ABOVE THE KNEE AMPUTATION Operative Technique Patient supine under SAB/CLEA/General Anesthesia Asepsis and antisepsis technique

Sterile drapes placed Incision made creating anterior and posterior skin flaps on the thigh Superficial vessels cut and ligated Flaps of skin and subcutaneous tissue reflected proximally Quadriceps muscles cut; bleeders ligated Femoral vessels and nerve identified at the subsartorial canal; Femoral vessels individually identified, divided and doubly ligated Posterior muscle group cut; bleeders ligated Sciatic nerve identified divided and ligated Periosteum of femur elevated Femur cut with bone saw Edges of stump bone filed NSS wash Hemostasis Anterior and posterior myofascial flap sutured with figure of eight using vicryl 0 Subcutaneous tissue approximated by inverted T sutures using chromic 2.0 Skin closed interruptedly Betadine paint Dry sterile dressing placed.

BELOW THE KNEE AMPUTATION Operative Technique Patient supine under SAB/CLEA/General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Incision made creating Long Posterior Flap carried from skin through subcutaneous tissue Superficial vessels ligated Anterior muscle group cut; bleeders ligated Anterior tibial vessels individually identified, divided and doubly ligated Deep peroneal nerve ligated proximally Lateral muscle group cut; bleeders ligated Posterior tibial vessels identified at the posteromedial aspect of tibia, individually identified and doubly ligated Posterior tibial nerve highly ligated Periosteum of tibia-fibula elevated Tibia-fibula individually cut with Giggli saw Fibular vessels identified individually, divided, and ligated Posterior muscle group cut; bleeders ligated Edges of tibia-fibular stump bone filed NSS wash Hemostasis Posterior myofascial flap sutured with the anterior myofascial flap by figure of eight vicryl 0 sutures Subcutaneous tissue approximated with inverted T sutures using chromic 2.0 Skin closed interruptedly using nylon 4.0 Betadine paint Dry sterile dressing applied.

APPENDECTOMY (Acute Perforative Appendicitis with Generalized Peritonitis) Operative Technique: Patient supine under SAB/CLEA/General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Incision made ( Rocky-Davis with Fowler-Weir/ Right Paramedian / Midline ), carried from skin through subcutaneous tissue Fascia cut and opened, (Rocky-Davis, External oblique aponeurosis cut along its fibers; Right paramedian, Anterior Rectus Sheath cut and opened longitudinally; Midline, opened along linea alba) Muscle splitting along muscle fibers done for Rocky-Davis and Right paramedian incisions Peritoneum entered ( Rocky-Davis, peritoneum cut and opened transversely; Right paramedian, Posterior Rectus Sheath and peritoneum cut and opened longitudinally; Midline, peritoneum cut and opened longitudinally) Intra-operative Findings noted Intra-abdominal purulent discharge evacuated Appendix identified Mesoappendix serially clamped, divided and ligated Base of appendix tied, milked, clamped and cut Appendiceal stump painted with betadinized cotton Copious peritoneal lavage Hemostasis Correct sponge/instrument count Peritoneum closed continuously using vicryl 0 for Rocky-Davis; Peritoneum with posterior rectus sheath closed continuously for Right paramedian; Peritoneum and Fascia closed as single layer in midline incisions NSS wash External Oblique aponeurosis closed continuously in Rocky-Davis; Anterior Rectus sheath closed continuously in Right paramedian NSS was Skin left open Wet to dry sterile dressing placed.

APPENDECTOMY (Acute Non-Perforative Appendicitis) Operative Technique: Patient supine under SAB/CLEA/General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Incision made ( Rocky-Davis[transverse] and McBurney[oblique]) carried from skin through subcutaneous tissue External oblique aponeurosis cut and opened along its fibers Muscle splitting along fibers Peritoneum entered Intra-operative Findings noted Appendix identified Mesoappendix serially clamped, divided and ligated Base of appendix tied, milked, clamped and cut Appendiceal stump painted with betadinized cotton Hemostasis Correct sponge/instrument count Peritoneum closed continuously using vicryl 0 NSS wash External Oblique aponeurosis closed continuously using vicryl 0 NSS was Skin closed interruptedly using silk 4.0 Betadine paint Dry sterile dressing placed.

CHOLECYSTECTOMY Operative Technique Patient supine under SAB/CLEA/GA Asepsis and antisepsis technique Sterile drapes placed Incision made carried from skin through subcutaneous tissue Midline Fascia cut and opened through linea alba Kochers (Right Subcostal) Anterior rectus sheath cut and opened Right belly of Rectus muscle cut Posterior Rectus sheath cut and opened Peritoneum cut and opened Exploration of entire abdomen carried out Intra-operative findings noted Retractors applied accordingly Gallbladder identified and clamped with a Kelly at the ampulla applying traction Triangle of Calot dissected, cutting the peritoneum that covers the area; Cystic duct identified, isolated and a temporary silk 4-0 ligature applied. Intra-operative cholangiogram done, findings noted Cystic artery identified, isolated, ligated and divided Gallbladder deperitonealization done and dissected from the liver bed using electrocautery Cystic duct divided and doubly ligated Common bile duct palpated Peritoneal lavage Hemostasis Complete sponge and instrument count Closure layer by layer Peritoneum and Fascia Vicryl 0 continuous Subcutaneous layer chromic 2-0 inverted T-sutures Skin silk 3-0 interrupted sutures Betadine paint Dry sterile dressing placed

CHOLECYSTECTOMY With CBD EXPLORATION Operative Technique Patient supine under SAB/CLEA/GA Asepsis and antisepsis technique Sterile drapes placed Incision made carried from skin through subcutaneous tissue Midline Fascia cut and opened through linea alba Kochers (Right Subcostal) Anterior rectus sheath cut and opened Right belly of Rectus muscle cut Posterior Rectus sheath cut and opened Peritoneum cut and opened Exploration of entire abdomen carried out Intra-operative findings noted Retractors applied accordingly Gallbladder identified and clamped with a Kelly at the ampulla applying traction Triangle of Calot dissected, cutting the peritoneum that covers the area; Cystic duct identified, isolated and a temporary silk 4-0 ligature applied. Intra-operative cholangiogram done, findings noted Cystic artery identified, isolated, ligated and divided Gallbladder deperitonealization done and dissected from the liver bed using electrocautery Cystic duct divided and doubly ligated CBD Exploration: Noted stones in IOC, palpate CBD Kocher maneuver done by incising the lateral peritoneal attachments along the descending duodenum Palpate distal CBD Distal to entrance of cystic duct, incision made on the peritoneum overlying CBD 2 guide sutures placed silk 4-0 RB1 one opposite the other on the anterior wall of the CBD Incision made, CBD opened Calculi extracted Bakes dilator passed Intra-operative chlangiogram done, findings noted T-tube placed Choledochotomy incision closed using silk 4-0 interrupted sutures

Closure: Peritoneal lavage Hemostasis Complete sponge and instrument count Penrose drain placed area of choledochotomy and exteriorized on lateral part of abdomen End of T-tube exteriorized in most direct manner Closure layer by layer Peritoneum and Fascia Vicryl 0 continuous Subcutaneous layer chromic 2-0 inverted T-sutures Skin silk 3-0 interrupted sutures T-tube anchored with silk 2-0 to the skin Betadine paint Dry sterile dressing placed

CLOSURE OF TEMPORARY COLOSTOMY Operative Technique Patient supine under SAB/CLEA/GA Asepsis and antisepsis technique Colostomy occluded by inserting a small sponge packing moistened with betadine solution Sterile drapes placed Incision made on skin around the colostomy site, about 0.5cm margin Allis forceps applied to the lips of the colostomy and lifted upwards With sharp dissection incision extended deep until the seromuscular coat of colon is identified Serosa and surrounding subcutaneous fat separated by metzenbaum/electrocautery dissection carried meticulously down to the point where colon meets the anterior rectus sheath Fascial ring identified Colon dissected away from the fascial ring until peritoneal cavity is entered Peritoneal cavity entered and identified, transverse colon dissected away from adjoining peritoneal attachments Colostomy freed Rim of skin incised from the colon Colostomy defect closed in transverse direction with continuous chromic 3-0 Connell suture followed by interrupted silk 4-0 Lembert sutures to invert first layer Abdominal wall defect closed Posterior Rectus Fascia including peritoneum continuous vicryl 0 sutures Anterior rectus sheath continuous vicryl 0 suture Skin silk 4-0 interrupted suture Betadine paint Dry sterile dressing placed

CRICOTHYROIDOTOMY Operative Technique Patient supine Folded sheet placed under shoulders Neck extended Asepsis and antisepsis Sterile drapes placed Cricothyroid space accurately located Line of incision infiltrated with local anesthesia (lidocaine) Transverse incision made in the cricothyroid space carried from skin down to the cricothyroid membrane Bleeders suture ligated Stab incision made on cricothyroid membrane Stab wound enlarged, spreading the tissues transversely until the opening is sufficient enough to insert a low-pressure cuff tracheostomy tube Tube fixed in place Sterile dressing

FISTULOTOMY

Transsphincteric fistula

Intersphincteric fistula

Operative Technique Simple Low Fistula Intersphincteric/Transsphincteric Patient supine on lithotomy position/ prone on jackknife position under SAB/CLEA Asepsis and antisepsis technique Sterile drapes placed Rectal speculum inserted Internal opening located with use of probe inserted on the external opening following the fistulous tract carefully Incision made with probe as guide starting on the external opening carried from skin through subcutaneous tissue, and division of overlying anoderm, and: IntersphinctericFistula - internal sphincter up to the internal orifice of the fistula Transsphincteric Fistula external and internal sphincters up to the internal orifice of the fistula Necrotic tissues removed by curettage NSS wash Hemostasis OS packing

GASTRECTOMY Billroth I Operative Technique Patient supine under General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Midline incision made, carried from skin through subcutaneous tissue Fascia cut and opened Peritoneum entered Intra-operative findings noted Incision done on the avascular portion of the gastrohepatic ligament to the right of the lesser curvature Index finger of left hand passed behind the lesser curvature and antrum of the stomach, emerging deep to the gastroepiploic arcade along the greater curvature of the stomach. This serves to elevate the greater omentum from the underlying mesocolon. Branches from gastroepiploic arcade serially isolated, clamped divided and ligated, up along the greater curvature of the stomach until the halfway point between the pylorus and the diaphragm is reached. Distal segment of gastroepiploic arcade from the antrum dissected. Dissect the attachments between the back wall of the antrum and the pancreas, freeing the entire distal half of the gastric greater curvature. On the lesser curvature, halfway between the esophagogastric junction and the pylorus, vascular bundle was divided and doubly ligated with silk 0 sutures Stomach divided, Allen clamps applied for a distance of 3 4cm, at an angle 90o to the greater curvature of the stomach and then divided. Another set of Allen clamps applied midway to the lesser curvature and divided. Side of lesser curvature closed with continuous running suture using chromic 3.0. Then mucosa inverted using one layer of interrupted 4-0 silk Lembert sutures. Right gastric artery identified, divided and doubly ligated Specimen carefully pulled in an anterior direction exposing the posterior wall of the duodenum and the anterior portion of the pancreas Vessels encountered carefully divided and ligated, until 1.5cm of the posterior duodenal wall has been freed from the underlying pancreas Ampulla of vater identified Duodenum divided Gasroduodenal anastomosis created, corner Cushing sutures made then interrupted 4-0 silk seromuscular Lembert sutures placed on the remainder of the posterior layer Gastoduodenal mucosal layer approximated using chromic 3-0 continuous Connell technique Anterior layer reinforced with silk 4-0 interrupted Lembert sutures Peritoneal lavage Hemostasis

Complete sponge and instrument count Peritoneum and fascia closed in one layer using Vicryl 0 continuous suture External bolsters placed Skin closed using interrupted silk 3-0 sutures Dry sterile dressing placed

GASTROSTOMY Operative Technique Patient supine under General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Midline incision made Stomach identified, and exposed Stamm Gastrostomy Circular purse-string suture made on the midportion of the stomach closer to the greater than to the lesser curvature using silk 2-0 atraumatic suture External opening for tube created at the area of left rectus muscle at the level of the purse-string suture Left side of linea alba grasped with Kocher clamp, stab wound made on the middle third of left rectus muscle, Kelly forcep passed from peritoneum outward. A Fr.24 foley catheter was grasped by the Kelly forcep drawing it inside the abdominal cavity With the use of electrocautery a stab wound was created into the anterior gastric wall in the middle of the previously placed purse-string suture Foley Catheter inserted into the stomach Purse-string suture tightened so as to invert the gastric serosa A second purse-string suture made Foley catheter balloon inflated Stomach drawn to the anterior abdominal wall Lembert sutures made in four quadrants around the foley catheter to the sew the stomach to the anterior abdominal wall around the stab wound Foley catheter secured on the skin using silk 2-0 suture Fascia including peritoneum closed with continuous vicryl 0 suture Subcutaneous approximated with inverted T suture using chromic 2-0 Skin closed interruptedly using silk 4-0 sutures Betadine paint Dry sterile dressing placed

HEMORRHOIDECTOMY Operative Technique Patient supine positioned into lithotomy under SAB Asepsis and antisepsis technique Sterile drapes placed Lords maneuver Hill-Ferguson retractor inserted Inspection done Wet sponge inserted as rectal pack Hemorrhoidal clamp applied and retracted hemorrhoids downwards Hemorrhoidal pedicle suture-ligated with chromic 2.0 Elliptical incision made on the anoderm and mucosa overlying the hemorrhoid towards pedicle Hemostasis Continuous running suture made to close mucosal defect anchoring to underlying internal sphincter Anoderm left open Saline irrigation Hemostasis Wet sponge removed Anal packing with small wet sponge Dry sterile dressing placed

HERNIORRHAPHY BASSINI Operative Technique: patient supine under asepsis and antisepsis technique sterile drapes placed incision done external oblique aponeurosis cut and opened spermatic cord identified cremasteric muscle opened hernial sac identified and separated from rest of spermatic cord hernial sac ligated highly inguinal floor repaired (Bassini internal oblique muscle, transversus abdominis muscle, and transverse aponeurosis and fascia approximated to the iliopubic tract and the shelving of the inguinal ligament with interrupted sutures.)

NSS wash Hemostasis secured Correct OS and instrument count verified Cremasteric muscle closed continuously using chromic 3.0 External oblique aponeurosis closed by continuous interlocking using vicryl 0 Subcutaneous tissue approximated by inverted T sutures using chromic 3.0 Skin closed subcuticularly using vicryl 4.0 Betadine paint Dry sterile dressing applied

HERNIOTOMY Operative Technique Patient supine under General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Inguinal transverse incision made, carried from skin through subcutaneous tissue External Oblique Aponeurosis cut and opened along its fibers Ilioinguinal nerve identified and spared Spermatic cord identified Cremasteric muscle opened Hernial sac identified and isolated. Freed from rest of spermatic cord structures up to internal ring. High ligation of the hernial sac done. Hemostasis External oblique aponeurosis closed using vicryl 2.0 continuous interlocking sutures Subcutaneous tissue reapproximated using chromic 4.0 interrupted sutures Skin closed subcuticularly using vicryl 5.0 suture. Betadine paint Dry sterile dressing applied.

INCISION AND DRAINAGE

Intersphincteric abscess Ischiorectal abscess

Perianal abscess

Operative Technique Patient supine on lithotomy position/prone on jackknife position under SAB Asepsis and antisepsis technique Sterile drapes placed Inspection done Findings noted Incision made over fluctuant mass Perianal Abscess - Ellipse incision, radially in relation to the anal opening Ischiorectal Abscess cruciate incision over inflamed area Intersphincteric Abscess with internal sphincterotomy Pus drained Cavity of the abscess explored breaking loculations NSS wash Necrotic tissues removed NSS with hydrogen peroxide wash Hemostasis OS packing

MODIFIED RADICAL MASTECTOMY Operative Technique: Patient supine under General Anesthesia Ipsilateral arm abducted from axilla Pad placed underneath patients scapula and posterior hemithorax Asepsis and antisepsis technique Sterile drapes placed Elliptical incision made encompassing mass with 3-5cm margin together with the nipple-areola complex. Depth of incision carried from skin through subcutaneous tissue.

Towel clips applied to edge of skin on flap about 2 3cm apart Ask Assistant to elevate skin flap by drawing towel clips upward making it perpendicular to the breast tissue while applying countertraction by depressing breast. Dissection carried out by use of electrocautery incising coopers ligaments which attach breast to subcutaneous tissue Skin flaps extended: Superiorly subclavius muscle; Medially sternum; Inferiorly about 2 3 cm inferior to the inframammary fold; Laterally anterior border of the latissimus dorsi

From the sternum to the lateral margin, fascia incised with the use of electrocautery overlying pectoralis major muscle. Bleeders either electrocoagulated or suture-ligated. At the lateral margin of the pectoralis major elevate the edge of the pectoral muscle from its investing fascia using blunt and sharp dissection maintaining continuity between the breast, the pectoral fascia, and the lymph nodes of the axilla Pectoralis minor preserved Axillary vein identified, adventitial sheath incised Level I and II axillary nodes and Rotters nodes removed Thoracodorsal and long thoracic nerve identified and preserved

Copious saline irrigation Hemostasis Complete sponge and instrument count Closed-suction drain placed laterally and medially and positioned in the inferior flap Subcutaneous tissue approximated with vicryl 2.0 sutures Skin closed interruptedly with silk 3.0 Drain secured with silk 2.0 sutures Floppy dressing applied

PAROTIDECTOMY Operative Technique Patient supine under General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Y incision made, with the anterior limb done just anterior to the tragus and posterior limb over the mastoid process in the caudal direction roughly parallel to the underlying sternocleidomastoid muscle down to a point about 1 cm below the angle of the mandible. Incision made from skin through platysma. Anterior flap made to the level of the zygomatic process and anteriorly to the anterior margin of the parotid gland Posterior flap made to expose 1-2cm of underlying sternocleidomastoid muscle, mastoid process, and cartilage of the external auditory canal Branch of great auricular nerve that enters the parotid gland divided External jugular vein posterior to the parotid gland divided and ligated Dense layer of temporoparotid fascia elevated and divided, exposing tympanomastoid fissure Branch of posterior auricular artery identified, divided, and ligated Posterior portion of the parotid gland retracted away from the mastoid process Main trunk of the facial nerve identified Traction applied to the superficial lobe of the parotid gland Dissection carried carefully just superficial to the facial nerve creating a plane until each of the branches of the facial nerve has been separated from the overlying parotid tissue. On the anterior margin of the parotid gland, Stensens duct identified, divided, and ligated Superficial lobe of the gland removed Removing the Deep Lobe of Parotid Gland Lower division of the facial nerve carefully freed from the underlying tissue Piecemeal removal of deep lobe carefully undertaken Posterior facial vein separated from the marginal mandibular nerve branch then divided and ligated Superficial temporal artery and vein divided and ligated Lower border of the gland elevated External carotid artery divided and ligated Internal maxillary and the transverse facial arteries at the anterior border of the gland divided and ligated Deep lobe removed.

Closure NSS wash Hemostasis Closed suction drain placed (feeding tube Fr. 8) Platysma and Subcutaneous tissue closed using vicryl 4.0 interrupted sutures Skin closed subcuticularly using vicryl 5.0 Betadine paint Dry sterile dressing placed.

PLICATION OF PERFORATED PEPTIC ULCER Operative Technique: Patient supine under General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Midline incision made Intra-operative findings noted Edges of perforation debride Continuous chromic 3-0 suture used approximating full thickness of the margins Interrupted silk 4-0 seromuscular Lembert sutures placed with omental overlay Copious peritoneal lavage Hemostasis Complete sponge and instrument count Peritoneum and fascia closed in one layer with interrupted external bolsters Skin partially closed. Dry sterile dressing applied.

RIGHT HEMICOLECTOMY Operative Technique: Patient supine under General Anesthesia Asepsis and antisepsis technique Sterile drapes placed Midline incision made Findings noted Umbilical tape ligature applied proximal and distal to the tumor Right paracolic peritoneum divided using either metzenbaum and electrocautery Ureter identified Ascending and transverse colon mobilized Ileal mesentery divided Ileocolic vessels identified, isolated, doubly ligated and divided Intestinal/Allen clamps placed 10cm of terminal ileum Middle colic vessels identified For cecal masses left branch of middle colic artery preserved and the right branch divided and ligated just beyond the bifurcation For masses near hepatic flexure middle colic vessels dissected and divided Intestinal/Allen clamps applied Cecal mass mid-transverse colon Mass near hepatic flexure distal transverse colon Wound protector drape placed into the abdominal incision Division of ileum and colon, Intestinal clamps reapplied leaving 10 cm margin fro anastomosis Viability of ileum and colon end for anastomosis evaluated Two layer end-to-end anastomosis done Chromic 3-0 continuous suture using Connell Silk 4-0 interrupted Lembert sutures to invert first layer Peritoneal lavage Hemostasis Complete sponge and instrument count Peritoneum and Fascia closed using continuous vicryl 0 suture with interrupted external bolsters Skin closed partially Dry sterile dressing applied

THORACOSTOMY Operative Technique Patient supine if possible upright, if can tolerate sitting with arms held high on the head Asepsis and antisepsis technique Sterile drapes palced Lidocaine injected subcutaneously at area of incision, Level of 6th rib anterior axillary line Transverse incision made directly over 6th rib anterior axillary line

Kelly curve forcep passed just above 6th rib AAL and inserted through 5th intercostals space anterior axillary line, entering pleural space

Incision digitally explored, assess pleural adhesions, etc and to make incision wide enough to allow thoracic catheter to pass.

Thoracic catheter inserted through 5th intercostal space, anterior axillary line

Thoracostomy tube attached to a closed suction drain (thora-bottle) Tube secured with silk 0 sutures Betadine paint Vasilinized sponge applied OS pack Leukoplast applied

THYROIDECTOMY Operative Technique Patient supine under General Anesthesia Head and neck extended by placing a shoulder pad Asepsis and antisepsis technique Sterile drapes placed Low collar incision made, placed at a level 2 fingerbreadths above the sternal notch, extending just beyond anterior borders of sternocleidomastoid muscles Incision made from skin through platysma

Superior and inferior subplatysmal flaps created, with the Superior flap dissected to the level of the thyroid cartilage and the Inferior flap to the level of the suprasternal notch

Flaps secured by temporary sutures Midline identified, incision made through the cervical fascia in the midline Strap muscles elevated from thyroid capsule using blunt dissection. Sternohyoid first then the sternothyroid laterally. Middle thyroid vein identified by retracting thyroid lobe anteromedially and strap muscles laterally, middle thyroid vein divided and ligated Superior thyroid pole identified Superior pole vessels individually identified, skeletonized and doubly ligated. External laryngeal nerve identified and preserved Superior parathyroid gland dissected away from thyroid gland Inferior thyroid artery identified and ligated. Used as a guide to locate recurrent laryngeal nerve.

Recurrent laryngeal nerve followed in a cephalad direction up to the inferior cornu of the thyroid cartilage, the point near which the nerve enters the larynx. Lower pole of the thyroid lobe dissected. Inferior parathyroid glands separated from thyroid gland Inferior thyroid veins ligated Posterior aspect of the thyroid lobe exposed fully Subtotal Thyroidectomy (Total Lobectomy; Isthmectomy) after following all steps above, identifying both parathyroid glands and recurrent laryngeal nerve, all of which left in their normal locations Posterior lobe exposed until the anterior surface of the trachea has been reached Hemostats applied at the isthmus Isthmus transected serially Remaining lobe sutured with continuous chromic 4.0 Total Thyroidectomy same steps followed on the contra lateral side as previously done Carefully identifying parathyroid glands, recurrent laryngeal nerves, and external laryngeal nerves on both sides. Closure NSS wash Hemostasis Complete sponge count Cervical fascia reapproximated by continuous running chromic 4.0 Platysma reapproximatted using vicryl 4.0 interrupted sutures Subcutaneous tissue closed using chromic 4.0 interrupted sutures Skin closed cubcuticularly using vicryl 5.0 sutures. Betadine paint Dry sterile dressing placed

TRACHEOTOMY Operative Technique Patient supine on General Anesthesia Folded sheet placed underneath the shoulders, neck extended Asepsis and antisepsis Sterile drapes placed Incision made vertically beginning at the level of cricoid and continuing caudal direction 4 5cm. Incision carried from skin through subcutaneous tissue and platysma muscle directly over the midline of the trachea Sternohyoid muscle exposed Hemostasis with electrocoagulation Strap muscles elevated and vertical incision made down the midline separating the two muscles. Incision carried down to the upper trachea Cricoid cartilage and first tracheal ring visualized and preserved Capsule of the thyroid gland exposed and divided Thyroid isthmus identified and elevated from the trachea Isthmus divided between clamps and suture ligated with chromic 4.0 2nd and 3rd tracheal rings identified Hemostasis 2nd ring elevated by a hook transverse incision made just above the 2nd ring 2nd ring divided with the scalpel, (and also the third ring if necessary) Edges of trachea retracted using hooks Tracheotomy tube inserted carefully while anesthesiologist pull endotracheal tube Aspirate mucous using suction catheter Attach anesthesia line to the tracheotomy tube Hemostasis Sternohyoid muscles reapproximated using interrupted vicryl 4.0 Platysma reapproximated using interrupted vicryl 4.0 Skin closed loosely with interrupted 4.0 nylon sutures Tracheotomy tube hold in place by silk 2.0 sutures in two places Fix tracheotomy tube with tapes