Three main groups of patients that benefit from elective tracheotomy: required prolonged intubation; cannot manage their airway secretions; or have an upper airway obstruction. Tracheotomies can improve the quality of life for patients by allowing return of speech with the use of a Passy-Muir valve or a fenestrated tube, allowing oral intake, improving oral hygiene, and promoting patient mobility. An elective surgical tracheotomy is performed in the operating room under general anesthesia. In cases where difficult intubation is anticipated an elective awake tracheotomy may be performed under local anesthesia. Proper tracheotomy tube selection will minimize discomfort and avoid damage to the tracheal wall. Bleeding intraoperatively or postoperatively is the most common complication from tracheotomies. Inadvertent decannulation is a serious complication that can arise in the early postoperative period. Complications from tracheotomies can be minimized by proper surgical technique and postoperative care.