation (5). As such, effective surgical techniques to safely create a tracheostomy remain essential. This video describes pediatric tracheostomy with maturation sutures in detail.

Materials and Methods
Children with airway obstruction not amenable to immediate correction, or those with either prolonged ventilation needs or need for pulmonary toilet are among the candidates for tracheostomy. Preoperative evaluation may include endoscopic evaluation of the airway to exclude underlying treatable pathology (7). There are no absolute contraindications to this procedure, although coagulopathies, associated co-morbidities and underlying respiratory status must be considered when determining candidacy.
Ideally, tracheostomy is completed under general anaesthetic with the patient already intubated. The child is positioned supine, with the neck slightly extended to permit better exposure and landmarking of the cricoid cartilage and sternal notch. The skin is then incised and the underlying fat is removed aiming to decrease granulation tissue postoperatively, to facilitate exposure of the trachea as well as minimize dead space anterior to the trachea. The strap muscles are identified and divided in the midline raphe, moving them laterally. Retractors are used to maximize exposure, repositioning them to keep the trachea in the midline of the surgical field. Dissection continues until the thyroid isthmus is identified and elevated away from the trachea. The thyroid isthmus is then divided with cautery, allowing the thyroid lobes to fall to either side of the trachea. A cotton peanut is used to clear the adventitial tissue and expose the anterior wall of trachea.
Once the trachea is exposed from the thyroid cartilage to the 4th tracheal ring, retraction sutures are placed. Care is taken to ensure the suture needle tip is angled superiorly to avoid injury to the apices of the lungs, which may be found extending upwards in the neck of young children. The retraction sutures enable the trachea to be stabilized and gently retracted anteriorly towards the skin. They also facilitate replacement of the tracheostomy tube in the event of accidental decannulation prior to complete maturation of the tracheocutaneous fistula tract. The retraction sutures are labelled “left” and “right” relative to the patient and are secured to the child’s chest with transparent dressings at the end of the surgery. They are usually removed after the first tracheostomy tube change. Any remaining adventitia is cleared from the trachea with bipolar cautery to prevent injury to the recurrent laryngeal nerves and tracheal cartilages.
Following communication with the anaesthesiologist, the airway is incised vertically in the midline through two to three tracheal rings. Maturation sutures are then placed to secure the skin to the tracheal cartilages, facilitating replacement of the tracheostomy tube in event of accidental decannulation. Typically, sutures are placed inferiorly on either side of the trachea; and an optional third suture is placed at the superior edge of the tracheal incision. After all mattress sutures are placed, they are tied. Coordinating with the anaesthesiologist, the endotracheal tube is withdrawn slightly until the tip is at the superior aspect of the tracheal incision. The tracheostomy tube is then placed and the ventilation circuit reconnected. Once the placement of the tracheostomy tube is confirmed, the endotracheal tube can be fully removed and the tracheostomy tube is secured in position with ties. Age appropriate pediatric or neonatal tracheostomy tubes are selected, taking into consideration the possible need for a cuffed tracheostomy tube, a tube with an extension of the proximal flange, or specific orientation of the flanges depending on the patient specific needs (8).

Discussion and Results
Pediatric tracheostomy is a relatively routine and safe procedure, however, like all interventions, there are inherent risks. Risks can be divided into intraoperative, early post-operative and late post-operative risks. Intra-operative risks include bleeding, pneumothorax, esophageal injury, and ventilator related complications (8). Early postoperative risks include accidental decannulation, the inability to replace the tracheostomy tube, creation of a false passage, stoma breakdown, neck skin erosion, interstitial air, as well as ventilator issues. Late post-operative risks include accidental decannulation, stoma tracheocutaneous fistula (TCF) and ventilatory failure due to air leaks around the tracheostomy tube (8). Intra-operative risks can generally be mitigated with careful hemostasis, good surgical technique, and effective communication with the anaesthesia team.
The most significant early post-operative risk is accidental decannulation with a reported incidence of 0.7% to 18% (9, 10). This can result in the inability to reinsert the tracheostomy tube and create a false passage with the subsequent inability to ventilate the child (8). As such, various strategies are employed to prevent accidental decannulation. These include sedation and possibly paralyzing the patient to reduce patient related movement, adding ties or sutures to secure the tracheostomy tube in place, retention sutures to facilitate tracheostomy tube replacement, or the addition of TCF maturation sutures (7, 10, 11).
Maturation sutures can be used to both diminish subcutaneous dead space anterior to the trachea as well as to minimize the risk of creating a false passage in the event of accidental decannulation and reinsertion of the tracheostomy tube (2, 10, 11). Maturation sutures are usually absorbable horizontal mattress sutures that secure the tracheal wall to the skin (7) and the use of maturation sutures have been shown to benefit the pediatric tracheostomy populations. Woods et al. (2019) reported earlier discharge from the Intensive Care Unit with associated reduction in hospital costs. Patients also received less sedation, they were mobilized earlier, and parent/carer training was initiated earlier as a result of earlier tracheostomy tube changes facilitated by the addition of maturation sutures. Other methods of stoma maturation include tracheal wall flaps or partial tracheal excision, Z-plasty, and starplasty (2). As an example, an inferiorly based anterior tracheal wall flap from a single tracheal ring is sutured to the skin in a Bjork flap (12). Other adaptations are described with excision of the tracheal wall, or a superior based tracheal flap (13). Tracheal wall flaps, or excision of the anterior tracheal wall are generally not preferred in pediatric patients as long term tracheal stenosis or malacia often accompany such manoeuvres (13). Starplasty is a three-dimensional modification of a Z-plasty technique with an “x” shaped skin incision and a “+” tracheal incision. The skin flap tip is aligned to the tracheal troughs and sutured (13). One of the criticisms of stoma maturation is the increased incidence of persistent TCF after successful decannulation, ranging from 11% to 100% (10, 13) depending on the technique used. For instance, Levi et al. found no change in TCF with simple horizontal mattress sutures compared to no stomal maturation, whereas TCF rates with starplasty are reported at 100% (13).
Pediatric tracheostomy has other early post-operative risks that include wound complications of the stoma or neck that can occur in up to 29% of pediatric tracheostomy patients (6, 9). In children requiring mechanical ventilation there is also a risk of subcutaneous emphysema and possible pneumothorax or pneumomediastinum. Additionally, mechanical problems with the tracheostomy tubing or ventilator may arise.
Late post-operative risks include accidental decannulation, persistent TCF after successful decannulation, tracheostomy tube occlusion, bleeding, suprastomal collapse, tracheomalacia, lower respiratory infections, and ventilatory failure due to air leaks around the tracheostomy tube (8). Tracheostomy tube occlusion occurs commonly, with up to 72% in premature patients and infants, with the incidence decreasing in children over the age of 12 months to 14%. The increased frequency of tube occlusion in the younger children is likely related to the smaller internal diameters of the smaller tracheostomy tubes as well as increased underlying pulmonary conditions in the very young patients (Deutsch 2010). Bleeding, another potential complication, may be mild from stomal granulation. It may, however, be life threatening in the event of trachea-innominate artery fistulas, with a published rate of 0.02% to 4.5% (14). Pediatric patients with tracheostomies who are less than a year of age have an increased risk of mortality, and neonates (<28 days) have twice that risk (5, 6). The overall mortality risk in children with tracheostomies is reported at 18%, although the majority are due to underlying conditions rather than the tracheostomy itself (8).
Pediatric tracheostomy is a relatively common procedure that provides an alternate airway in children with airway obstruction, ongoing mechanical ventilation needs, or those who require assistance for pulmonary toilet. Like any surgical intervention, there are inherit risks of the surgery itself as well as risks in the peri-operative period. This video describes in detail the surgical procedure with maturation sutures of the tracheocutaneous fistula tract to mitigate the risk of accidental decannulation in the early post-operative period. When performed in the manner described, the risk of persistent TCF after successful decannulation is minimal. As the need for pediatric tracheostomy persists, it is to the surgeons’ advantage to employ the technique that best suits the needs of their patient.

Disclosures and Conflicts of Interest
None

Acknowledgments
To our patient and staff at Perth Children’s Hospital, Perth, WA, Australia

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