Comparison of outcomes between vertical and transverse skin incisions in percutaneous tracheostomy for critically ill patients: a retrospective cohort study

Abstract

BackgroundPercutaneous tracheostomy (PT) is a common procedure in critical care medicine. No definite clinical practice guidelines recommended on the choice of the direction of skin incision, vertical or transverse for tracheostomy in critically ill patients. The objective of this retrospective study was to compare the outcomes associated with vertical and transverse skin incisions in patients undergoing PT.MethodsPatients who underwent PT between March 2011 and December 2015 in the intensive care unit (ICU) of a tertiary hospital were retrospectively included. PTs were performed by pulmonary intensivists at the ICU bedside using the single tapered dilator technique assisted by flexible bronchoscopy. The primary outcome was the incidence of tracheostomy site ulcers at 7 days after PT.ResultsOf the 458 patients who underwent PT, a vertical incision was made in 27.1% and a transverse incision was made in 72.9%. There were no tracheostomy-related mortalities, and no significant difference in the incidence of immediate postoperative complications, including bleeding, tracheal ring fracture, and subcutaneous emphysema. Thirty-five patients (7.6%) developed complications within 7 days after PT, in which tracheostomy-related pressure ulcers were the most frequent. Compared with vertical incisions, transverse incisions were associated with significantly lower incidence of complications (14.1% vs. 5.4%, P = 0.001).ConclusionsThis retrospective study showed that transverse skin incisions in PTs for critically ill patients, resulted in a significant decrease in overall complications, particularly ulcers in the tracheostomy site.

Prevention of hyper- and hypotrophic scars through surgical incisions in the direction of the “main folding lines” of the skin

“…Surgical mistakes must be kept to an absolute minimum on the face, where existing folds and wrinkles [36] determine the logical direction of an incision or a fusiform skin excision [Figure 15]. For young patients, mimic movement of the face [Figure 16A and B] or a textbook on facial incisions [2,4,6-8] may serve as a guide for optimal directions.…”

“…Incisions for tracheotomies [36] , thyroidectomies, or access to cervical discs should always be done higher up in the lower horizontal neck fold and clear of the jugulum to avoid hypertrophic scarring [5] [Figure 17A]. The "Kocher collar incision" dates back to the late 19th century [2] , when women were wearing high-necked dresses or heavy jewelry.…”

“…The "Kocher collar incision" dates back to the late 19th century [2] , when women were wearing high-necked dresses or heavy jewelry. Vertical tracheotomy incisions against the folding lines of the neck are often followed by ugly contracted scars [36] [Figure 17B]. On the arms, striae do not develop straight vertically, but somewhat obliquely from the anterior axilla to the inner elbow.…”

Development of a comprehensive Percutaneous Dilatational Tracheostomy process model for procedural training: A Delphi‐based experts consensus

“…38 On the other hand, a retrospective study showed that transverse incision, compared to cephalo-caudal incision, resulted in less bleeding rates and tracheostomy site ulcers. 39 This study has several limitations. Firstly, the study was performed in Spanish, restricting participation to experts fluent in this language, which could reduce the external validity of our results.…”

“…It has been suggested that direct tracheal visualization and adequate dissection allows one to reduce both short‐term and long‐term complications 38 . On the other hand, a retrospective study showed that transverse incision, compared to cephalo‐caudal incision, resulted in less bleeding rates and tracheostomy site ulcers 39 …”