Background: In the intensive care unit (ICU), surgical tracheostomy (ST) is a popular procedure and elective technique. Percutaneous dilatation tracheostomy (PDT) offers numerous advantages compared to operative tracheostomy. Objective: This study aimed to select the most safe, inexpensive, rapid technique of tracheostomy in intensive care unit patients through comparing between surgical tracheostomy and flexible fiberoptic endoscopic guided percutaneous dilatation tracheostomy. Patients and methods: This comparative prospective randomized observational study was carried out on 34 cases admitted to the Intensive Care Unit of Zagazig University Hospital. All of them had either medical causes or surgical causes for prolonged intubation and ventilation. The patients were randomly divided into two groups: Group A was assigned for PDT and group B for ST. Each group included 17 patients. Results: The incision length and duration were significantly longer among surgical group. Surgical group significantly associated with more ventilator needing. Concerning postoperative complications, such as air leak from a tracheostomy or infection, there was a statistically significant difference between the two groups in favor of PDT. The cost in surgical group was significantly cheaper than the percutaneous group. Conclusion: In intensive care unit patients, PDT can be chosen as the main tracheostomy procedure. It can be performed faster along with fewer complications compared to ST. ST is more liable to early infections, air leak from tracheostomy fistula with larger incision length however of low cost than PDT. Because PDT is done at the patient's bedside, there is no risk of transportation to the operating room, which is one of the advantages.