Total Laryngectomy an overview

Dr T Balasubramanian

History

1866 Patrick watson credited with the first laryngectomy

1873 Billroth of Vienna performed total laryngectomy on a pt with growth larynx

Bottini of Turin has the longest surviving record of a total laryngectomy pt 10 yrs

ActuallyPerformedtracheostomy

History (Contd) Gluck's hypothesis

Discovered 50% mortality rates when laryngectomy pts were studied

Suggested two stage procedure

Stage I Tracheal separation

Stage II Total laryngectomy 2 weeks later

This staging ensured that tracheo cutaneous fistula healed before the actual laryngectomy surgery

History (Contd) Sorenson's contribution

Sorenson was the student of Gluck

1890 He popularized single staged procedure

Still practised incision was first conceived by him

Total laryngectomy not preferred?

Organ preservation is the order of the day

Partial laryngectomy and near total laryngectomy are commonly performed

Permanent tracheostomy is avoided

Indications

Advanced laryngeal malignancies with extensive cartilage destruction and extra laryneal spread

Involvement of posterior commissure / both arytenoids

Circumferential submucosal disease with / without vocal fold paralysis

Subglottic extension to involve cricoid cartilage

Indications (Contd)

Completion procedure after failed partial laryngectomy / irradiation

Hypopharyngeal tumors originating / spreading to post cricoid area

Radiation necrosis of larynx unresponsive to antibiotics / hyperbaric oxygen therapy

Severe aspiration following partial / near total laryngectomy

Massive nodal metastasis

Selection criteria

Pt should be fit for general anaesthesia

Pt should be motivated for post surgical life

Hands and fingers should be dexterous since handling of tracheatosmy tubes need to be done on a daily basis

Positive biopsy

Screening for metastasis

Second primary to be ruled out in all these cases

Air way assessment

Pts with stridor should undergo preliminary tracheostomy under LA

Skin incision should be sited at the level of future permanent tracheostome

Bipedicled skin bridge between skin flap and tracheostomy site should be avoided

Position

Supine

Mild extension of neck

Ryles tube to be inserted prior to surgery

Incision choice

Whether pt has been irradiated / not

Whether block neck dissection has been planned along with total laryngectomy

Types of incision

Gluck Sorenson

Vertical

Double horizontal

Crile Y incision

Low neck horizontal

Gluck Sorenson incision

U shaped

Stoma is incorporated into the incision

Vertical Limb situated just medial to medial border of sternomastoid muscle

Highest limit is the mastoid process on both sides

Horizontal limb encircles tracheostome

Advantage of Gluck Sorenson Incision

Provides good exposure

Three point junction is avoided

Pharyngeal closure line is entirely within the apron flap

Since the plane of elevation is subplatysmal the vascularity of the flap is not compromised

Flap elevation

Flap is elevated in the subplatysmal plane and stitched out of the way

Anterior jugular vein and Delphian node is left undisturbed. They can be removed along with specimen

Flap sutured

Flap elevation (Contd)

Medial border of sternomastoid identified on each side

General investing layer of cervical fascia is incised vertically from the hyoid bone above to the clavicle below

Omohyoid muscle is divided at this stage

This enables entry into the loose areolar compartment of neck

Loose areolar compartment Boundaries

Laterally sternomastoid muscle and carotid sheath

Medially visceral compartment of neck containing pharynx and larynx

Division of strap muscles

Muscles are divided close to their sternal margins

Division of strap muscles exposes thyroid gland

Thyroid

Total / hemithyroidectomy

Massive midline / bilateral tumors Total thyroidectomy preferred

Unilateral laryngeal tumors Hemithyroidectomy is preferred

Total thyroidectomy

Middle thyroid vein secured

Both superior and inferior thyroid vascular pedicles

Parathyroid glands should be preserved

Hemithyroidectomy

On the side of preservation the superior pedicle and middle thyroid vein alone are clamped leaving the inferior pedicle intact

One half of the thyroid gland is removed by sectioning the isthumus

Thyroid mobilization

Middle thyroid vein

Recurrent laryngeal nerve and inf pedicle

Parathyroid

Suprahyoid dissection

Hyoid bone is skeletonized

Mylohoid, geniohyroid, digastric sling and hyoglossus separated from hyoid from medial to lateral

Pharynx is entered and epiglottis is delivered into the neck

Sternohyoid and thyrohyoid muscle attachments to the inferior border of hyoid bone

Suprahyoid dissection

Skeletonization of larynx

Posterior border of thyroid cartilage is rotated anteriorly

Constrictor muscles released from superior and inferior cornu by sharp dissection

Laryngeal branch of superior thyroid artery should be identified and ligated before it penetrates the thyrohyoid membrane

Epiglottis delivery

High pharyngeal entry is made avoiding preepiglottic space.Epiglottis is visualizedSurgeon moves to head end and grasps the epiglottis with a forceps

Head end dissection

Larynx removal

From above downwards

Epiglottis is held with a forceps and pulled forwards

Pharyngeal mucosa cut laterally with scissors on both sides of epiglottis aiming towards the superior cornua of thyroid cartilage

Constrictor muscles are divided along the posterior edge of thyroid cartilage

Pharyngeal cuts

Lateral cuts are joined by horizontal

Horizontal cut is given just below the level of arytenoid cartilages

Larynx separated by incising the tracheal rings (between 1st and 2nd )

Pharyngeal defect

Pharyngeal closure

Vertical

T shaped closure (3 point junction) seen

3-0 vicryl is used

Extramucosal connel suture is performed

Suture knots should be inside

Pharyngeal closure can be reinforced using cervical fascia and muscle layers

Connel suture

T shaped closure

Skin flap closure

Skin flap is repositioned

Flap is sutured after anchoring the tracheostome

Suction drain is placed in the neck to prevent hematoma formation that could compromise the flap

Complications

Drain failure

Hematoma

Skin flap infection

Pharyngocutaneous fistula -after 2nd week. Common in irradiated pts

Flap necrosis

Tracheal stenosis

Oesophageal stenosis

Hypothyroidism / Hypoparathyroidism

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