Secondary Tracheostomy Stoma Closure
For established tracheostomy stomas that fail to close spontaneously after 2 months of conservative monitoring following decannulation, surgical closure is indicated using local flap techniques that reconstruct the anterior tracheal wall and provide adequate skin coverage. 1
Timing and Indications for Surgical Closure
A surgically-formed stoma can be expected to mature sufficiently for safe tube exchange after 3 days, depending on patient factors and local practices. 2
Conservative monitoring should continue for at least 2 months after cannula removal before proceeding with surgical closure, as many stomas will close spontaneously during this period. 1
The distinction between "NEW tracheostomy" (up to first tube change) and established "Tracheostomy" status is critical for management planning, with stay sutures typically removed at the first tube change when transitioning from critical care to ward-level care. 2
Surgical Techniques for Closure
Recommended Approach: Three Local Flaps Technique
The most effective technique involves creating two hinge flaps on either side of the tracheostomy opening, turning the skin surface to the luminal side to form the anterior tracheal wall, with multiple skin layers sutured together to prevent air leakage. 1
A cover flap is then produced to close the skin defect over the reconstructed anterior tracheal wall. 1
This approach has demonstrated 100% successful closure rates without tracheal stenosis in reported case series. 1
Alternative Technique: Turnover Flap with Medialization
A turnover flap combined with medialization of fibroadipose tissue, followed by additional closure with an advancement skin flap, represents another reliable option. 3
This technique has shown satisfactory functional and cosmetic results with minimal major complications over long-term follow-up (mean 3.2 years). 3
Simplified Deepithelialization Technique
For select cases, a simple deepithelialization technique can be performed under local anesthesia with lower complication rates compared to traditional three-layer closures. 4
This approach is particularly useful when avoiding the 30% complication rate associated with traditional three-layer closures, which can include stridor, subcutaneous emphysema, pneumomediastinum, and need for re-tracheostomy. 4
Critical Safety Considerations
Stoma Maturation Status
Percutaneously-formed stomas require special attention, as dilated tissues are likely to recoil in the event of tube displacement, making re-insertion potentially more difficult, especially in the first 7-10 days following insertion. 2
This knowledge should be clearly documented on bedhead signs and may direct responders to manage the upper airway as a priority during the early post-operative period. 2
Multidisciplinary Coordination
Completion of bedhead signs should be mandated as part of the theatre sign-out procedure following any tracheostomy procedure or airway management in theatre. 2
Details of who to call in an emergency should be clearly displayed and agreed upon at admission or upon insertion of a new tracheostomy. 2
Post-Closure Monitoring
Postoperative fiberscopic examination of the tracheal lumen is essential to assess for stenosis or other complications. 1
Continuous monitoring should include assessment for signs of airway compromise, including changes in respiratory rate, heart rate, blood pressure, and level of consciousness. 2
A multidisciplinary quality improvement approach with standardized care protocols and continuous prospective data collection can reduce tracheostomy-related complications. 5
Common Pitfalls to Avoid
Do not attempt surgical closure before allowing adequate time (minimum 2 months) for spontaneous closure after decannulation. 1
Avoid single-layer skin closure techniques, as multiple skin layers sutured together are necessary to prevent air leakage between hinge flaps. 1
Traditional three-layer closure techniques carry significantly higher complication rates (30%) compared to modern local flap techniques and should be avoided when alternatives are available. 4
Ensure proper documentation of stoma type (surgical vs. percutaneous) and maturation status, as this critically impacts management decisions and complication risk. 2