How I do it: surgical access flexible endoscopic tracheostomy—the “SAFE” technique

Introduction

The relative merits of surgical versus percutaneous dilatational tracheostomy have long been debated. In contemporary intensive care unit (ICU) practice, most tracheostomies are performed percutaneously by anaesthetists or intensivists and, in experienced hands, are associated with lower morbidity than open surgical techniques (1,2). However, complications such as uncontrolled bleeding or loss of anatomical landmarks may necessitate a conversion to an open approach (1). Transfer of critically ill patients to the operating theatre increases morbidity and mortality, and limited theatre access may delay intervention. As such, performing tracheostomy in the ICU is an attractive alternative, though its safety and practicality remain contested (3). To address these challenges, the Surgical Access Flexible Endoscopic (“SAFE”) tracheostomy was developed at Warrington Hospital, United Kingdom, 15 years ago in collaboration with anaesthetic colleagues. This hybrid technique incorporates elements of both surgical and percutaneous approaches and has been adopted at Tauranga Hospital, New Zealand. It is intended as a complementary option for selected complex cases rather than a replacement for standard percutaneous or open techniques. It may be considered where there is sufficient time for pre-procedural planning, or for patients requiring tracheostomy under local anaesthesia who cannot be safely intubated. Potential indications include patients with challenging anatomy, altered cervical anatomy, cervical spine instability, and those at increased risk of bleeding.

Hybrid tracheostomy, whilst not a novel technique, has only been described by a limited number of centres since 2011. Its proposed advantages over open tracheostomy include reduced surgical trauma, decreased reliance on bronchoscopic expertise and applicability to ICU-based practice in appropriately selected patients (4-10). However, existing literature remains constrained by the absence of stepwise operative detail. Published reports predominantly focus on feasibility or clinical outcomes, with minimal operative guidance, limited use of annotated imagery, and little emphasis on trainee-level education.

Our approach provides a structured, sequential operative guide designed for ENT trainees under supervision, with emphasis on anatomical planes, surgical reasoning, and team-based execution. In addition to describing technique, this framework aims to support progressive acquisition of open airway skills at a time when purely percutaneous methods have reduced exposure to surgical tracheostomy. The hybrid approach thereby serves as a practical operative option, but also as a structured opportunity to reinforce core tracheostomy principles under specialist supervision.

Technique

The study is reported according to the SUPER reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-79/rc).

Setup and equipment

To improve access and minimise operator strain, the patient’s head is placed at the top right corner of the bed. Ideally the patient’s neck should be placed in extension, using shoulder bolsters and/or a head ring placed in the reverse position, though a neutral position is acceptable if the cervical spine is unstable.

Required equipment includes a tracheostomy surgical set, percutaneous tracheostomy set (Figure 1), bipolar diathermy, and a video flexible intubating bronchoscope (VFB).

Figure 1 Representative illustration of a percutaneous tracheostomy kit based on the ULTRAperc^® device.

Stage 1: Surgical access through skin and soft tissue

The primary operator performs the procedure from the right-hand side of the patient and the assistant approaches from the top end (Figure 2). The anaesthetist is not required to access the airway at this stage.

Figure 2 Images demonstrating patient positioning and team setup for Stage 1 of SAFE technique. The primary operator is positioned on the right, with the assistant at the head of the bed. These images are published with the patient’s consent. SAFE, Surgical Access Flexible Endoscopic

Surface landmarks (midline, thyroid, cricoid cartilages and sternal notch) are marked. Subcutaneous infiltration with 0.5% Bupivacaine and 1:200,000 Adrenaline is recommended for analgesia and haemostasis. A midline 2–3 cm transverse incision between the cricoid cartilage and sternal notch is made with a scalpel through the skin, subcutaneous fat and platysma muscle. Care is taken to avoid injury to the anterior jugular veins. Vessels that cross the midline should be divided with ligature or cauterisation. The midline raphe of the sternohyoid muscles are divided with Metzenbaum scissors. The strap muscles are retracted with Langenbeck retractors by the assistant (Figure 3) or using a self-retainer device. If the thyroid isthmus obscures access to the trachea, it should be divided in the midline. Removal of the pre-tracheal adipose tissue with a swab or a peanut sponge is optional. Once the cricoid and tracheal rings are identified by sight or palpation, the Langenbeck retractors can be removed and part 2 of the surgery can be initiated.

Figure 3 Midline raphe of the sternohyoid muscles are divided with Metzenbaum scissors, while strap muscles are retracted with Langenbeck retractors by the assistant. These images are published with the patient’s consent.

Stage 2: Endoscopic dilatation and tracheostomy insertion

Tracheostomy cuff integrity should be verified first by inflation. The operator remains in position, while the assistant moves to the right, and the anaesthetist approaches the head to operate the VFB and withdraw the endotracheal tube (ETT) (Figure 4). Under direct or video laryngoscopic view, the ETT is withdrawn until the cuff lies at the level of the vocal cords. Occasionally, due to relative lengths of the ETT and the patient's anatomy, the ETT is withdrawn until the cuff sits above the cords. This is so that the ETT tip does not hinder access through the proximal trachea with the needle/dilator. Minor adjustments, including cuff reinflation or gentle downward pressure on the ETT, may be required to minimise air leak.

Figure 4 Animated schematic and live image demonstrating team setup for Stage 2 of SAFE technique. The primary operator remains positioned on the patient’s right, the assistant stands adjacent on the operator’s right, and the anaesthetist is positioned at the head of the bed. This image is published with the patient’s consent. SAFE, Surgical Access Flexible Endoscopic.

In the meantime, the operator can stabilise the larynx by gently gripping the thyroid laminae between the left thumb and middle finger. To locate the cricoid, run a finger along the anterior tracheal surface from the sternal notch towards the larynx- the first prominent hard structure felt is the cricoid.

Place the pulp of the left index finger on the inferior margin of the cricoid cartilage like a hook to retract it superiorly. A cricoid hook may also be used for this purpose. If the neck is extended there will be ample space inferior to the finger for needle access. However, if the neck is in neutral position, the trachea can be displaced superiorly up to 1 cm. This is only necessary if the gap between the cricoid and sternal notch is small. Beware of the rare high-riding brachiocephalic vessel.

The tip of the left finger should lie immediately over the whole 1st and possibly 2nd tracheal ring. In a controlled manner, the needle with a sheath from the Portex^® ULTRAperc^® set is placed parallel to the distal phalanx of the left index finger, which acts as a guide (Figure 1). Aim for the needle to penetrate the intercartilaginous membrane between the 1^st & 2^nd or the 2^nd & 3^rd tracheal ring at the midline anteriorly (Figure 5). If an initial resistance is felt when the needle is being advanced, the needle tip has likely hit the cartilaginous tracheal ring. Walk the needle with 1–2 mm steps superiorly or inferiorly until an area of minimal resistance representing the intercartilaginous membrane is met. Once the membrane is penetrated, advance the needle 1 cm. To ensure that the needle does not advance further, wrap a tape around the needle at 1 cm proximal to the tip intraoperatively immediately prior to insertion. Also, a slight angulation of the needle inferiorly lowers the risk of injury to the posterior tracheal wall.

Figure 5 Needle with a sheath from the Portex^® ULTRAperc^® set penetrating the intercartilaginous membrane between the 1^st & 2^nd tracheal ring at the midline anteriorly. This image is published with the patient’s consent.

If a second resistance is encountered during needle advancement, contact with the ETT is likely. By rotating the ETT 20–30 degrees in oscillating motion, the operator can feel if the needle is still engaged with the ETT wall and withdraw. The anaesthetist then gradually withdraws the tube in 1cm increments, until the needle can be advanced into the tracheal lumen unhindered, which may involve brief cuff deflation, retraction above the cords, and then reinflation. The VFB is then placed into the ETT lumen through a silicone valve swivel connector and advanced to confirm needle placement.

Once the needle is in view, the tracheostomy can be completed using the Portex^® ULTRAperc^® set (Figure 1). The surgical assistant’s role at this point is to pass and rail-road instruments for the operator as quickly as possible. Firstly, the introductory needle is removed, leaving only the plastic sheath in the trachea. Then, guide wire is inserted into the tracheal lumen through the sheath (Figure 6), before the plastic sheath is removed.

Figure 6 Guide wire insertion into the tracheal lumen through sheath. This image is published with the patient’s consent.

At this point:

• Railroad the tracheal pre-dilator over the guide wire to dilate the tracheal opening and then remove leaving the guide wire in place (Figure 7).
• Railroad the plastic guide catheter over the guide wire, then the tracheal dilator over this, until it reaches the black demarcation.
• Using these instruments as one apparatus, advance the dilator into the trachea in a rotating fashion to dilate the intercartilaginous membrane enough for the tracheostomy tube.
• Have the tracheostomy tube loaded onto the introducer, and ready to be railroaded over the wire and plastic guide (Figure 8).
• In swift and controlled manner, remove the dilator, leaving the wire and plastic catheter in the trachea. Railroad the introducer with the tracheostomy tube. Disengage the introducer from the tracheostomy tube and remove. Inflate the tracheotomy cuff (Figure 9).
• Remove the introducer and plastic guide, leaving the tracheostomy tube in the trachea.

Figure 7 Tracheal pre-dilator. This image is published with the patient’s consent.

Figure 8 Tracheostomy tube loaded onto the introducer. This image is published with the patient’s consent.

Figure 9 Inflation of the tracheostomy cuff following successful insertion. This image is published with the patient’s consent.

The ventilator is then connected to the tracheostomy tube and adequate ventilation confirmed prior to removal of the ETT (Figure 10). The tracheostomy is secured using 2-0 silk sutures and a Velcro neck strap. To minimise tube laxity and reduce the risk of accidental decannulation, the flange should be sutured to the skin close to its proximal edge.

Figure 10 Confirmation of ventilation following tracheostomy tube insertion. This image is published with the patient’s consent.

The VFB is used to confirm correct tube position, exclude false passage, assess haemostasis, and estimate the distance between the tracheostomy tube tip and the carina (typically 4–5 cm) (Figure 11). This distance is measured by advancing into the tracheostomy tube to the carina, marking its position at the connector, and withdrawing until the tube tip is reached.

Figure 11 Video flexible intubating bronchoscope confirmation of correct tube position. This image is published with the patient’s consent.

Successful completion is defined by correct tube placement with stable ventilation. The procedure takes approximately 30 minutes.

Discussion

Our hybrid tracheostomy approach most closely aligns with that of Harrer et al. (4) and recent hybrid case reports (5)while offering more procedural clarity and structured team integration. Unlike the limited dissection described by Kang et al. (6), the SAFE technique uses a formal layered approach, sequentially opening the soft-tissue planes to the tracheal rings, permitting direct exposure of the strap muscles and trachea. This facilitates meticulous haemostasis and reduces the risk of uncontrolled bleeding. Controlled dilatation minimises air leak, while continuous endoscopic visualisation mitigates the likelihood of airway loss or false tract creation.

Other minimally invasive techniques rely solely on external landmarks or direct vision through the tracheal window (7).By contrast, the SAFE technique combines external palpation with internal endoscopic confirmation-ensuring accurate tracheostomy placement and haemostasis without the need for routine postoperative imaging.

A further distinction lies in airway management. Whereas other techniques withdraw the ETT to a predetermined depth (typically 16–18 cm at the incisors) (6),the SAFE technique maintains continuous coordination with the anaesthetist, who preserves ventilation until the needle is in situ and actively manipulates both the ETT and the VFB throughout.

Although slightly more resource intensive than purely percutaneous methods, the SAFE technique has clear educational value, combining tactile feedback from open dissection with real-time endoscopic guidance. Our experience suggests that shared visualisation enhances trainee safety during the learning curve by enabling clear anatomical orientation and a controlled, stepwise approach. This may make the technique particularly suitable for trainees in earlier stages of skill acquisition, provided it is performed under appropriate senior supervision. With increasing experience, the endoscope may be omitted while utilising the same anatomical access principles.

Early in our experience, the main complication encountered was scope damage caused by inadvertent needle puncture; the described technique has been refined to avoid such a complication. Another issue was inadvertent extubation of the tracheostomy tube after surgery. Therefore, the tracheostomy tube is routinely sutured to the skin in addition to placing Velcro straps around the neck.

Potential complications that have not been encountered in our series include oesophageal perforation, false tract formation, and inadvertent ETT extubation during the second stage. Continuous intraluminal visualisation effectively minimises the first two risks. If unintentional extubation occurs, the airway can be restored as follows:

• If the VFB is already in the ETT lumen, advance the VFB into the trachea then railroad the ETT over it.
• If the VFB is not in the ETT, then re-intubate under direct laryngoscopy.
• If neither are feasible, maintain oxygenation with bag-mask ventilation until the second stage tracheostomy is completed. There should be ample time to complete this if well oxygenated. If the patient becomes unstable and desaturates, conversion to an open tracheostomy is straightforward, as the stage 1 surgical access is already completed.

Limitations

This report describes a single institutional technique and does not provide comparative outcome data. The perceived advantages described are based on institutional experience and have not been formally evaluated against standard surgical or percutaneous tracheostomy techniques. Further prospective evaluation would be required to determine comparative safety, efficiency and educational benefit.

Conclusions

We describe a decade of departmental experience with the SAFE tracheostomy technique-a structured, hybrid teaching approach integrating key advantages of both percutaneous dilatational and open surgical methods. The article provides a reproducible, standardised framework with troubleshooting techniques to facilitate its adoption and enhance procedural safety.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-79/rc

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-79/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-79/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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