The Journal of Laryngology & Otology

Clinical Records

Surgical tracheostomy in morbidly obese patients: technical considerations and a two-flap technique for access

S G Khooa1 c1 and N Rajaretnama1

a1 Department of Otolaryngology – Head and Neck Surgery, Mater University Hospital, Dublin, Ireland


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.

Case report: 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.

Conclusion: 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.

(Accepted August 05 2011)

(Online publication January 30 2012)


c1 Address for correspondence: Mr S G Khoo, St Joseph's Ward, Mater University Hospital, Dublin 7, Ireland E-mail:


Presented at the Royal Academy of Medicine in Ireland – Otolaryngology Section, 4th January 2011, Royal College of Physicians in Ireland, Dublin, Ireland

Mr S G Khoo takes responsibility for the integrity of the content of the paper

Competing interests: None declared