The patient was brought to the operating room and placed under general anesthetic

The patient was brought to the operating room and placed under general anesthetic. The neck was prepped and draped. 1 percent lidocaine with epinephrine was injected into the neck. The patient was extremely obese. A 3-cm incision was made approximately two fingerbreadths above the sternal notch. A large amount of subcutaneous fat was dissected and removed with Bovie cautery. The strap muscles were identified and divided in the midline, exposing a large thyroid isthmus. Bipolar cautery was taken down to the cricoid. The thyroid isthmus was divided with bipolar cautery exposing the trachea. An incision was made between the second and third tracheal ring and an inferior based tracheal flap was created with heavy Mayos. The inferior tracheal flap was sewn to the inferior skin edge, creating a skin flap in order to mature the stoma with 3-0 Vicryl. Next, the ET tube was slowly withdrawn to just above the tracheostomy site. An 8.0 XLT Shiley trach was inserted with no difficulties. The balloon was inflated and hooked up