A new technique of surgical tracheostomy is described. Prior to performing the tracheostomy, the endotracheal tube (ETT) is advanced further down the trachea so that the end of the tube is positioned just above the carina. Using the flexible endoscope within the ETT the positioning can be done with precision. This manoeuvre avoids the cuff of the ETT being perforated as it is well below the site of the tracheal window. Following the creation of an opening in the trachea, the patient continues to have a definitive airway. In this controlled environment, time is taken to obtain haemostasis at the tracheostomy site, place a rescue stitch and also suction above the cuff of the ETT. A study was carried out in a series of 15 patients by recording various measurements during the procedure to confirm the accuracy of this technique.