Outer Cannula Research Articles

Outcomes of bilateral temporomandibular joint arthroscopy: an international multicentric prospective study including 524 joints.

This study aimed to evaluate the efficacy of bilateral TMJ arthroscopy in patients with different Wilkes stages, comparing the results obtained in different arthroscopic levels on a larger scale, unifying similar populations. A multicentric prospective clinical study was conducted in three TMJ departments performing temporomandibular joint surgery in Portugal and Brazil, with an enrolling window active from January 1, 2019, to December 1, 2022. The primary clinical outcome was TMJ pain evaluated through a visual analogue scale. The secondary clinical outcome was the maximum mouth opening (MMO). TMJ arthroscopy was performed with a 1.9-mm arthroscope, including a video system with a 2.8-mm outer protective cannula. 262 patients, representing a total of 524 operated joints were enrolled. The mean age was 35.3 years. A significant decrease postoperatively in VAS pain was observed for all Wilkes stages. The lowest value of VAS pain was observed in Wilkes II compared to Wilkes III and IV. In the secondary outcome, MMO was observed to have a significant improvement in all Wilkes stages. In this multicentric study, bilateral TMJ arthroscopy was shown to be an effective procedure to reduce pain and increase maximum mouth opening in patients with different Wilkes stages, representing a valid minimally invasive solution.

A Semi-Autonomous Stereotactic Brain Biopsy Robotic System With Enhanced Surgical Safety and Surgeon-Robot Collaboration.

Despite benefits brought by recent neurosurgical robots, surgical safety and surgeon-robot collaboration remain significant challenges. In this article, we analyze and address these problems in the context of brain biopsy, by proposing a semi-autonomous system. A robotic module is designed for the automation of all the brain biopsy procedures, and a biopsy cannula with tissue blocker is developed to avoid tissue excess and haemorrhage. In addition, two methods are proposed for surgical safety and surgeon-robot collaboration enhancement. First, a priority-based control framework is proposed for neuronavigation with simultaneous optical tracking line-of-sight maintenance and surgeon avoidance. Second, after neuronavigation, an adaptive reconfiguration method is developed to optimize the arm angle of KUKA robot based on the surgeon's pose, for workspace interference minimization, high robot dexterity, and joint-limit avoidance. Effectiveness of the proposed solution demonstrated by simulations and experiments. The system can perform automatic navigation with simultaneous optical tracking maintenance and surgeon avoidance, autonomous brain biopsy, and adaptive reconfiguration for workspace interference minimization. This work improves existing neurosurgical systems, in terms of autonomy level from mechanical guidance to task autonomy, surgical safety, and surgeon-robot collaboration.

One-Insertion Stereotactic Brain Biopsy Using In Vivo Optical Guidance-A Case Study.

Stereotactic neurosurgical brain biopsies are afflicted with risks of inconclusive results and hemorrhage. Such complications can necessitate repeated trajectories and prolong surgical time. To develop and introduce a 1-insertion stereotactic biopsy kit with direct intraoperative optical feedback and to evaluate its applicability in 3 clinical cases. An in-house forward-looking probe with optical fibers was designed to fit the outer cannula of a side-cutting biopsy kit. A small aperture was made at the tip of the outer cannula and the edges aligned with the optical probe inside. Stereotactic biopsies were performed using the Leksell Stereotactic System. Optical signals were measured in millimeter steps along the preplanned trajectory during the insertion. At the region with the highest 5-aminolevulinic acid (5-ALA)-induced fluorescence, the probe was replaced by the inner cannula, and tissue samples were taken. The waiting time for pathology diagnosis was noted. Measurements took 5 to 10 minutes, and the surgeon received direct visual feedback of intraoperative 5-ALA fluorescence, microcirculation, and tissue gray-whiteness. The 5-ALA fluorescence corroborated with the pathological findings which had waiting times of 45, 50, and 75 minutes. Because only 1 trajectory was required and the patient could be prepared for the end of surgery immediately after sampling, this shortened the total surgical time. A 1-insertion stereotactic biopsy procedure with real-time optical guidance has been presented and successfully evaluated in 3 clinical cases. The method can be modified for frameless navigation and thus has great potential to improve safety and diagnostic yield for both frameless and frame-based neurosurgical biopsy procedures.

P07.12.B Brain Biopsy with Optical Guidance

Abstract Background Accurate stereotactic biopsies of brain tumors are imperative for diagnosis and decisions on therapy. Repetitive needle insertions owing to inconclusive tissue samples enhance increased risks of brain lesioning, hemorrhage and prolonged procedure. Previously we reported on frame-based stereotactic biopsies with a combined 5-ALA fluorescence and laser Doppler flowmetry detection system[1]. The system has now been adapted to frameless navigation with a modified biopsy needle and a new registration system[2]. Material and Methods Planning was effected with the Medtronic Stealth System. The optical probe was inserted inside the outer cannula of the biopsy needle, which had an opening at the tip, enabling optical measurements ahead of the needle in real-time while manually forwarding it along the trajectory to the target. Fluorescence spectra, microvascular blood flow, and tissue grayness were recorded during insertion. The biopsies were taken where the fluorescence indicated tumor tissue; the optical probe was replaced by the inner cannula. The diagnoses were compared with the fluorescence signals. Results In the 9 examined patients the fluorescence measurements and pathological diagnosis of high-grade gliomas or lymphomas matched. Only one needle insertion was necessary. The optical measurements along the trajectory took 5-10 min to the target, the pathological diagnosis was reported after 30-70 min. The probe provided direct feedback of increased blood flow along the trajectory and of malignant tissue in the vicinity of the target. Conclusion The optical probe can detect tumor before any tissue is retrieved. If fluorescence is registered, pathological tissue is safely identified. The method can increase the precision and safety of the biopsy and shorten the procedure. The new multimodal probe and the improved registration unit will be tested with other stereotactic and navigation systems and at other neurosurgical centers. Also, the parallel project on fluorescence guided resection of high-grade gliomas is continued[3].

89. Comparison of pedicle screw accuracy using two different robotic techniques: a matched cohort study

BACKGROUND CONTEXT Adoption of robotic technology in spine fusion surgery has expanded significantly in recent years, yet several different techniques exist. Robotic spine surgery allows trajectory guidance and combined navigation allows real-time visualization of instrument/screw placement. Instrumentation of the pedicle can be performed through the robotic arm using anti-skive pin (ASP) or navigated high-speed drill (NHSD). PURPOSE The NHSD may show a decrease in the incidence of skive compared to ASP. STUDY DESIGN/SETTING Matched cohort series. PATIENT SAMPLE This study included 117 patients. OUTCOME MEASURES Screw placement was compared between two groups and incidence of skive compared to ASP. METHODS A total of 737 screws were placed in 117 patients and measurements were recorded. Screw placement was compared in the control group ASP (n=65) and the study group NHSD (n=52). RESULTS Of 117 patients, 65 in the ASP control group had 364 instrumented pedicles and 311 (85.4%) placed robotically. The NHSD study group consisted of 52 patients with 373 instrumented pedicles and 352 (94.4 %) placed robotically. In the control group, a drill guide was placed down the outer cannula, an ASP was manually tapped into the pedicle, then the drill guide tapped into the bone with an outer cannula before drilling into the pedicle under navigation. In the study group, four instruments combined into one and were implemented with NHSD into the pedicle in a single step without additional cannulas or pins. A significant decrease in the number of cases with skive and the total skived screws was found between groups. The control group reported skive in 17% of patients (11/65) which corresponded to 4.7% of screws robotically placed (17/311). The study group reported 1 (1.9%) case with only 2 (0.5%) screws that skived (same as above). Skive occurred in fewer patients with NSHD (p=.002) and in fewer of the NSHD placed screws (p=.014). CONCLUSIONS Pedicle instrumentation with NHSDs shows a decrease in the incidence of skive compared to an ASP. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Adoption of robotic technology in spine fusion surgery has expanded significantly in recent years, yet several different techniques exist. Robotic spine surgery allows trajectory guidance and combined navigation allows real-time visualization of instrument/screw placement. Instrumentation of the pedicle can be performed through the robotic arm using anti-skive pin (ASP) or navigated high-speed drill (NHSD). The NHSD may show a decrease in the incidence of skive compared to ASP. Matched cohort series. This study included 117 patients. Screw placement was compared between two groups and incidence of skive compared to ASP. A total of 737 screws were placed in 117 patients and measurements were recorded. Screw placement was compared in the control group ASP (n=65) and the study group NHSD (n=52). Of 117 patients, 65 in the ASP control group had 364 instrumented pedicles and 311 (85.4%) placed robotically. The NHSD study group consisted of 52 patients with 373 instrumented pedicles and 352 (94.4 %) placed robotically. In the control group, a drill guide was placed down the outer cannula, an ASP was manually tapped into the pedicle, then the drill guide tapped into the bone with an outer cannula before drilling into the pedicle under navigation. In the study group, four instruments combined into one and were implemented with NHSD into the pedicle in a single step without additional cannulas or pins. A significant decrease in the number of cases with skive and the total skived screws was found between groups. The control group reported skive in 17% of patients (11/65) which corresponded to 4.7% of screws robotically placed (17/311). The study group reported 1 (1.9%) case with only 2 (0.5%) screws that skived (same as above). Skive occurred in fewer patients with NSHD (p=.002) and in fewer of the NSHD placed screws (p=.014). Pedicle instrumentation with NHSDs shows a decrease in the incidence of skive compared to an ASP.

Is Wrist Arthroscopy Safer with the Nanoscope?

Background Nanoscope, given its smaller size, may be safer when establishing dorsal wrist arthroscopy portals compared with the traditional 2.7 mm arthroscope. Case Description Ten fresh frozen cadaver specimens were utilized. Dorsal radiocarpal portals were established with the Nanoscope and calipers were used to measure the distance between the portals and the surrounding anatomical structures. The only structure that was pierced during portal placement was the dorsal sensory branch of the ulnar nerve (DSUN) in one specimen when establishing the 6U portal. Our study did not note any tendon injuries. Literature Review Traditional wrist arthroscopy may be performed with a 2.7 mm arthroscope. With its larger outer sheath cannula, this may place adjacent anatomical structures at risk of injury. Clinical Relevance During wrist arthroscopy, the Nanoscope may be safer when creating portals to underlying structures. Level of Evidence This is a Level IV study.

In vitro CT visualization of the biopsy location by filling the core biopsy needle with contrast media.

BackgroundWhen performing computed tomography (CT)-guided biopsy procedures with non-disposable, automatic biopsy instruments, the actual course of the biopsy needle is not registered.PurposeTo evaluate the ability to visualize the sampling location after CT-guided biopsy in vitro using a novel method, where the space between the inner needle and the outer cannula in a core biopsy needle is filled with contrast media; and to compare the grade of visibility for two different concentrations of contrast media.Material and MethodsCore needle biopsies were performed in a tissue phantom using biopsy needles primed with two different iodine contrast media concentrations (140 mg I/mL and 400 mg I/mL). Commercially available needle-filling contraptions with sealing membranes were used to fill the needles. Each biopsy was imaged with CT, and the visibility was evaluated twice by three senior radiologists in a randomized order.ResultsThe presence of traces was confirmed after biopsy, almost without exception for both concentrations. The visibility was sufficient to determine the biopsy location in all observations with the 400 mg I/mL filling, and in 7/10 observations with the 140 mg I/mL filling. The grade of visibility of the trace and the proportion of the biopsy needle course outlined were higher with the 400 mg I/mL filling.ConclusionWith CT-guided biopsy in vitro, the sampling location can be visualized using a novel method of priming the biopsy needle with iodine contrast media, specifically highly concentrated contrast media.

Biopsy with Side-Cutting Coaxial Needle-Knowing the "Cutting Length" and "Throw Length".

Image-guided Trucut biopsy is a well-established procedure. The length of the side notch in the stylet is the “cutting length,” which entraps the tissue sample and contributes to the yield. The total distance by which the inner stylet protrudes from the outer cannula with the cutting notch open is the “throw length.” It is inevitably longer than the cutting length does not add to the yield of the sample, but potentially to the complication of the procedure. The authors highlight the importance of knowing this distinction to minimize complications during the procedure.

Effectiveness of Cytological Diagnosis with Outer Cannula Washing Solution for Computed Tomography-Guided Needle Biopsy

We evaluated the availability of cytological diagnosis with outer cannula washing solution (C-OCWS) as a clinical diagnostic tool for computed tomography (CT)-guided needle biopsy. We retrospectively assessed 109 consecutive patients (71 males, 38 females; median age 68 years), who underwent CT-guided needle biopsy. In all patients, the specimens sampled by the inner needle were used for histological diagnosis, and those taken from the outer cannula were rinsed with 0.9% saline solution: outer cannula washing solution for cytological diagnosis. The accuracy of C-OCWS in addition to histological diagnosis were compared with that of histological diagnosis alone. We used binary logistic regression analysis to determine the variables associated with diagnostic accuracy for malignancy and lesion characteristics. The C-OCWS method precisely diagnosed 7 (6.4%) malignant lesions (i.e., effective cases) in the 109 patients characterized as "negative for malignancy" via histological diagnosis alone. The accuracy of the combination of C-OCWS and histological diagnoses was significantly higher than that of histological diagnosis alone (0.95 vs. 0.89, respectively; p = 0.023). Multivariate logistic regression analysis showed that increasing only a marginal ratio (failure rate for proper position of biopsy needle within the tumor) was independently associated with a high rate of effective cases (p = 0.003). C-OCWS may be helpful for improving the quality of CT-guided needle biopsy, and is a simple method that may not necessarily increase the patients' physical burden.

Dynamic Needle Tip Positioning for Ultrasound-Guided Placement of a Peripherally Inserted Central Catheter in Pediatric Patients

Although a few studies have reported the efficacy of ultrasound-guided peripherally inserted central catheter placement for pediatric patients, the procedure still is challenging. Ultrasound-guided dynamic needle tip positioning technique is useful for vascular catheterization. There have been no reports on using dynamic needle tip positioning for peripherally inserted central catheter placement. The authors assessed the rate of successful peripherally inserted central catheter placement with dynamic needle tip positioning. Case series. Single tertiary institution. Forty patients <5 years old who were admitted to the pediatric intensive care unit after cardiac surgeries and required peripherally inserted central catheter placement. Peripherally inserted central catheter placement was performed under ultrasound guidance with dynamic needle tip positioning. The authors recorded the first attempt and overall success rates of peripherally inserted central catheter and outer cannula placement, time needed for outer cannula and peripherally inserted central catheter placement, and number of attempts. The first attempt and overall success rates of peripherally inserted central catheter placement were 85% (n = 34) and 97.5% (n = 39), respectively. The first attempt and overall success rates of outer cannula placement were 87.5% (n = 35) and 100% (n = 40), respectively. Time needed for outer cannula placement was 59.5 (interquartile range 40.5-80.5) seconds and for peripherally inserted central catheter placement was 112.5 (interquartile range 91.5-159.5) seconds. The number of attempts was 1 (interquartile range 1-1 [range 1-5]). In pediatric patients, ultrasound-guided peripherally inserted central catheter placement using dynamic needle tip positioning attained a high success rate.

Using Simulation to Help Specify Design Parameters for Vacuum-Assisted Needle Biopsy Systems

Needle biopsy is a routine medical procedure for examining tissue or biofluids for the presence of disease using standard methods of pathology. The finite element analysis (FEA) methodology can provide guidance for optimizing the geometric parameters. The needle biopsy is simulated and analyzed while varying the needle angle, the aperture size and the slice-push ratio k. The results indicate that tissue reaction force in the axial direction of needle gradually decreases, and the stress and strain are more concentrated at the tip of needle with the increases of tip angle; the tissue reaction force decreases, and the torque increases while the slice-push ratio increases; and higher slice–push ratio can increase the peak stress concentration on the cutting edge and deformation of tissue; in the process of core needle cutting, increasing slice–push ratio can reduce the tissue reaction force significantly. While the aperture on distal wall of outer cannula becomes wider, the tissue reaction force increases significantly, and the cutting process will be more unstable. The results have the potential to provide important insight for improving the needle biopsy design process.

P1.05-21 CT-Guided Biopsy of Lung Lesions with Outer Cannula Washing Cytology

Although several studies have reported the use of CT lung biopsy for histological diagnosis or aspiration cytology, only a few have reported on the simultaneous use of biopsy and cytodiagnosis. Our hospital has used an outer cannula washing solution cytology in conjunction with a biopsy. We examined the usefulness of outer cannula washing cytodiagnosis. At our hospital, 37 patients (mean age, 68 [range, 33-84] years; 23 males and 14 females; 15 adenocarcinomas, 4 small cells, 3 SCC, 10 other cases, and 5 metastases) were diagnosed with pulmonary lesions between June 2016 and March 2018. While the inner needle was washed with formalin and submitted for tissue examination, the washing solution inside the outer cannula was submitted for cytodiagnosis. In all 37 patients, we successfully performed the procedure without any serious complications. In 33 patients, we observed malignant findings in histopathology or cytodiagnosis. However, we obtained only cytological malignant findings in the three patients. Although one case was negative for histological diagnosis and cytological examination, it was malignant after that. Of note, remaining three other cases were benign. The sensitivity, specificity, and accuracy of the cutting-needle histological biopsy were 88.2%, 100%, and 89.2%, respectively; of washing cytology were 82.6%, 81.3%, and 81.8%, respectively; and of histology and cytology were 97.1%, 100%, and 97.3%, respectively. Although the accuracy was 89.2% only by the conventional tissue method, it was 97.3% when combined with cytodiagnosis (P=0.072). Washing cytology of the outer cannula could be beneficial in the biopsy.

Transarterial Infusion Chemotherapy/Embolization in the Pelvic Cavity Using a Steerable Microcatheter Alone Through the Outer Cannula of an 18G Needle (SMOC)

Transarterial Infusion Chemotherapy/Embolization in the Pelvic Cavity Using a Steerable Microcatheter Alone Through the Outer Cannula of an 18G Needle (SMOC)

Establishing phonation using the Blom® tracheostomy tube system: A report of three cases post cervical spinal cord injury

Objective: Mechanically ventilated patients with cervical spinal cord injury (CSCI) have few options for verbal communication in the acute phase post injury. Leak speech and one-way speaking valves can restore laryngeal airflow; however, both methods require deflation of the tracheostomy cuff which is not always possible. The Blom® tracheostomy tube system (Blom® TTS) provides an option for restoring speech while maintaining cuff inflation, through insertion of a flexible tapered speech cannula into a fenestrated outer cannula. Two studies have reported on the speech achieved with this tube, yet these focused on mixed clinical groups and only examined immediate changes to communication. Longer-term use and patient perceptions of communicating with this system have not been reported.Methods: This paper describes the introduction of the Blom® TTS into three individuals with tetraplegia following CSCI and follows their outcomes throughout their intensive care admission.Results: The tube was successfully placed in two of the three participants. Of these two, phonation was easily established and high levels of patient-perceived comfort and ease and quality of voicing were found when speaking and breathing with the Blom® speech cannula in situ. One patient was sensitive to respiratory changes imposed by the three different inner cannulas of the Blom® TTS and did not complete weaning with the speech cannula in situ.Conclusions: The current research adds support for early restoration of speech via a cuffed tracheostomy during mechanical ventilation in the intensive care unit. Long-term use however identified some potential issues with patient tolerance and safety of the different inner cannulas which may need to be considered for longer-term clinical management. The cases highlight differences in use of the Blom® TTS depending on the degree of respiratory impairment and prognosis for weaning following CSCI.

Ultra-mini-percutaneous nephrolithotomy: A minimally-invasive option for percutaneous stone removal.

Introduction:Percutaneous nephrolithotomy (PCNL) has witnessed rapid advancements, the latest being ultra-mini-percutaneous nephrolithotomy (UMP), which makes the use of 11–13F sheaths as compared to 24–30F sizes used in conventional PCNL. This miniaturization aims to reduce morbidity and improve patient outcomes. We evaluated the safety and efficacy of UMP and report our ourtcomes.Patients and Methods:A total of 120 patients underwent UMP from July 2012 to March 2014. These patients had a single unilateral renal stone measuring between 8 and 20 mm. All patients underwent UMP using a 3F nephroscope, 7.5F inner sheath, and 11F or 13F outer metallic cannula, which served as the Amplatz sheath. Stone fragmentation and clearance were achieved with holmium laser. No nephrostomy or stent was used routinely.Results:Complete stone fragmentation was achieved in 114 out of 120 patients (95%) using UMP; whereas the remaining 6 were converted into mini-PCNL using a 12.5F nephroscope and 15F Amplatz sheath. The mean operative time was 39.7 ± 15.4 min, and the mean postoperative hospital stay was 22.3 ± 2.2 h. Postoperatively, 6 (5%) patients had residual fragments measuring ≤4 mm. At the 2 weeks follow-up, the stone-free status was >99% (119/120). There were no significant postoperative complications.Conclusion:This study shows UMP to be an effective and safe procedure for managing stones up to 20 mm. This procedure offers an attractive alternative to shock wave lithotripsy and retrograde intrarenal surgery for managing small stones.

Tracheostomy management

Tracheostomy management

Needle Trajectory and Tip Localization in Real-Time 3-D Ultrasound Using a Moving Stylus

Described here is a novel approach to needle localization in 3-D ultrasound based on automatic detection of small changes in appearance on movement of the needle stylus. By stylus oscillation, including its full insertion into the cannula to the tip, the image processing techniques can localize the needle trajectory and the tip in the 3-D ultrasound volume. The 3-D needle localization task is reduced to two 2-D localizations using orthogonal projections. To evaluate our method, we tested it on three different ex vivo tissue types, and the preliminary results indicated that the method accuracy lies within clinical acceptance, with average error ranges of 0.9°–1.4° in needle trajectory and 0.8–1.1 mm in needle tip. Results also indicate that method performance is independent of the echogenicity of the tissue. This technique is a safe way of producing ultrasonic intensity changes and appears to introduce negligible risk to the patient, as the outer cannula remains fixed.

Human skeletal muscle biopsy procedures using the modified Bergström technique.

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly effective. This video describes the percutaneous biopsy technique using a modified Bergström needle to obtain skeletal muscle tissue samples from the vastus lateralis of human subjects. The Bergström needle consists of an outer cannula with a small opening ('window') at the side of the tip and an inner trocar with a cutting blade at the distal end. Under local anesthesia and aseptic conditions, the needle is advanced into the skeletal muscle through an incision in the skin, subcutaneous tissue, and fascia. Next, suction is applied to the inner trocar, the outer trocar is pulled back, skeletal muscle tissue is drawn into the window of the outer cannula by the suction, and the inner trocar is rapidly closed, thus cutting or clipping the skeletal muscle tissue sample. The needle is rotated 90°and another cut is made. This process may be repeated three more times. This multiple cutting technique typically produces a sample of 100-200 mg or more in healthy subjects and can be done immediately before, during, and after a bout of exercise or other intervention. Following post-biopsy dressing of the incision site, subjects typically resume their activities of daily living right away and can fully participate in vigorous physical activity within 48-72 hr. Subjects should avoid heavy resistance exercise for 48 hr to reduce the risk of herniation of the muscle through the incision in the fascia.

Compact Robotically Steerable Image-Guided Instrument for Multi-Adjacent-Point (MAP) Targeting

Accurately targeting multi-adjacent points (MAPs) during image-guided percutaneous procedures is challenging due to needle deflection and misalignment. The associated errors can result in inadequate treatment of cancer in the case of prostate brachytherapy, or inaccurate diagnosis during biopsy, while repeated insertions increase procedure time, radiation dose, and complications. To address these challenges, we present an image-guided robotic system capable of MAP targeting of irregularly shaped volumes after a single insertion of a percutaneous instrument. The design of the compact CT-compatible drive mechanism is based on a nested screw and screw-spline combination that actuates a straight outer cannula and a curved inner stylet that can be repeatedly straightened when retracted inside the cannula. The stylet translation and cannula rotation/translation enable a 3-D workspace to be reached with the stylet's tip. A closed-form inverse kinematics and image-to-robot registration are implemented in an image-guided system including a point-and-click user interface. The complete system is successfully evaluated with a phantom under a Siemens Definition Flash CT scanner. We demonstrate that the system is capable of MAP targeting for a 2-D shape of the letter “H” and a 3-D helical pattern with an average targeting error of 2.41 mm. These results highlight the benefit and efficacy of the proposed robotic system in seed placement during image-guided brachytherapy.

A broken metallic tracheostomy tube.

Tracheostomy is an upper airway bypass which is life saving in certain occasions. However, there are several early and late complications. One of these rare mishaps is the broken cannula, few cases of which has been reported so far. Herein we are reporting a rare case of broken tube as a late complication of indwelling tracheostomy tube. A 52 year old woman with moderate respiratory distress was brought to the otolaryngology emergency ward. The patient’s past history included 2 thyroid surgeries for papillary carcinoma 3 years earlier and since then she was dependant on the tracheotomy tube. She had been using the metallic double lumen tube and she did frequently take the tube out (the outer cannula!), clean it and put it back in place. About 2 hours before admission she felt difficult air passage due to the dried secretions and she had tried to take the tube out but it broke and only the neckplate came out with the cannula remaining in the trachea. X-ray was taken which confirmed the patient’s statement. The patient was admitted in the operating room and under systemic intravenous sedation the tube which had moved a bit deeper then, was taken out using long forceps. The patient was discharged the day after (fig.1). Fig. 1 Chest-X-ray showing the metallic cannula within the trachea