1- Inject 1% novocain and adrenaline along anterior border of both sternomastoid muscles and along the upper border of thyroid cartilage.
2- No anesthesia in urgent cases.
3- The patient should be supine with extended neck.
4- Midline longitudinal incision from upper border of cricoid cartilage to suprasternal notch including “skin – subcutaneous tissue – platysma and fascia”.
5- Separate between sternohyoid and sternothyroid in the midline.
6- Retract thyroid isthmus upward.
7- Dissect pretracheal fascia from anterior tracheal wall.
8- Open trachea and avoid blood aspiration or cough reflex.
9- Remove circular portion of 3, 4 tracheal rings.
10- Insert tube to be of same diameter of the opening.