Langenbeck's Archives of Surgery

, Volume 403, Issue 2, pp 137–149 | Cite as

Percutaneous versus surgical strategy for tracheostomy: a systematic review and meta-analysis of perioperative and postoperative complications

  • Rosa Klotz
  • Pascal Probst
  • Marlene Deininger
  • Ulla Klaiber
  • Kathrin Grummich
  • Markus K. Diener
  • Markus A. Weigand
  • Markus W. Büchler
  • Phillip Knebel
Systematic Reviews and Meta-analyses



Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches are open surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PDT). This systematic review summarizes and analyzes the existing evidence regarding perioperative and postoperative parameters of safety.


A systematic literature search was conducted in the Cochrane Library, EMBASE, LILACS, and MEDLINE to identify all randomized controlled trials (RCTs) comparing complications of ST and PDT and to define the strategy with the lower risk of potentially life-threatening events. Risk of bias was assessed using the criteria outlined in the Cochrane Handbook.


Twenty-four citations comprising 1795 procedures (PDT: n = 926; ST: n = 869) were found suitable for systematic review. No significant difference in the risk of a potentially life-threatening event (risk difference (RD) 0.01, 95% CI − 0.03 to 0.05, P = 0.62, I 2 = 47%) was found between PDT and ST. There was no difference in mortality (RD − 0.00, 95% CI − 0.01 to 0.01, P = 0.88, I 2 = 0%). An increased rate of technical difficulties was shown for PDT (RD 0.04, 95% CI 0.01, 0.08, P = 0.01, I 2 = 60%). Stomal infection occurred more often with ST (RD − 0.05, 95% CI − 0.08 to − 0.02, P = 0.003, I 2 = 60%). Both techniques can be safely performed on the ICU. Meta-analysis of the duration of procedure was not possible owing to high heterogeneity (I 2 = 99%).


ST and PDT are safe techniques with low incidence of complications. Both techniques can be performed successfully in an ICU setting. ST can be performed on every patient whereas PDT is restricted by several contraindications like abnormal anatomy, previous surgery, coagulopathies, or difficult airway of the patient.

Systematic review registration

PROSPERO CRD42015021967


Tracheostomy Percutaneous dilatational tracheostomy Surgical tracheostomy Systematic review with meta-analysis 


Authors’ contributions

MAW, MKD, MWB, PK, and RK designed the study. KG, MD, RK, and UK acquired the data; PK, PP, and RK analyzed and interpreted the data. MKD, PK, and RK drafted the manuscript. All authors critically revised the manuscript.


This work was funded by a grant from the Heidelberger Stiftung Chirurgie (

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Supplementary material

423_2017_1648_MOESM1_ESM.doc (22 kb)
ESM 1 (DOC 22 kb)


  1. 1.
    Kollef MH, Ahrens TS, Shannon W (1999) Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 27(9):1714–1720. CrossRefPubMedGoogle Scholar
  2. 2.
    Freeman BD, Isabella K, Lin N, Buchman TG (2000) A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. CHEST J 118(5):1412–1418. CrossRefGoogle Scholar
  3. 3.
    Krankenhausstatistik F (2009) Operationen und Prozeduren der vollstationären Patientinnen und Patienten in Krankenhäusern-Ausführliche Darstellung. Statistisches Bundesamt, WiesbadenGoogle Scholar
  4. 4.
    Marx WH, Ciaglia P, Graniero KD (1996) Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique. CHEST J 110(3):762–766. CrossRefGoogle Scholar
  5. 5.
    Mittendorf EA, McHenry CR, Smith CM, Yowler CJ (2002) Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit/discussion. Am Surg 68(4):342PubMedGoogle Scholar
  6. 6.
    Jackson C (1909) Tracheotomy. Laryngoscope 19(4):285–290CrossRefGoogle Scholar
  7. 7.
    Ciaglia P, Firsching R, Syniec C (1985) Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report. CHEST J 87(6):715–719. CrossRefGoogle Scholar
  8. 8.
    Zgoda MA, Berger R (2005) Balloon-facilitated percutaneous dilational tracheostomy tube placement: preliminary report of a novel technique. CHEST J 128(5):3688–3690. CrossRefGoogle Scholar
  9. 9.
    Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg J (1990) A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 170(6):543–545PubMedGoogle Scholar
  10. 10.
    Frova G, Quintel M (2002) A new simple method for percutaneous tracheostomy: controlled rotating dilation. Intensive Care Med 28(3):299–303. CrossRefPubMedGoogle Scholar
  11. 11.
    Byhahn C, Lischke V, Halbig S, Scheifler G, Westphal K (2000) Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy: technique and early clinical results. Anaesthesist 49(3):202–206. CrossRefPubMedGoogle Scholar
  12. 12.
    Fantoni A, Ripamonti D (1997) A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intensive Care Med 23(4):386–392. CrossRefPubMedGoogle Scholar
  13. 13.
    Kaiser E, Cantais E, Goutorbe P, Salinier L, Palmier B (2006) Prospective randomized comparison of progressive dilational vs forceps dilational percutaneous tracheostomy. Anaesth Intensive Care 34(1):51–54PubMedGoogle Scholar
  14. 14.
    Gysin C, Dulguerov P, Guyot J-P, Perneger TV, Abajo B, Chevrolet J-C (1999) Percutaneous versus surgical tracheostomy: a double-blind randomized trial. Ann Surg 230(5):708–714. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Douglas W, Flabouris A (1999) Surgical emphysema following percutaneous tracheostomy. Anaesth Intensive Care 27(1):69–72PubMedGoogle Scholar
  16. 16.
    Bodenham A, Diament R, Cohen A, Webster N (1991) Percutaneous dilational tracheostomy. Anaesthesia 46(7):570–572. CrossRefPubMedGoogle Scholar
  17. 17.
    Leinhardt D, Mughal M, Bowles B, Glew R, Kishen R, MacBeath J, Irving M (1992) Appraisal of percutaneous tracheostomy. Br J Surg 79(3):255–258. CrossRefPubMedGoogle Scholar
  18. 18.
    Fikkers BG, van Veen JA, Kooloos JG, Pickkers P, van den Hoogen FJA, Hillen B, van der Hoeven JG (2004) Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study. Chest 125(5):1805–1814. CrossRefPubMedGoogle Scholar
  19. 19.
    Putensen C, Theuerkauf N, Guenther U, Vargas M, Pelosi P (2014) Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis. Crit Care 18(6):544. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Antonelli M, Michetti V, Di Palma A, Conti G, Pennisi MA, Arcangeli A, Montini L, Bocci MG, Bello G, Almadori G (2005) Percutaneous translaryngeal versus surgical tracheostomy: a randomized trial with 1-yr double-blind follow-up. Crit Care Med 33(5):1015–1020. CrossRefPubMedGoogle Scholar
  21. 21.
    Lukas J, Duskova J, Lukas D, Paska J, Stritesky M, Haas T (2007) Standard surgical versus percutaneous dilatational tracheostomy in intensive care patients. Saudi Med J 28(10):1529–1533PubMedGoogle Scholar
  22. 22.
    Youssef TF, Ahmed MR, Saber A (2011) Percutaneous dilatational versus conventional surgical tracheostomy in intensive care patients. N Am J Med Sci 3(11):508–512. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Holdgaard H, Pedersen J, Jensen R, Outzen K, Midtgaard T, Johansen L, Møller J, Paaske P (1998) Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy. Acta Anaesthesiol Scand 42(5):545–550. CrossRefPubMedGoogle Scholar
  24. 24.
    Celedón L, Walker J, Naser G, Neumann M, Nazar S (2007) Traqueostomía abierta vs traqueostomía percutánea. Rev otorrinolaringol cir cabeza cuello 67(3):222–228CrossRefGoogle Scholar
  25. 25.
    Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, Schuller DE (2001) Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope 111(3):494–500. CrossRefPubMedGoogle Scholar
  26. 26.
    Bowen C, Whitney LR, Truwit JD, Durbin CG, Moore MM (2001) Comparison of safety and cost of percutaneous versus surgical tracheostomy. Am Surg 67(1):54–60PubMedGoogle Scholar
  27. 27.
    Barba CA, Angood PB, Kauder DR, Latenser B, Martin K, McGonigal MD, Phillips GR, Rotondo MF, Schwab CW (1995) Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure. Surgery 118(5):879–883. CrossRefPubMedGoogle Scholar
  28. 28.
    Delaney A, Bagshaw SM, Nalos M (2006) Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 10(2):R55. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Higgins KM, Punthakee X (2007) Meta‐analysis comparison of open versus percutaneous tracheostomy. Laryngoscope 117(3):447–454. CrossRefPubMedGoogle Scholar
  30. 30.
    Oliver ER, Gist A, Gillespie MB (2007) Percutaneous versus surgical tracheotomy: an updated meta‐analysis. Laryngoscope 117(9):1570–1575. CrossRefPubMedGoogle Scholar
  31. 31.
    Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A (2016) Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev 20(7):CD008045Google Scholar
  32. 32.
    Blot F, Similowski T, Trouillet JL, Chardon P, Korach JM, Costa MA, Journois D, Thiery G, Fartoukh M, Pipien I, Bruder N, Orlikowski D, Tankere F, Durand-Zaleski I, Auboyer C, Nitenberg G, Holzapfel L, Tenaillon A, Chastre J, Laplanche A (2008) Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med 34(10):1779–1787. CrossRefPubMedGoogle Scholar
  33. 33.
    Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4(1):1. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Klotz R, Klaiber U, Grummich K, Probst P, Diener MK, Büchler MW, Knebel P (2015) Percutaneous versus surgical strategy for tracheostomy: protocol for a systematic review and meta-analysis of perioperative and postoperative complications. Syst Rev 4(1):1CrossRefGoogle Scholar
  35. 35.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269. CrossRefPubMedGoogle Scholar
  36. 36.
    Higgins, Julian PT, and Sally Green, (eds) 2011 Cochrane handbook for systematic reviews of interventions. Vol. 4. John Wiley & SonsGoogle Scholar
  37. 37.
    Group GW (2004) Grading quality of evidence and strength of recommendations. BMJ: Bri Med J 328(7454):1490CrossRefGoogle Scholar
  38. 38.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5(1):13. CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Ahn JJ, Koh YS, Chin JY, Lee KM, Park W, Hong SB, Shim TS, Lee SD, Kim WS, Kim DS (1998) Comparison of clinical efficacy between percutaneous dilatational tracheostomy and surgical tracheostomy. Tuberculosis Respir Dis 45(6):1277–1283. CrossRefGoogle Scholar
  40. 40.
    Crofts SL, Alzeer A, GP MG, Wong DT, Charles D (1995) A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 42(9):775–779. CrossRefPubMedGoogle Scholar
  41. 41.
    Freeman BD, Isabella K, Cobb JP, Boyle WA III, Schmieg RE Jr, Kolleff MH, Lin N, Saak T, Thompson EC, Buchman TG (2001) A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med 29(5):926–930. CrossRefPubMedGoogle Scholar
  42. 42.
    Friedman Y, Fildes J, Mizock B, Samuel J, Patel S, Appavu S, Roberts R (1996) Comparison of percutaneous and surgical tracheostomies. CHEST J 110(2):480–485. CrossRefGoogle Scholar
  43. 43.
    Hasanloei MAV, Mahoori A, Bazzazi AM, Golzari SE, Karami T (2014) Percutaneous dilatational tracheostomy and surgically created thracheostomy in ICU patients. J Cardiovasc Thorac Res 6(1):43Google Scholar
  44. 44.
    HAZARD P, JONES C, BENITONE J (1991) Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 19(8):1018–1024. CrossRefPubMedGoogle Scholar
  45. 45.
    Heikkinen M, Aarnio P, Hannukainen J (2000) Percutaneous dilational tracheostomy or conventional surgical tracheostomy? Crit Care Med 28(5):1399–1402. CrossRefPubMedGoogle Scholar
  46. 46.
    Kaylie DM, Andersen PE, Wax MK (2003) An analysis of time and staff utilization for open versus percutaneous tracheostomies. Otolaryngol Head Neck Surg 128(1):109–114. CrossRefPubMedGoogle Scholar
  47. 47.
    Kumar AR, Mohanty S, Senthil K, Gopinath M (2005) Comparative study of percutaneous dilatational tracheostomy and conventional tracheostomy in the intensive care unit. Indian J Otolaryngol Head Neck Surg 57(3):202–206. PubMedPubMedCentralGoogle Scholar
  48. 48.
    Melloni G, Muttini S, Gallioli G, Carretta A (2002) Surgical tracheostomy versus percutaneous dilatational tracheostomy: a prospective-randomized study with long-term follow-up. J Cardiovasc Surg 43(1):113Google Scholar
  49. 49.
    Muttini S, Melloni G, Gemma M, Casati A, CARRETTA A, GIUDICI D, COZZI S, CHIESA G, GALLIOLI G, BERETTA L (1999) Tracheotomia percutanea e chirurgica: confronto prospettico, randomizzatodell’incidenza di complicanze precoci e tardive. Minerva Anestesiol 65(7–8):521–527PubMedGoogle Scholar
  50. 50.
    Porter JM, Ivatury RR (1999) Preferred route of tracheostomy—percutaneous versus open at the bedside: a randomized, prospective study in the surgical intensive care unit. Am Surg 65(2):142–146PubMedGoogle Scholar
  51. 51.
    Raine R, Michell W, Ruttmann T, Bloch M, Thorp M, Gough A Late outcome after guide-wire forceps percutaneous tracheostomy-a prospective, randomised comparison with open surgical tracheostomy. In: British Journal of Anaesthesia, 1999. PROF SCI PUBL TAVISTOCK HOUSE EAST, TAVISTOCK SQUARE, London, England WC1H 9JR, pp 168–168Google Scholar
  52. 52.
    Silvester W, Goldsmith D, Uchino S, Bellomo R, Knight S, Seevanayagam S, Brazzale D, McMahon M, Buckmaster J, Hart GK (2006) Percutaneous versus surgical tracheostomy: a randomized controlled study with long-term follow-up. Crit Care Med 34(8):2145–2152. CrossRefPubMedGoogle Scholar
  53. 53.
    Stocchetti N, Parma A, Lamperti M, Songa V, Tognini L (2000) Neurophysiological consequences of three tracheostomy techniques: a randomized study in neurosurgical patients. J Neurosurg Anesthesiol 12(4):307–313. CrossRefPubMedGoogle Scholar
  54. 54.
    Stoeckli SJ, Breitbach T, Schmid S (1997) A clinical and histologic comparison of percutaneous dilational versus conventional surgical tracheostomy. Laryngoscope 107(12):1643–1646. CrossRefPubMedGoogle Scholar
  55. 55.
    Sustic A, Krstulovic B, Eskinja N, Zelic M, Ledic D, Turina D (1976) Surgical tracheostomy versus percutaneous dilational tracheostomy in patients with anterior cervical spine fixation: preliminary report. Spine 27(17):1942–1945CrossRefGoogle Scholar
  56. 56.
    Tabaee A, Geng E, Lin J, Kakoullis S, McDonald B, Rodriguez H, Chong D (2005) Impact of neck length on the safety of percutaneous and surgical tracheotomy: a prospective, randomized study. Laryngoscope 115(9):1685–1690. CrossRefPubMedGoogle Scholar
  57. 57.
    Wu J-K, Huang M-S, Tang G-J, Shih S-C, Yang C-C, Kao W-F, Huang M-H, Lee C-H (2003) Percutaneous dilatational tracheostomy versus open tracheostomy—a prospective, randomized, controlled trial. J Chin Med Assoc: JCMA 66(8):467–473PubMedGoogle Scholar
  58. 58.
    Yaghoobi S, Kayalha H, Ghafouri R, Yazdi Z, Khezri MB (2014) Comparison of complications in percutaneous dilatational tracheostomy versus surgical tracheostomy. Glob J Health Sci 6(4):p221CrossRefGoogle Scholar
  59. 59.
    Chen B, Wei ZP, Li PF, Ni SL, Li JX, Tan JG (2008) Comparative study of percutaneous tracheostomy and conventional tracheostomy. Mod J Integr Tradit Chin West Med [xian Dai Zhong Xi Yi Jie He za Zhi] 17(5):705–706Google Scholar
  60. 60.
    Lukas J, Valvoda J, Rambousek P, Belohlavek J, Novak F, Stritesky M, Duskova J, Haas T (2006) Standard and puncture dilatation tracheostomy: comparison of results and complications. Otorinolaryngologie a Foniatrie 55(3):144–149Google Scholar
  61. 61.
    Xu J, Chen X, Pan Y (2007) Comparison between percutaneous dilational tracheotomy and surgical tracheotomy. Zhonghua er bi yan hou tou jing wai ke za zhi= Chin J Otorhinolaryngol Head Neck Surg 42(11):869–870Google Scholar
  62. 62.
    Cheng E, Fee WE (2000) Dilatational versus standard tracheostomy: a meta-analysis. Ann Otol Rhinol Laryngol 109(9):803–807. CrossRefPubMedGoogle Scholar
  63. 63.
    Reilly PM, Anderson HL, Sing RF, Schwab CW, Bartlett RH (1995) Occult hypercarbia: an unrecognized phenomenon during percutaneous endoscopic tracheostomy. CHEST J 107(6):1760–1763. CrossRefGoogle Scholar
  64. 64.
    Reilly MP, Sing FR, Giberson AF, Anderson LH III, Rotondo FM, Tinkoff HG, Schwab WC (1997) Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Intensive Care Med 23(8):859–864. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Rosa Klotz
    • 1
    • 2
  • Pascal Probst
    • 1
    • 2
  • Marlene Deininger
    • 3
  • Ulla Klaiber
    • 1
    • 2
  • Kathrin Grummich
    • 1
  • Markus K. Diener
    • 1
    • 2
  • Markus A. Weigand
    • 4
  • Markus W. Büchler
    • 2
  • Phillip Knebel
    • 1
    • 2
  1. 1.Study Center of the German Surgical Society (SDGC)University of HeidelbergHeidelbergGermany
  2. 2.Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelbergGermany
  3. 3.Department of Anaesthesiology and Intensive Care Medicine, Division of General Anaesthesiology, Emergency- and Intensive Care MedicineUniversity Hospital Graz, Medical University of GrazGrazAustria
  4. 4.Department of AnesthesiologyUniversity of HeidelbergHeidelbergGermany

Personalised recommendations