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Comment & Response
October 8, 2020

Use of Bookwalter Retractor to Create a Working Space for Tracheostomy During the Coronavirus Disease 2019 Pandemic

Author Affiliations
  • 1Division of Otolaryngology–Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
JAMA Otolaryngol Head Neck Surg. 2021;147(1):108. doi:10.1001/jamaoto.2020.3589

To the Editor The ongoing coronavirus disease 2019 (COVID-19)-related pandemic has created a challenge with performance of tracheostomy due to the high risk of aerosolization of potentially infectious materials. This creates a significant hazard for operating room staff and surgeons. Dr Bertroche and colleagues1 have described an excellent method for creating an enclosed negative-pressure environment for performance of tracheostomy, with the purpose of minimizing release of aerosol. We present a modification of this description (Figure).

Figure.  Intraoperative Clinical Image
Intraoperative Clinical Image

Rather than the laryngoscope holder, our group has used the Bookwalter retractor as the arm for drape placement. This is a commonly used retractor system for abdominal surgery, and is placed after draping the patient. After the ring is positioned, a C-arm drape or radio frequency room scanner wand drape is used, with creation of working arm ports similar to the description provided by Bertroche and colleagues.1 The drape is held stable with towel clamps. For the purposes of tracheostomy, we find several advantages. The ring of the retractor creates a flat view of the operating field, which permits a similar view between surgeon and first assistant clinician. Second, the ring prevents collapse of the drape with application of negative pressure. We find that excessive collapse and folding amplify the glare issues that occur when working through a drape material. The major disadvantage of this setup is the restriction in vertical working room above the surgical field, depending on the placement of the ring on the Bookwalter arm. We overcame this by avoiding elongated instruments, specifically the Yankauer suction.

Given the high-risk aerosolization potential of tracheostomy, we completely agree with the creation of an enclosed working space over the surgical field. We hope this modification can assist with ease of performing the procedure.

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Article Information

Corresponding Author: Bharat Bhushan Yarlagadda, MD, Division of Otolaryngology–Head and Neck Surgery, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA 01805 (bharat.b.yarlagadda@lahey.org).

Published Online: October 8, 2020. doi:10.1001/jamaoto.2020.3589

Conflict of Interest Disclosures: None reported.

Bertroche  JT, Pipkorn  P, Zolkind  P, Buchman  CA, Zevallos  JP.  Negative-pressure aerosol cover for COVID-19 tracheostomy.   JAMA Otolaryngol Head Neck Surg. 2020;146(7):672-674. doi:10.1001/jamaoto.2020.1081PubMedGoogle ScholarCrossref