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Alternative approach to total laryngectomy
ALTERNATIVE APPROACH TO
TOTAL LARYNGECTOMY BARRY L. WENIG, MD
Despite the conventional use of the apron flap incision pronged blunt hook under the lateral cartilaginous edge , and transecting the middle and inferior constrictor musto perform a total laryngectomy, the current preference is that of a horizontal incision at the level of the cricothyroid cles from the greater to the lesser cornua. A peanut dissector is used to bluntly separate the pyriform sinus mumembrane. This allows for separate placement of the stoma at least 5 em below the incision line, thereby sep- , cosa from the cut muscle edge, thereby "stealing" additional mucosa to assist in the closure. arating the two incisions (Fig 1). In the event of develAt this point, the strap muscles are transected approxopment of a fistula postoperatively, the pharyngeal conimately one finger-breadth above the clavicular heads. tents will not spill into the trachea. Furthermore, the The thyroid isthmus is exposed, mobilized off the underhorizontal incision can be extended in either direction to lying trachea, and transected. If the thyroid gland is to incorporate a neck dissection as indicated. be left intact, then the individual lobes are elevated off The procedure is carried out entirely using a Bovie cauthe underlying trachea bilaterally . However, if one Or tery (Valley Lab, Boulder, CO) in the coagulation mode both of the lobes are to be sacrificed, then dissection is (Fig 2). The flaps are elevated in a plane deep to the carried out to incorporate its removal in continuity with platysma muscle to a level slightly above the hyoid bone the laryngeal specimen. With the preservation of one Or superiorly and to the clavicular heads inferiorly. The fascia over the anterior border of the sternocleidomastoid both thyroid lobes comes the obligation of preservation of muscle on the involved side is freed, and the jugulodithe blood supply of the inferior thyroid vessels, as well as gastric groo ve is then palpated for gross cervical adenopelevation of the gland sufficiently posterolateral, to enathy. In the event that no disease is detected, the omoable transection of the trachea without interference. hyoid muscle is isolated and transected. A similar proA separate stomal skin jncision is created, and both the cedure is then performed on the opposite side, thereby skin and the underlying soft tissue are removed in a cirisolating the larynx from the great vessels bilaterally. cular pattern of approximately 2 to 3 cm in diameter. At Attention is then directed towards the superior aspect the level of the third tracheal ring a horizontal incision is of the field, where the hyoid bone is skeletonized by remade between adjacent rings, and a 3-0 nylon suture is placed through the anterior tracheal wall and anchored to leasing the suprahyoid musculature. The greater cornua is dissected free of its attachments and the lateral aspect the skin. This will prevent the trachea from slipping into of the bone is cut with a small bone -cutter to prevent the chest and potentially creating an airway emergency. Following completion of the anterior wall cut, the surdamage to the great vessels by the bone when the larynx is subsequently rotated. Between the greater cornua of geon will then bevel the tracheal cut laterally and supethe hyoid bone and that of the thyroid cartilage, the neuriorly to provide for a greater cross-sectional stomal area . The endotracheal tube is removed from the mouth and an rovascular pedicle is identified, ligated, and divided. The thyroid cartilage is skeletonized by placing a doubleanode tube is placed through the transected trachea. FIGURE 1. A separate horizo ntal incision separated from the stomal incision by at least 5 mm is shown on t e righ t. This is pre ferred ove r the s and ard ap ron incision seen on the eft.
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T RA D I T I O
From the Division of Head and Neck Surgery, Departmen t o f Otolaryngology-Head and Neck Surgery, University of Ill inois College of . edicine at Chicago, Chicago, IL. Address repr int requests to Barry L. Wenig, MD, FACS, 1855 W Taylor St, S ite 2.42, Chicago, IL 60612. :<:> 1990 b)' W.B. Saunders Comp any. 1 43-1810/9010101-00 9505.00/0
A L
T E H
I
A TE
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 1 (MARCH), 1990: PP 45-46
45
FIGURE 3. Shown is the entry through the vallecula following transection of the trachea.
FIGURE 4. A pharyngeal constrictor myotomy is shown performed on the posterolateral wall.
With ventilation continuing in this manner, the tube is sewn to the skin with interrupted 2-0 silk sutures. A tracheal hook is then placed in the anterior wall of the trachea at the most inferior aspect of the specimen and the subglottic space is examined. While upward retraction is maintained, the posterior muscular wall is transected and separated from the party wall of the hypopharynx superiorly to the level of the postcricoid region. The larynx can be entered in one of several ways depending on the location of the tumor. The most common method is to enter through the vallecula in the midline (Fig 3). Once the pharynx has been penetrated, care
46
must be taken not to transect the superior tip of the epiglottis, which is located approximately 4 em above the hyoid bone. Lateral cuts are then created and the lesser or uninvolved side is exposed first. A needlepoint is placed on the cautery to create a more exact cut, and to prevent damage to the mucosa as it is transected. Once the lesser involved side has been treed, a finger is placed in the upper esophagus to prevent its transection and the remaining cuts are carried out under direct visualization. After appropriate irrigation and inspection, frozen section margins are taken and the closure is begun. A finger is replaced in the upper esophagus and the muscular layers are cut down to the mucosa (Fig 4). Similarly, the myotomy is continued superiorly on the posterior pharyngeal wall to the level of the superior constrictor. This maneuver facilitates swallowing and the subsequent development of speech. If voice restoration is to be performed secondarily, then a nasogastric tube is inserted and closure of the pharyngeal mucosa is performed with a running submucosal suture of 3-0 Vicryl without closure of the muscular layer over the pharynx. If a primary tracheoesophageal puncture is planned, then a fistula is fashioned between the posterior tracheal wall and the anterior pharyngeal wall with passage of a 14 red rubber catheter through the fistula and downward into the esophagus. This serves the dual role of acting as a stent to maintain patency, as well as functioning as a feeding tube in the immediate postoperative period. Similarly, the overlying muscle "is not reapproximated. Hemovac (Davol, Cranston, RI) drains are inserted and sutured to the skin, and the subcutaneous and skin layers are then closed. Finally, the stoma is fashioned by using interrupted 3-0 nylon sutures.
TOTAL LARYNGECTOMY: TECHNIQUE
TOTAL LARYNGECTOMY BARRY L. WENIG, MD
Despite the conventional use of the apron flap incision pronged blunt hook under the lateral cartilaginous edge , and transecting the middle and inferior constrictor musto perform a total laryngectomy, the current preference is that of a horizontal incision at the level of the cricothyroid cles from the greater to the lesser cornua. A peanut dissector is used to bluntly separate the pyriform sinus mumembrane. This allows for separate placement of the stoma at least 5 em below the incision line, thereby sep- , cosa from the cut muscle edge, thereby "stealing" additional mucosa to assist in the closure. arating the two incisions (Fig 1). In the event of develAt this point, the strap muscles are transected approxopment of a fistula postoperatively, the pharyngeal conimately one finger-breadth above the clavicular heads. tents will not spill into the trachea. Furthermore, the The thyroid isthmus is exposed, mobilized off the underhorizontal incision can be extended in either direction to lying trachea, and transected. If the thyroid gland is to incorporate a neck dissection as indicated. be left intact, then the individual lobes are elevated off The procedure is carried out entirely using a Bovie cauthe underlying trachea bilaterally . However, if one Or tery (Valley Lab, Boulder, CO) in the coagulation mode both of the lobes are to be sacrificed, then dissection is (Fig 2). The flaps are elevated in a plane deep to the carried out to incorporate its removal in continuity with platysma muscle to a level slightly above the hyoid bone the laryngeal specimen. With the preservation of one Or superiorly and to the clavicular heads inferiorly. The fascia over the anterior border of the sternocleidomastoid both thyroid lobes comes the obligation of preservation of muscle on the involved side is freed, and the jugulodithe blood supply of the inferior thyroid vessels, as well as gastric groo ve is then palpated for gross cervical adenopelevation of the gland sufficiently posterolateral, to enathy. In the event that no disease is detected, the omoable transection of the trachea without interference. hyoid muscle is isolated and transected. A similar proA separate stomal skin jncision is created, and both the cedure is then performed on the opposite side, thereby skin and the underlying soft tissue are removed in a cirisolating the larynx from the great vessels bilaterally. cular pattern of approximately 2 to 3 cm in diameter. At Attention is then directed towards the superior aspect the level of the third tracheal ring a horizontal incision is of the field, where the hyoid bone is skeletonized by remade between adjacent rings, and a 3-0 nylon suture is placed through the anterior tracheal wall and anchored to leasing the suprahyoid musculature. The greater cornua is dissected free of its attachments and the lateral aspect the skin. This will prevent the trachea from slipping into of the bone is cut with a small bone -cutter to prevent the chest and potentially creating an airway emergency. Following completion of the anterior wall cut, the surdamage to the great vessels by the bone when the larynx is subsequently rotated. Between the greater cornua of geon will then bevel the tracheal cut laterally and supethe hyoid bone and that of the thyroid cartilage, the neuriorly to provide for a greater cross-sectional stomal area . The endotracheal tube is removed from the mouth and an rovascular pedicle is identified, ligated, and divided. The thyroid cartilage is skeletonized by placing a doubleanode tube is placed through the transected trachea. FIGURE 1. A separate horizo ntal incision separated from the stomal incision by at least 5 mm is shown on t e righ t. This is pre ferred ove r the s and ard ap ron incision seen on the eft.
J
.
\
,
.--
\
\ \
\
\
\
\
T RA D I T I O
From the Division of Head and Neck Surgery, Departmen t o f Otolaryngology-Head and Neck Surgery, University of Ill inois College of . edicine at Chicago, Chicago, IL. Address repr int requests to Barry L. Wenig, MD, FACS, 1855 W Taylor St, S ite 2.42, Chicago, IL 60612. :<:> 1990 b)' W.B. Saunders Comp any. 1 43-1810/9010101-00 9505.00/0
A L
T E H
I
A TE
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 1 (MARCH), 1990: PP 45-46
45
FIGURE 3. Shown is the entry through the vallecula following transection of the trachea.
FIGURE 4. A pharyngeal constrictor myotomy is shown performed on the posterolateral wall.
With ventilation continuing in this manner, the tube is sewn to the skin with interrupted 2-0 silk sutures. A tracheal hook is then placed in the anterior wall of the trachea at the most inferior aspect of the specimen and the subglottic space is examined. While upward retraction is maintained, the posterior muscular wall is transected and separated from the party wall of the hypopharynx superiorly to the level of the postcricoid region. The larynx can be entered in one of several ways depending on the location of the tumor. The most common method is to enter through the vallecula in the midline (Fig 3). Once the pharynx has been penetrated, care
46
must be taken not to transect the superior tip of the epiglottis, which is located approximately 4 em above the hyoid bone. Lateral cuts are then created and the lesser or uninvolved side is exposed first. A needlepoint is placed on the cautery to create a more exact cut, and to prevent damage to the mucosa as it is transected. Once the lesser involved side has been treed, a finger is placed in the upper esophagus to prevent its transection and the remaining cuts are carried out under direct visualization. After appropriate irrigation and inspection, frozen section margins are taken and the closure is begun. A finger is replaced in the upper esophagus and the muscular layers are cut down to the mucosa (Fig 4). Similarly, the myotomy is continued superiorly on the posterior pharyngeal wall to the level of the superior constrictor. This maneuver facilitates swallowing and the subsequent development of speech. If voice restoration is to be performed secondarily, then a nasogastric tube is inserted and closure of the pharyngeal mucosa is performed with a running submucosal suture of 3-0 Vicryl without closure of the muscular layer over the pharynx. If a primary tracheoesophageal puncture is planned, then a fistula is fashioned between the posterior tracheal wall and the anterior pharyngeal wall with passage of a 14 red rubber catheter through the fistula and downward into the esophagus. This serves the dual role of acting as a stent to maintain patency, as well as functioning as a feeding tube in the immediate postoperative period. Similarly, the overlying muscle "is not reapproximated. Hemovac (Davol, Cranston, RI) drains are inserted and sutured to the skin, and the subcutaneous and skin layers are then closed. Finally, the stoma is fashioned by using interrupted 3-0 nylon sutures.
TOTAL LARYNGECTOMY: TECHNIQUE