Most surgeons prefer to perform standard elective tracheostomy in an operating room where sterility is more easily maintained and specialized lighting is readily available. Most also prefer to use general anesthesia, although local anesthesia is sometimes used. The patient is positioned supine, usually with a roll beneath the shoulders to extend the neck. After the anterior neck has been cleaned and painted with antiseptic, a 4-cm transverse incision is made over the second, third, or fourth tracheal ring. The subcutaneous tissues are divided, and the anterior neck muscles and vessels are retracted. If the thyroid isthmus overlies the region selected for tracheostomy, it is ligated and transected. After the trachea has been exposed, one or more cartilages are incised to create an opening into which to place the tube. In some cases, a plug of cartilage is excised from one or more rings. The tracheostomy tube is inserted into the opening, and the incision is closed with sutures or staples. Some surgeons elect to suture the flanges of the tube to the skin, whereas others are content to secure the tube with cloth ties.
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