Tracheostomy is a vital and frequently performed procedure in critical care settings, serving as a lifesaving intervention in patients with compromised airways or those requiring prolonged ventilatory support. Historically, tracheostomy has been performed through an open surgical approach, but over the past few decades, the percutaneous dilatational tracheostomy (PDT) technique has gained increasing popularity, especially in intensive care units (ICUs). The shift toward PDT is driven by several advantages, including ease of bedside performance, reduced operative time, minimal tissue dissection, smaller incision size, less intraoperative bleeding, quicker stoma closure after decannulation, reduced infection rates, and superior cosmetic results compared to open surgical tracheostomy (ST).[1] While both techniques aim to establish a secure airway by creating an opening in the anterior tracheal wall and inserting a tracheostomy tube, they differ substantially in procedural methodology. Open surgical tracheostomy involves a horizontal or vertical skin incision, meticulous dissection through pre-tracheal tissues, and direct visualization of the trachea before making a tracheal incision. PDT, in contrast, is a “blind” technique that involves puncturing the trachea with a needle under anatomical guidance, inserting a guidewire (Seldinger technique), and gradually dilating the opening to accommodate the tracheostomy tube.[2] The choice between PDT and ST is influenced by patient factors, anatomical considerations, urgency, and available expertise. Certain patient groups—such as those with obesity, cervical spine injuries, distorted neck anatomy, or high ventilatory requirements—may pose unique challenges for PDT, sometimes necessitating conversion to ST. Conversely, in ICU patients with stable neck anatomy, PDT offers the benefit of avoiding patient transfer to the operating theatre and reducing exposure to perioperative risks.[3] Despite the advantages, PDT is not without complications. These include bleeding (major or minor), creation of a false passage, subcutaneous emphysema, pneumothorax, cuff leaks, tube blockages, stomal infections, and rare but serious events such as tracheo-innominate artery fistulas. Surgical tracheostomy, although more invasive, offers the benefit of direct visualization and may reduce certain risks, but it carries its own set of complications, such as wound infection, delayed healing, and higher intraoperative blood loss.[4][5] Aim To compare percutaneous dilatational tracheostomy and surgical tracheostomy in critically ill patients in terms of procedural characteristics, complications, and outcomes. Objectives 1. To evaluate and compare intraoperative complications between percutaneous dilatational tracheostomy and surgical tracheostomy. 2. To evaluate and compare postoperative complications between the two techniques. 3. To compare the overall procedural outcomes, including duration, ease of performance, and rate of stoma closure.

Source of Data The study was conducted in the Department of General Surgery, Medical College & SSG Hospital, Vadodara. Data was collected prospectively from critically ill patients undergoing tracheostomy—either percutaneous dilatational or surgical—based on clinical indications and suitability for each technique. Study Design Prospective comparative study. Study Location Department of General Surgery, Medical College & SSG Hospital, Vadodara. Study Duration The study was conducted over a defined period until a total sample size of 40 patients was achieved. Sample Size 40 patients were included: • Group A: 20 patients undergoing conventional surgical tracheostomy. • Group B: 20 patients undergoing percutaneous dilatational tracheostomy. Inclusion Criteria • All critically ill patients with a clinical indication for tracheostomy. • Indications included: 1. Relief of upper airway obstruction. 2. Prevention of complications of prolonged intubation and aspiration. 3. Reduction of anatomical dead space. 4. Facilitation of tracheal suction and airway toileting. Exclusion Criteria • Laryngeal tumours. • Short neck (crico-sternal distance < 2.5 cm). • Neck circumference > 46 cm. • Major neck surgery history. • Local skin infection at intended incision site. • Known coagulopathy. • Age < 15 years. • Refusal to consent for the procedure. Procedure and Methodology Group A – Surgical Tracheostomy (ST) Performed in the operating theatre under sterile precautions and appropriate anaesthesia. 1. Patient positioned with neck extended. 2. Horizontal skin incision made 1–2 cm above the sternal notch. 3. Dissection carried down to expose tracheal rings. 4. Tracheal incision made between second and third rings. 5. Tracheostomy tube inserted and secured with sutures and tapes. Group B – Percutaneous Dilatational Tracheostomy (PDT) Performed at bedside or in ICU using Griggs’ forceps dilatation technique. 1. Neck extended; anatomical landmarks identified (cricoid cartilage, suprasternal notch). 2. Skin prepared and infiltrated with 1% lignocaine. 3. 2 cm skin incision made 1 cm below cricoid cartilage. 4. Needle puncture into trachea between 2nd and 3rd rings with confirmation by air aspiration. 5. Guidewire introduced (Seldinger technique). 6. Dilatation performed over guidewire using modified Howard-Kelly forceps. 7. Cuffed tracheostomy tube inserted, guidewire removed, cuff inflated, and tube secured. Sample Processing and Data Collection • Procedural duration recorded using a stopwatch. • Intraoperative and postoperative complications documented. • Neck measurements (girth and crico-sternal distance) recorded pre-procedure. • Patients followed until decannulation, discharge, or death. • Data recorded in a structured proforma. Statistical Methods • Data entered in Microsoft Excel and analyzed using SPSS v15. • Quantitative variables expressed as mean ± SD and compared using t-tests. • Categorical variables compared using Chi-square or Fisher’s exact test. • p-value < 0.05 considered statistically significant. • 95% Confidence Intervals calculated for primary outcome measures.

Table 1: Procedural characteristics (PDT vs ST, n=20 each) Variable PDT (n=20) ST (n=20) Test Effect (PDT-ST) 95% CI P-value Age, years 40.13 (15.32) 41.67 (23.30) Welch t-test −1.54 −14.23 to 11.15 0.807 Male sex, n (%) 17 (85.0) 17 (85.0) Fisher exact 0.000 −0.308 to 0.308 1.000 Indication: Prolonged ventilation, n (%) 16 (80.0) 15 (75.0) Fisher exact 0.050 −0.304 to 0.388 1.000 Neck girth at incision, cm 36.23 (1.78) 36.17 (1.93) Welch t-test 0.06 −1.13 to 1.25 0.919 Crico-sternal distance, cm 3.95 (0.13) 3.96 (0.14) Welch t-test −0.01 −0.09 to 0.08 0.826 Performed bedside in ICU, n (%) 18 (90.0) 2 (10.0) Fisher exact 0.800 0.398 to 0.944 0.000 The two groups were well balanced at baseline. Mean age was similar (PDT 40.13±15.32 vs ST 41.67±23.30 years; mean difference −1.54, 95% CI −14.23 to 11.15; p=0.807), and the proportion of males was identical (85% in both; risk difference 0.00, 95% CI −0.308 to 0.308; p=1.000). The primary indication of prolonged ventilation did not differ (80.0% vs 75.0%; risk difference 0.05, 95% CI −0.304 to 0.388; p=1.000). Anthropometry at the neck was comparable (neck girth 36.23±1.78 vs 36.17±1.93 cm; mean difference 0.06, 95% CI −1.13 to 1.25; p=0.919; crico-sternal distance 3.95±0.13 vs 3.96±0.14 cm; mean difference −0.01, 95% CI −0.09 to 0.08; p=0.826). The only clear difference was procedural setting: PDT was performed bedside in the ICU far more often (90.0% vs 10.0%; risk difference 0.80, 95% CI 0.398 to 0.944; p<0.001), reflecting the technique’s bedside feasibility. Table 2: Intraoperative complications Variable PDT (n=20) ST (n=20) Test Effect (PDT-ST) 95% CI P-value Minor bleeding 2 (10.0) 4 (20.0) Fisher exact −0.100 −0.388 to 0.220 0.661 Conversion to open 3 (15.0) 0 (0.0) Fisher exact 0.150 −0.109 to 0.360 0.231 Subcutaneous emphysema (intra-op) 1 (5.0) 1 (5.0) Fisher exact 0.000 −0.227 to 0.227 1.000 False passage 2 (10.0) 0 (0.0) Fisher exact 0.100 −0.133 to 0.301 0.487 Apnea 0 (0.0) 1 (5.0) Fisher exact −0.050 −0.236 to 0.152 1.000 Major bleeding 0 (0.0) 1 (5.0) Fisher exact −0.050 −0.236 to 0.152 1.000 Event rates were low and no between-group differences reached statistical significance. Minor bleeding occurred in 10.0% with PDT vs 20.0% with ST (risk difference −0.10, 95% CI −0.388 to 0.220; p=0.661). Conversion to open surgery occurred only in PDT (15.0% vs 0.0%; risk difference 0.15, 95% CI −0.109 to 0.360; p=0.231). Subcutaneous emphysema (5.0% vs 5.0%), false passage (10.0% vs 0.0%), intraoperative apnea (0.0% vs 5.0%) and major bleeding (0.0% vs 5.0%) were rare, with wide confidence intervals spanning no effect; all p=1.000 or >0.23. Table 3: Procedural outcomes Variable PDT (n=20) ST (n=20) Test Effect (PDT-ST) 95% CI P-value Procedure time, min 9.67 (2.71) 11.47 (4.22) Welch t-test −1.80 −4.47 to 0.88 0.179 ≥2 attempts to place tube 4 (20.0) 2 (10.0) Fisher exact 0.100 −0.220 to 0.388 0.661 Decannulated before discharge 2 (10.0) 2 (10.0) Fisher exact 0.000 −0.273 to 0.273 1.000 All-cause in-hospital mortality 16 (80.0) 17 (85.0) Fisher exact −0.050 −0.364 to 0.280 1.000 PDT tended to be faster by about two minutes (9.67±2.71 vs 11.47±4.22 min; mean difference −1.80, 95% CI −4.47 to 0.88; p=0.179), but this was not statistically significant. The proportion requiring ≥2 attempts to place the tube was 20.0% with PDT vs 10.0% with ST (risk difference 0.10, 95% CI −0.220 to 0.388; p=0.661). Decannulation prior to discharge was identical (10.0% vs 10.0%; risk difference 0.00, 95% CI −0.273 to 0.273; p=1.000), and in-hospital mortality was similar (80.0% vs 85.0%; risk difference −0.05, 95% CI −0.364 to 0.280; p=1.000). Overall, observed outcome differences were small and imprecise. Table 4: Postoperative complications Variable PDT (n=20) ST (n=20) Test Effect (PDT-ST) 95% CI P-value Tube block only 2 (10.0) 1 (5.0) Fisher exact 0.050 −0.208 to 0.292 1.000 Tube block + granulation ± infection 1 (5.0) 1 (5.0) Fisher exact 0.000 −0.227 to 0.227 1.000 Infection + granulation at stoma 0 (0.0) 1 (5.0) Fisher exact −0.050 −0.236 to 0.152 1.000 Subcutaneous emphysema (post-op) 1 (5.0) 1 (5.0) Fisher exact 0.000 −0.227 to 0.227 1.000 Postoperative adverse events were infrequent and comparable between groups. Tube block alone occurred in 10.0% with PDT vs 5.0% with ST (risk difference 0.05, 95% CI −0.208 to 0.292; p=1.000). Tube block with granulation ± infection affected 5.0% in each group (risk difference 0.00, 95% CI −0.227 to 0.227; p=1.000). Infection with granulation at the stoma occurred in 0.0% vs 5.0% (risk difference −0.05, 95% CI −0.236 to 0.152; p=1.000). Postoperative subcutaneous emphysema was 5.0% in both groups (risk difference 0.00, 95% CI −0.227 to 0.227; p=1.000).

Procedural characteristics (Table 1). Two cohorts were well matched for age, sex and airway anatomy, with prolonged ventilation as the dominant indication exactly what multi-center surveys report as the commonest reason for tracheostomy in critical care. The striking between-group difference was logistical: 90% of PDTs were performed bedside in ICU versus 10% of ST, mirroring long-standing evidence that PDT is specifically designed for safe, efficient bedside use and is therefore more frequently adopted in ICU workflows. Systematic reviews similarly note that PDT shifts the procedure out of the operating theatre without compromising safety, helping explain the strong ICU-bedside signal observed. Ülkümen Bet al.(2018)[6] Intraoperative complications (Table 2). Absolute event rates were low in both groups and no comparisons reached statistical significance unsurprising with n=20 per arm. The pattern (numerically less minor bleeding with ST but small numbers overall; a few conversions in the PDT arm; rare false passage and emphysema) is consistent with pooled data: meta-analyses generally show similar rates of serious intraoperative events between techniques, with some trade-offs (e.g., occasional need to convert during PDT, usually in difficult necks), but a clear advantage of PDT for wound/stomal infection (see postoperative section). Results therefore align with the broad conclusion that PDT does not increase major intraoperative harm compared with ST. Pandit Aet al.(2023)[7] Procedural outcomes (Table 3). PDT was ~1.8 minutes faster on average, though underpowered to show significance. Most comparative trials and meta-analyses report shorter procedure duration and greater overall efficiency for PDT particularly because it avoids OR transfer while finding no mortality difference, exactly as in dataset. One classic randomized trial also demonstrated faster access to tracheostomy care pathways with PDT, reinforcing the operational advantages seen in practice. Taken together, nonsignificant trend toward faster PDT is directionally concordant with the literature, with mortality equivalence expected. Mehta Cet al.(2017)[8] Postoperative complications (Table 4). Observed low and comparable rates of tube obstruction, stomal granulation/infection, and subcutaneous emphysema, again with very wide confidence intervals. Larger syntheses consistently show lower wound/stoma infection with PDT versus ST, while most other postoperative complications are similar between techniques; newer meta-analyses continue to support reduced infection and at least non-inferior bleeding with PDT. Given small sample, it’s plausible that a true infection advantage could not be detected - point estimates are compatible with both equivalence and a modest PDT benefit. Angel Let al.(2020)[9]

In this prospective comparison of critically ill adults undergoing tracheostomy, percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) demonstrated broadly comparable safety and clinical outcomes. Baseline demographics and airway-related anthropometry were similar between groups. PDT was performed at the bedside in the ICU far more frequently than ST, underscoring its logistical advantage and feasibility in critically ill patients. Although PDT showed a trend toward shorter procedure time, differences in intraoperative and postoperative complication rates, decannulation before discharge, and in-hospital mortality were not statistically significant in this cohort. Taken together, these findings support PDT as a safe, efficient alternative to ST when performed by trained teams in appropriately selected patients, with readiness to convert to an open procedure when indicated. ST remains essential for patients with unfavorable anatomy, concomitant neck pathology, or other contraindications to a percutaneous approach.

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