What we follow is to create a new skin stoma beneath the suture line and bring out the trachea to skin through that. We also take care not to bevel the tracheal edges passing through multiple tracheal rings.

Advantages of this technique is to avoid trifurcates in the suture line. And also isolate the permanent stoma from the incision- suture site.

This problem was faced by us in the beginning. To avoid this, we excise semilunar skin to fit the size of the stoma from both the lower and upper flaps. Also, cutting through the tracheal ring is avoided which can cause stenosis in the process of healing.. creating a separate stoma away from the suture line is a good method, as mentioned by Dr Manoharan. however in this process we are creating a small bridge of skin between the stoma and suture line, which has a potential risk (more theoretical) of necrosis.

Thanks Dr Manoharan , actually there is no solid evidence to support an ideal method for fashioning a stoma after laryngectomy

however, I am aware of two studies of good quality which support beveling of the tracheal cut, to increase the cross sectional area of the stoma, over the straight transection with stenosis rate of 71% for straight cut against 15% for beveling (Griffith GR et al ) and 75% and 33% in another study respectively (Wax MK et al )

But some authors also believe that beveling of the cut transect the rings cartilage plate and exposes them to the infection and subsequently healing and potential stenosis moreover intact ring is more supportive for a stoma against narrowing overtime (Vlantis AC et al)

Thanks Dr Bhat for your contribution

The question of involving the stoma in the incision or not is very controversial

proponents of separate incision would claim that this technique provides:

- less downwards traction by trachea on the stoma which may evetually contribute to stenosis

- gentle equal traction on the stoma by healthy skin

- unified blood supply around the stoma ( I agree with you , Dr Bhat that on contrary, this island is theoretically risky of ischemia)

- less effect of the neck movement on the stoma than in main incision stoma

BUT Others would support the inclusion of the stoma in the incision on the basis that the lateral pull of the wound healing would help keep the stoma wide

from my own point of view ... trifurcation at the stoma side would break the circle of circumferential skin healing to reduce the concentric healing which is considered a main factor in postoperative stenosis

Dr Manoharan .... what do you think is the problem of a trifurcation at the stoma side ??? I really donot know the potential risk of this situation

Trifurcation at a stoma may have over-riding stiches, as a general rule skin corners at trifurcations have lower vascularity and s they are exposed to tracheal secretions has a potential for tip necrosis.

We used to manage trifurcation at the stoma side by " army - Navy" stitch. The stitch would run from the skin side to the tracheal stoma sub-mucosally , coming out through the inferior flap as a vertical mattress stich. We did not have any significant wound break down at the site. just that we had mild erythema at the site post op day 4-5; until we resorted to the technique previously described

Your experience looks very rich Dr Manoharan .. we also reported these findings at the trifurcation site ... thaks for sharing this valuable feedbacks