DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Tracheotomy dependence.
POSTOPERATIVE DIAGNOSIS:
Tracheotomy dependence.
OPERATION PERFORMED:
Tracheotomy tube change.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General anesthesia
INDICATION FOR OPERATION: The patient is a (XX)-year-old male who was recently hospitalized at this facility for ventilator dependent respiratory failure. He also has neurologic delay. Therefore, to assist with long-term pulmonary needs and management of secretions, tracheotomy was performed. Nasal tract change was successful on approximately postoperative day 6. However, at home, Nursing had difficulty removing the cuffed #4 Shiley tracheotomy tube. Rather than do this in the office, we elected to schedule it in the operating room in the event that there was obstructive granulation tissue or other issues, which could induce airway compromise. Furthermore, general anesthesia was felt to help with the patient’s comfort. Risk, benefits, alternative and indications were reviewed with the mom. She agreed to proceed as planned.
PROCEDURE FINDINGS: It was observed that the restriction to removal of the tube was indeed due to the cuff. A cuffless #4 Shiley nonfenestrated tracheotomy tube was placed without difficulty. No significant granulation tissue was observed. Minor bleeding from around the tracheotomy site was observed.
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and placed on the operating room table in the supine position. General anesthesia was established with sevoflurane via the tracheotomy tube. Next, the area was draped with sterile towels. The cuff was deflated and the tube removed. During the removal, there was moderate resistance due to the size of the cuff. This induced minor bleeding in the soft tissue, in the inferior aspect of the stoma. Trachea was suctioned.
Next, a #4 Shiley nonfenestrated uncuffed tracheotomy tube was placed without difficulty. The obturator was removed and replaced with an inner cannula. Velcro ties were used to secure the tube. The patient was then turned over to the care of the anesthesia team for awakening and return to the recovery room. The patient tolerated the procedure well without any immediate complication.
