TLT overcomes the needs of external dilation of the trachea with less pressure on the trachea and pre-tracheal tissue and, thus, limiting the risks of compression of the tracheal lumen and injury of the posterior tracheal wall. For the same reason, the TLT may be used in children and young adults with highly elastic trachea [6].

TLT may be particularly useful in patients with bleeding disorder [11, 12]. This is very important if we consider that bleeding is the most important cause of death during and after percutaneous tracheotomy [9]. In a randomised controlled trial [7] comparing TLT vs. surgical tracheostomy (ST), the authors reported major bleeding 0/67 in TLT group vs 8/72 in ST group (p < 0.03). Another randomised controlled trial [8] compared TLT vs forceps dilatational technique (FDT) showing minor bleeding in 4 % of patients in TLT group vs 23 % in FDT (p < 0.001). Only one massive haemorrhage, due to an erosive lesion in the posterior wall of the brachiocephalic artery, was reported in a single case report, 6 days after translaryngeal tracheostomy. Once bleeding was controlled, a “conventional” tracheostomy was performed.

TLT technique shows an optimal adaptation of the stoma to the cannula, leading to less stomal bleeding and less infectious complications [10].

TLT standard technique requires that the patient is intubated twice: the first time to position the rigid tracheoscope and the second one to replaced it with the narrow ventilation tube. These two manoeuvres could be risky in patients with difficult airways management, although the substitution of the original endotracheal tube could be made with tube exchangers. Cantais et al. [8] reported 9 % of loss of airways in TLT against 0 % in FDT (p < 0.001) without hypoxia and 6 % in TLT against 0 % in FDT (p < 0.001) with hypoxia. Nani et al. [14] in series of 220 reported four cases of hypoxemia (2.1 %) due to technical difficulties, even more in TLT in the rotational manoeuvres.

The gradual retraction of the cannula during the rotation phase can hesitate in a decannulation due to a small over shift of the cannula with the risk to put the cannula into pre-tracheal layers of the neck. According to Fantoni [15], complication is more frequent when the obturator is used while the telescope method (variant of the standard technique that uses telescope inside the cannula to provide the rotation manoeuvres) prevents it. Fantoni [15] reported 6 decannulations (1.39 %) out of 431 procedures. Adam et al. [13] reported an accidentally loss of tracheostomy tube, completely pulled out of the neck, in 9 patients (6.2 %). In 6 of the 9 patients, a second attempt, by an experienced physician, successfully placed the tracheostomy tube. A randomised controlled trial of 100 patients [8] reported problems with tube placement in 23 % (11/47) of cases. These included the guide wire breaking in 3 patients, difficult retrograde passage of the guide wire in 3 patients and accidental pull of the tube out of the neck in 5 patients. Other technical difficulties were ring fracture during traction and displacement/dislocation of the tube. Nani et al. [14] described accidental decannulation in 8/220 patients.

Another critical moment could be the change of the cannula. The maximal hyperextension of the neck, required to optimise the procedure, might promote a misalignment of the anatomical plans between the trachea and the stoma when the neck resumes its physiological position. Moreover a case report [16] described the embedding of the cannula in the tracheostomy opening that required surgical treatment. Therefore, as in all PDT, the first tracheostomy tube exchange should be performed in ICU with staff well trained in airway management. Finally, TLT, due to needs of some specific technical skills, requires a longer learning curve compared to other PDT techniques.