title: Surgical tracheostomy in morbidly obese patients: technical considerations and a two-flap technique for access.
abstract: OBJECTIVE
  In an era in which percutaneous tracheostomies are frequently performed in 'suitable' necks, more technically complex cases are referred to the otolaryngologist. We describe the surgical technique used and close cooperation required in securing the airway of a morbidly obese patient.
  
  
  METHODS
  A 52-year-old, morbidly obese man with significant comorbidities was referred for surgical tracheostomy following spinal fractures. This was complicated by a previous percutaneous dilatational tracheostomy scar. Tension-free skin advancement was not possible with a deeply plunging trachea; a vertical skin incision was dropped inferiorly to the sternum for access. A size 8 Shiley XLT Proximal Extension cuffed tracheostomy tube was inserted successfully.
  
  
  CONCLUSIONS
  We describe safe airway surgery in a morbidly obese man, and outline requirements including the use of a specially designed operating table, the need for an elongated proximal limb tracheostomy tube, and the use of a distal two-flap technique for access to a deeply plunging trachea.
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Mater University Hospital, Dublin, Ireland. sgkhoo@hotmail.com
authors.forename: S G
authors.initials: SG
authors.lastname: Khoo
authors.forename: N
authors.initials: N
authors.lastname: Rajaretnam
mesh_terms: D015992:Body Mass Index; D002921:Cicatrix / Q000150:complications / Q000601:surgery; D002983:Clinical Competence; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation*; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000033:anatomy & histology / Q000601:surgery; D010845:Obesity Hypoventilation Syndrome / Q000150:complications; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D010036:Otolaryngology / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D016103:Spinal Fractures / Q000150:complications; D013524:Surgical Flaps; D014139:Tracheostomy / Q000295:instrumentation / Q000379:methods*