Total Laryngectomy Technique

Updated: Feb 29, 2016
  • Author: Eelam Aalia Adil, MD, MBA; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Technique

Approach Considerations

A Foley catheter and an A-line are placed for hemodynamic monitoring. The patient is prepped with Betadine from the mentum to the sternum anteriorly and from the body of the mandible/mastoids to the clavicles laterally. Perioperative antibiotics with coverage against gram-positive organisms and anaerobes should be administered prior to skin incision.

If a neck dissection is planned in conjunction with a laryngectomy, then an apron incision is planned extending from both mastoid processes to approximately 2 fingerbreadths above the level of the sternal notch. If no neck dissection is planned, then a narrower incision may be used. The planned incision is injected with 1% lidocaine with 1:100,000 epinephrine. The incision is made with a 15-blade scalpel or Bovie electrocautery on cut mode.

Dissection is carried down through the platysmal muscle. A superior subplatysmal flap is then elevated to the level of the hyoid bone. A subplatysmal flap is also raised inferiorly to the level of the sternum and clavicles bilaterally. The skin flaps are secured using Lone Star hooks or sutures, rubber bands, and clamps. The anterior border of the sternocleidomastoid muscles are identified bilaterally. The superficial layer of the deep cervical fascia overlying the muscle is incised approximately 1 cm posterior to their anterior margin. Superior and inferior incisions through the deep cervical fascia were then performed. In the area of the anterior jugular veins, these vessels are carefully skeletonized, ligated, and divided.

Dissection of the "outer and deep tunnels" is performed next. [5] The deep cervical fascia between the sternocleidomastoid muscles and strap muscles is bluntly dissected bilaterally. Once the contents of the carotid sheath are identified, dissection is carried out bluntly between the laryngotracheal complex and the great vessels bilaterally. This frees the medial contents of the neck from the surrounding tissues.

The strap muscles are then released from the anterior trachea at the level of the sternal notch. Dissection proceeds superiorly until the thyroid gland is identified. The thyroid lobe ipsilateral to the laryngeal tumor is resected along with the specimen while the contralateral lobe is carefully left in situ. The thyroid isthmus is identified and divided using Bovie electrocautery or Harmonic shears. The ipsilateral thyroid lobe is left attached to the laryngotracheal complex. Its superior and inferior thyroid arteries are carefully skeletonized, divided, and suture ligated. The contralateral lobe is elevated off of the underlying trachea, and its vasculature is preserved.

Superiorly, the hyoid bone is then identified in the midline. Bovie electrocautery or Harmonic shears are used to release the suprahyoid musculature off of the superior border of the hyoid bone. The lateral aspects of the hyoid are then dissected, being careful not to injure either the lingual artery or hypoglossal nerve. Blunt dissection is carried out underneath the greater corner of the hyoid to minimize the potential injury to these structures.

Attention is then turned to the thyroid cartilage. The left thyroid ala is identified and grasped and retracted medially. The inferior constrictor muscles are divided off of the thyroid ala, and the underlying piriform mucosa is bluntly dissected off of the undersurface of the thyroid cartilage. A similar procedure is carried on the right, where the inferior constrictor muscles are divided off of the thyroid cartilage and the piriform mucosa bluntly dissected off of the deep surface of the thyroid cartilage using a Freer elevator. The entire specimen is now free, except for its pharyngeal mucosal attachments.

At this point, with the cooperation of anesthesia, the trachea is entered transversely between the second and third tracheal cartilages, unless subglottic extension of the tumor exists. An angled cut is then carried out superiorly and posteriorly using Mayo scissors beveling the tracheotomy incision. The endotracheal tube is then slowly removed, and an armored Laryngoflex tube placed in the tracheal stump. Ventilation is then carried out through this for the remainder of the case. A single 2-0 Prolene half mattress suture is placed to stabilize the trachea and begin maturation of the stoma. The posterior wall of the trachea is then sharply transected into the space between the trachea and esophagus, and the party wall between them is identified. Blunt dissection separates the trachea and esophagus to the level of the thyroid cartilage. Attention is then again turned superiorly.

A metal Yankauer suction or Deaver blade is placed through the oral cavity and placed into the vallecula. An incision is made directly onto this retractor entering the pharynx contralateral to the primary tumor. The epiglottis is then identified through the pharyngeal incision and grasped with an Allis clamp. Now with direct visualization through the vallecula, Bovie electrocautery or Harmonic shears are used to cut through the pharyngeal mucosa and underlying musculature. Care should be taken to resect an adequate margin of normal appearing mucosa and also to preserve enough mucosa for later closure. The entire specimen is handed off for permanent pathology review. The entire wound is then irrigated and suctioned clear.

A cricopharyngeal myotomy is then carried out. With one finger inside the esophageal lumen, the cricopharyngeal muscles are identified bilaterally. A 15-blade is used to slowly transect the musculature until adequate release of the constrictor exists.

An NG tube is then placed through a nostril and into the stomach. The pharyngeal defect may be closed linearly or with a T-type closure. (If a TEP is being performed, then pharyngeal closure is performed after maturation of the stoma). A running Connell inverting suture (true or modified) with 3-0 Vicryl is used to close the pharyngeal defect beginning inferiorly. During the course of closure, care must be taken to invert the mucosa after each pass of suture. Once the pharyngotomy is closed, a combination of hydrogen peroxide and water may be placed into the patient's oral cavity, and a bulb syringe is used to insufflate the oropharynx. Any areas of leak are reinforced with 3.0 Vicryl sutures.

Interrupted Lempert or horizontal mattress stitches are then placed through the fascia surrounding the pharyngeal closure in order to reinforce it. Care must be taken during this layer of closure to avoid overtightening because this may cause dysphagia. The entire oral cavity and oropharynx is then irrigated with sterile saline, and the nasogastric tube as well as oral cavity and oropharynx are suctioned free of the peroxide and water solution. The entire wound is copiously irrigated again and suctioned dry.

One or two 10-flat Blake drains are placed through separate stab incisions, being careful not to place the drains directly over the pharyngeal closure. These are secured in place using single 3-0 nylon sutures. The distal tracheal stump, which had been previously secured to the inferior skin flap using a Prolene stitch, is then matured into a tracheal stoma. 2-0 Prolene sutures are placed in a half-mattress fashion to mature the stoma. The cartilaginous trachea is matured to the inferior skin flap.

Once this is complete, the upper skin flap is brought down and secured to the posterior membranous trachea. The neck is then closed in layers bilaterally. The platysma is closed using 3-0 Vicryl in an interrupted fashion. The deep dermal layer is also closed using 4-0 Vicryl in an interrupted fashion. A 5-0 running Prolene, Nylon, or staples is used to close the skin. At this point, the Laryngoflex endotracheal tube is removed, and an 8-cuff Shiley tracheotomy tube is placed and secured with a Velcro neck strap.

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Complications

Hematoma/Seroma

These are rare complications following laryngectomy. [6] Hematomas should be evacuated in the operating room, and any bleeding controlled to prevent airway compromise or pharyngeal closure breakdown.

Wound Dehiscence

This can occur with excessive tension on the skin closure. Local wound care should allow the wound to heal by secondary intention. A regional or free flap such as a pectoralis major flap may be necessary if the carotid artery becomes exposed.

Wound Infection

Fever, erythema, or swelling can indicate a wound infection. Empiric antibiotic therapy should be initiated until more culture directed therapy is available.

Pharyngocutaneous Fistula

Patients with prior radiation therapy, poor nutritional status, hypothyroidism, diabetes, smokers, and positive surgical margins are at higher risk for development of a fistula. Initially, fistula packing with sterile saline soaked gauze and a pressure dressing may lead to closure. More advanced fistulas usually require a pedicled regional flap such as a pectoralis major or trapezius flap.

Stomal Stenosis

The incidence of stomal stenosis has been reported to be as high as 42%. [7] It can be prevented with proper attention to detail during stoma formation. If encountered, V-Y advancement flaps and Z plasties are useful stomaplasty techniques.

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