OT notes · ENT

Tracheostomy

Usual anaesthesia
Local infiltration for emergency tracheostomy in the awake patient; general anaesthesia through an endotracheal tube for elective tracheostomy
Position
Supine, shoulder roll, neck extended, head in the midline
Setting
emergency

Operative note template for open surgical tracheostomy, with a filled example for an emergency tracheostomy under local anaesthesia for stridor from bilateral vocal cord palsy.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding, early or delayed
  • tube displacement or blockage, which can be life-threatening
  • surgical emphysema, pneumothorax, pneumomediastinum
  • injury to recurrent laryngeal nerve or oesophagus
  • stopping of breathing just after the airway is opened
  • wound and chest infection
  • loss of voice while the tube is in, until it is plugged or a valve is used
  • late tracheal or subglottic narrowing, difficulty in removing the tube
  • persistent opening or scar after removal
  • rare delayed massive bleeding from erosion into the innominate artery

Pre-operative details for this operation

  1. UrgencyEmergencyElective / plannedif consent could not be taken because of emergency, write why
  2. IndicationUpper airway obstructionProlonged ventilationTracheobronchial toiletBefore major head and neck surgeryOtherthe cause, e.g. bilateral abductor palsy, laryngeal growth, deep neck abscess, head injury
  3. Airway status before surgerystridor at rest / on exertion, SpO2, oxygen given, intubated or not (ETT size and days)
  4. Laryngeal growth: invasion of trachea ruled outNeck X-ray / CT seenNot applicable
  5. Coagulation and antiplateletsrelevant in elective cases
  6. Tubes checked before incisionplanned size and a spare of the same size, cuff tested, obturator in place, suction and light working

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationGeneral through endotracheal tubeGeneral through laryngeal masklocal: drug, strength, volume
  2. PositionSupine, shoulder roll, neck extendedno extension if cervical spine injury is suspected
  3. Landmarks palpated and markedchin, hyoid, thyroid cartilage, cricoid, suprasternal notch

Operative findings

  1. Neckshort / thick / previous surgery or radiation / growth in front of trachea
  2. Thyroid isthmusRetracted upwardRetracted downwardDivided and transfixed
  3. Trachearings counted from cricoid; any deviation; tracheomalacia
  4. Airway secretions after openingblood, pus, mucus; sent for culture if purulent

Procedure (steps)

  1. Skin incisionVertical midlineHorizontal skin creaselevel and length
  2. Midline dissectionfascia divided, anterior jugular veins tied or retracted, strap muscles separated at the raphe
  3. Thyroid isthmus handledretracted, or clamped, divided and transfixed with suture (material)
  4. Pretracheal fascia cleared, rings counted from the cricoid
  5. Intratracheal lignocaine (awake patient)air aspirated with needle and syringe, then 4% lignocaine 0.5 ml instilled
  6. Stay suturesNoneOneTwo (either side of midline)material and size; which ring; how taped
  7. Tracheal openingHorizontal between 2nd and 3rd ringsInverted T (3rd ring split in midline)Vertical through 3rd and 4th ringsCruciateWindow of cartilage excised
  8. Endotracheal tube withdrawn (if intubated)tip pulled back to just above the tracheal opening, removed only after ventilation through the new tube
  9. Tracheostomy tube insertedtype (cuffed PVC / uncuffed / metal), size, cuff inflated with how much air
  10. Tube position confirmedair flow, bilateral air entry, end-tidal CO2, suction catheter passes freely
  11. Haemostasisvessel tied / cautery
  12. Tube securedtapes (knot side), flange sutured to skin, number of sutures

Closure, drains and dressing

  1. SkinLeft open around tubeLoosely approximatednever tight around the tube
  2. Dressingslit gauze between flange and skin
  3. Stay sutures labelledtaped to chest, marked 'do not remove', left until first tube change
  4. Spare tubes at bedsidesame size and type, obturator, tracheal dilator

Specimens and implants

  1. Tracheostomy tube detailstype, size (inner diameter), cuffed or not, make, lot number; sticker in file
  2. SpecimenNoneTracheal cartilage window for HPETracheal secretions for culture

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Bedside kitspare tube of the same size and type, tracheal dilator, suction, oxygen, call bell, paper and pen
  2. Suctionsterile catheter less than half the tube's inner diameter; suction only while withdrawing; frequency
  3. Humidificationhumidified oxygen or moist gauze over the tube opening; steam inhalation
  4. Cuff carecuff pressure check or deflation schedule as per unit protocol
  5. Inner tube care (metal / double-lumen tubes)remove, clean and replace every 4 hours or sooner
  6. Chest and neck X-raytube position; pneumothorax
  7. First tube changenot before 48 hours; write the planned date and who will do it
  8. Stay suturesdo not remove until first tube change
  9. Dressingchange daily with sterile gauze
  10. Watch forbleeding, surgical emphysema, tube displacement, blocked tube, desaturation
  11. Treat the cause and plan decannulationdownsize, corking trials

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. S.N., 44 years, stridor at rest for 6 hours. Bilateral vocal cords fixed near the midline on flexible laryngoscopy, 3 weeks after total thyroidectomy. SpO2 91% on 6 L oxygen by mask.

Case details

Date: 22/07/2026. Emergency. Main OT 3.

Decision 21:10. In OT 21:35. Incision 21:48. Tube in trachea 21:58. Procedure completed 22:15.

Surgeon: Dr A. (3rd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., informed and present from 21:50.

Anaesthetist: Dr D., standing by with difficult airway trolley. Scrub nurse: Sr E.

Indication and pre-op

Pre-op diagnosis: bilateral abductor vocal cord palsy after thyroidectomy, upper airway obstruction with stridor at rest.

Procedure planned and performed: emergency open tracheostomy under local anaesthesia.

Written consent taken from patient and husband in Hindi. Risks of bleeding, tube displacement, loss of voice while the tube is in, and later narrowing explained.

WHO checklist done in short form. Two cuffed PVC tubes 7.0 checked, cuffs tested, obturators in place. Suction working.

Anaesthesia and position

Local anaesthesia. Patient awake, oxygen by mask, SpO2 monitored throughout.

Supine, shoulder roll, neck extended, head in the midline. Landmarks palpated and marked. Parts painted with povidone-iodine and draped.

1% lignocaine with adrenaline, 8 ml, infiltrated along the incision line and in the deeper midline tissues.

Findings

Healed collar scar. Thyroid bed fibrosed. Thyroid isthmus absent (previous surgery).

Trachea central. Rings counted from the cricoid. Scanty clear secretions after opening.

Procedure

Vertical midline incision, 4 cm, from 1 cm below the cricoid downward.

Dissection kept in the midline. One anterior jugular communicating vein tied with polyglactin 910 (Vicryl) 3-0. Strap muscles separated at the raphe and retracted.

Pretracheal fascia cleared. Air aspirated from the trachea with a syringe, then 0.5 ml of 4% lignocaine instilled.

Two stay sutures of nylon (Ethilon) 2-0 placed around the 3rd ring on either side of the midline.

Horizontal incision between the 2nd and 3rd rings, 3rd ring split in the midline (inverted T). No cartilage excised.

Cuffed PVC tracheostomy tube, inner diameter 7.0 mm, inserted with obturator. Obturator removed. Cuff inflated with 3 ml air.

Position confirmed by air flow at the tube, equal air entry on both sides, and free passage of suction catheter. SpO2 rose to 98% on 4 L oxygen.

Haemostasis checked. Tube tied with tapes, knot at the side, and flange sutured to skin with nylon 2-0 at both wings.

Closure

Skin left open around the tube. Slit gauze dressing between flange and skin.

Stay sutures taped to the upper chest, labelled 'right' and 'left', 'do not remove'.

Spare cuffed tube 7.0, tracheal dilator and suction sent with the patient.

Specimens and implants

No specimen.

Tube: cuffed PVC tracheostomy tube, inner diameter 7.0 mm, lot number and sticker pasted in the file.

End of procedure

Estimated blood loss 30 ml. No transfusion.

Swab, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. No apnoea after opening the trachea.

Shifted to ICU. Pulse 96/min, BP 134/82 mmHg, SpO2 98% on 4 L humidified oxygen.

Post-op orders

Humidified oxygen by tracheostomy mask, flow as charted.

Suction as needed with sterile catheter size 10 FG, suction only while withdrawing.

Cuff pressure check as per ICU protocol.

Chest and neck X-ray tonight for tube position.

Dressing change daily. Watch for bleeding, surgical emphysema and tube displacement.

Stay sutures not to be removed. First tube change not before 48 hours, planned on 25/07/2026 by ENT resident.

Paper and pen at bedside. Indirect laryngoscopy review by consultant for further plan.

Signature

Dr A., JR-3, ENT. Reg. no. ________. 22/07/2026, 22:30.

Must document for this operation

  • Tube type, size (inner diameter), cuffed or uncuffed, and the make. Nurses and the on-call doctor must know what to replace it with in an emergency.
  • Level and type of tracheal opening, and whether cartilage was excised. It explains later stenosis and guides revision or laryngectomy planning.
  • Stay sutures: number, material and how they are labelled. They are used to pull the trachea up if the tube falls out before the tract forms.
  • Planned date of the first tube change. The tract is not formed in the first 48 hours, so an early change is dangerous and must be planned.
  • How the tube position was confirmed. A tube in the pretracheal space is a known cause of death, and the note must show it was checked.
  • If consent was not taken, the reason (emergency). In India an operation without consent is defended only when it was needed to save life or health and could not wait.

Common mistakes in these notes

  • Writing 'tracheostomy done, tube in situ' with no tube type or size.
  • No mention of stay sutures or of when the first tube change is due.
  • Not recording the ring level of the tracheal opening.
  • Suturing the skin tightly around the tube and not recording it.
  • Not recording the time the airway was secured in an emergency.

Indian practice and paperwork

  • An operation without consent is defensible only when it is needed to save life or health and waiting is unreasonable. Write the reason when an emergency tracheostomy is done without written consent. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • Name every anaesthetist present. A consumer forum held a hospital negligent when the op note left out an anaesthetist's name. (Thomas J. Indian J Urol 2009;25:384-8)
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. (NABH 5th ed., PRE.4(c))

Sources

  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 159, Tracheostomy in head and neck cancers (Hathiram BT, Rai R, Watve P, Khattar VS), pp. 1385-1393.
  • Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. Jaypee Brothers, Ch 129, Pediatric tracheostomy (Bajaj Y): stay sutures, tube fixation, pp. 1204-1206.
  • Scott-Conner CEH, ed. Scott-Conner & Dawson Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 3, Tracheostomy and cricothyroidotomy (Lee GO, Choi K); Ch 4, Percutaneous dilatational tracheostomy (local infiltration), pp. 17-27.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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