A properly placed tracheotomy tube is a safe and effective means to control the airway in patients who require prolonged ventilatory support or have significant upper airway obstruction. Compared with prolonged endotracheal intubation, a tracheotomy tube provides considerably more patient comfort, greatly facilitates airway care, and increases the options of appropriate health care settings where patients can be treated and their conditions managed. Two of the time-honored hallmarks of properly performed surgical procedures are the maintenance of good exposure and good control. Historically, surgeons have been reluctant to accept new techniques that severely violate either of these tenets. The introduction of percutaneous tracheotomy has been no exception. The review article by Bikhazi very nicely summarizes the high points of the controversy that exists at the present time between advocates of percutaneous tracheotomy and open tracheotomy techniques. The selection of a particular technique to accomplish tracheotomy tube placement should be based on what is the safest, most effective, and most efficient method of stabilizing the airway of a critically ill patient in a particular hospital environment. Bikhazi has presented a fairly accurate and balanced review of the pertinent data in the current literature. The conclusion one could draw from the article is that it is time for surgeons to reconsider their approach. However, the conclusion may not be to embrace percutaneous tracheotomy as the solution. The answer may be that surgeons need to be more flexible and willing to learn to perform open tracheotomy with minimally invasive surgical techniques in the ICU setting to avoid the transfer of critically ill patients. There are several reasons to consider this solution. Open tracheotomy has undergone refinements in technique, improvement in quality of materials, and better understanding of the importance of the timing of the procedure over the last 25 years that has made it a safe and effective adjunctive treatment in airway control. However, the management of patient medical care in an ICU setting over that same period has also increased in sophistication and complexity. Percutaneous tracheotomy was introduced to address some of the logistical issues of transporting critically ill patients from ICUs to operating rooms. Proponents have shown that it does successfully obviate the need for transport. Nevertheless, this procedure is not as revolutionary as it is sometimes claimed to be. The technique itself has not been shown to be safer and/or more effective than previous methods. In addition, percutaneous tracheotomy does not alter the patient’s underlying disease process, nor does it change the patient’s clinical course any more than open tracheotomy does. Open tracheotomy done in a controlled setting of an operating room by trained and experienced personnel can certainly be safe, minimally invasive, and effective. However, in the modern era of managing the complex conditions of critically ill patients with multiple lines, complicated monitors, and myriad medications, transporting these patients may compromise their safety and is rarely as efficient and almost never as cost-effective as performing the tracheotomy in the ICU setting. The principles of the proce