1. Tracheotomy/Tracheostomy Appendectomy
SUR 111
Tracheotomy/Tracheostomy
Appendectomy

2. Tracheotomy Tracheostomy

3. Tracheotomy/Tracheostomy
Tracheotomy temporary opening into the trachea to facilitate breathing
Tracheostomy permanent opening of the trachea and creation of a tracheal stoma
Must place tracheal tube with either
Patient will be hooked up to a ventilator
Long term tracheostomy may eventually be able to wean off ventilator, but maintain stoma that will function as their nose did prior to surgery

4. Tracheostomy is indicated for a patient who requires emergent or elective airway management for:
prolonged ventilator dependence
acute upper airway obstruction
chronic upper airway obstruction

5. Pathology for Tracheotomy or Tracheostomy
Vocal cord paralysis
Neck surgery
Trauma
Prolonged intubation
Secretion management
Cannot intubate
Stridor due to tracheal blockage
Sleep apnea
Stridor - a high-pitched sound heard best on inspiration.
Sleep apnea - A condition characterized by temporary breathing interruptions during sleep

6. Anatomy of the Neck
The neck is traditionally organized into triangles; each side is divided into two large triangles separated by the sternocleidomastoid muscle.
The neck has many significant structures, including
The carotid artery
The jugular vein
The vagus nerve
The recurrent laryngeal nerve
The esophagus
The trachea
The spinal accessory nerve (cranial nerve XI)
The digastric muscle
The hypoglossal nerve (cranial nerve XII)
The larynx
The pharynx
The thyroid
The parathyroid
The ansa cervicalis
Lymph nodes
(From Potter PA and Perry AG: Fundamentals of nursing, ed 5, St Louis, 2001, Mosby.)

7. Anatomy of the Larynx Posterior view of the pharynx
The larynx is composed of nine segments of cartilage, three paired sets and three unpaired segments as illustrated in Figure 25–18.
The hyoid bone - (Lingual Bone) is a bone in the human neck, and is the only bone in the skeleton not articulated to any other bone. It is supported by the muscles of the neck and in turn supports the root of the tongue.
Posterior view of the pharynx
Anterior view of the pharynx
(From Thibodeau GA and Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby.)

9. Anesthesia
General
Local

10. Medications
Local anesthetic: Lidocaine or bupivicaine with or without epinephrine
Antibiotic irrigation

11. Positioning Supine Shoulder roll Donut headrest Pillow under knees
Safety strap

12. Prep End of chin to midchest and bedsheet to bedsheet
Prep of choice: Duraprep, betadine scrub and/or paint

13. Draping
Towels
Small fenestrated sheet (Pediatric lap sheet)

14. Supplies, Equipment, Instruments
Minor basin
Basic pack
Pediatric lap sheet
Other small fenestrated sheet
Blades
Suture or ties of surgeon’s choice (prn)
Tracheotomy tray
Tracheotomy tube (Shiley)
Twill tape

15. Isthmus of thyroid is divided to expose the trachea
Surgical Procedures
Tracheotomy/Tracheostomy
Tracheostomy is indicated for patient who require emergent or elective airway management of prolonged ventilator dependence or acute or chronic upper airway obstruction.
Technique:
An incision is made over the anterior tracheal wall.
The surgeon visualizes the tracheal wall.
The tracheal incision is made, usually between the third and fourth tracheal rings.
The endotracheal tube is partially removed to the point superior to the tracheal incision.
The tracheostomy tube is inserted.
Hemostasis is achieved.
Tracheostomy tube is secured.
Dressings are applied.
The obturator from the endotracheal tube is sent with the patient.
Isthmus of thyroid is divided to expose the trachea
Two tracheal rings are cut, and the upper ring is partially resected. Tracheal hook pulls the trachea from the depth of the wound toward the surface
Tube is inserted
(Modified from DeWeese DD: Textbook of otolaryngology, ed 6, St Louis, 1982, Mosby.)

16. Operative Sequence Discussion

17. Considerations
Will make sure obturator goes with patient to PACU or ICU
Complications: hemorrhage, infection, damage to other structures

18. Large Intestine (Colon) Anatomy
Look to page in ST

19. Sigmoid colon most frequent site of colon cancer
Sigmoid colon most frequent site of colon cancer. Are recesses or folds above the anus that can become clogged with feces and lead to fissures or fistulas
Colon responsible for absorption of water and electrolytes, compaction of fecal waste, and production of Vitamin K Sigmoid colon 1° site of colon cancer

20. Becomes emergent procedure if ruptures
Appendectomy
Removal of the appendix
Appendicitis
Inflammation/infection of the appendix
Acute condition
Urgent procedure
Becomes emergent procedure if ruptures
Rupture leads to peritonitis which untreated leads to death
Sometimes Removed as Prophylactic Procedure (Incidental Appendectomy) in addition to other lower abdominal surgical procedures
The appendix is removed when acutely infected to prevent peritonitis, which will occur if it should rupture.
Many surgeons perform an appendectomy as a prophylactic (preventive) procedure when operating in the abdomen for other reasons. The procedure is then called an incidental appendectomy.
Technique:
The abdomen is entered.
The appendix is isolated from the mesoappendix.
The appendix is ligated and removed.
A purse-string suture is placed around the stump of the appendix.
The wound is closed.
Isolation or bowel technique is used for this procedure.

22. The base of the mesoappendix is coagulated using the endocoagulator
Laparoscopic Appendectomy
The appendix is attached to the mesoappendix, which is divided with scissors or ESU and ligated with vessel clips or surgical stapler. Mesoappendix - (mes(o)- a prefix meaning in the middle) the peritoneal fold attaching the appendix to the mesentery of the ileum.
The base of the mesoappendix is coagulated using the endocoagulator
(From Goldberg JM and Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)

23. The appendix is attached to the mesoappendix, which is divided with scissors or ESU and ligated with vessel clips or surgical stapler

24. The endo-loop is tightened at the base of the appendix
Laparoscopic Appendectomy, continued
Once the appendix is mobilized, it can be amputated from the cecum.
Two ties must be placed around the appendix between the lines of amputation.
The endo-loop is tightened at the base of the appendix
(From Goldberg JM and Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)

25. Once the appendix is mobilized, it can be amputated from the cecum
Two ties must be placed around the appendix between the lines of amputation

26. The appendix is excised with scissors
Laparoscopic Appendectomy, continued
The appendix is then transected with the ESU, scissors, or surgical stapler.
The stapler provides additional security against leakage. The specimen is brought out of the abdomen with a specimen retrieval bag.
The appendix is excised with scissors
(From Goldberg JM and Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)

27. The appendix is then transected with the ESU, scissors, or surgical stapler
The stapler provides additional security against leakage
The specimen is brought out of the abdomen with a specimen retrieval bag

28. Loop technique: http://www. dailymotion
Stapler technique: