Percutaneous tracheostomy has been touted as the preferred route of tracheostomy. However, to date, no prospective randomized study comparing bedside percutaneous (BP) to bedside open (BO) tracheostomy has been performed. Surgical intensive care unit (sICU) patients were randomized to receive either a BP or a BO tracheostomy. Patients were monitored for complications. Procedure time was documented. A group of medical ICU patients had open tracheostomies in the operating room (OR) and served as contemporaneous controls. Over 11 months, there were 24 surgical ICU patients randomized to receive either BP tracheostomy or BO tracheostomy, 12 in each group. Forty-six medical ICU patients received standard open tracheostomy in the OR. The number of ventilator days before placing the tracheostomy was similar between the BP and BO groups, 9.8 and 12.4, respectively. The clinical indications for tracheostomy were similar between the two groups. The procedure time for the BP group was 14.5 minutes, whereas 25.2 minutes for the BO group. There were no postprocedure complications in the BP and BO groups. There was a trend toward more complications in the BP group, including the loss of the airway, leading to death. The procedure time and complications were similar between the BO and OR groups. These data do not support that BP tracheostomy is the preferred route of tracheostomy when compared with BO tracheostomy. These data support that experienced surgical intensivists can perform BO tracheostomies with lower risk and cost, when compared with BP tracheostomy.