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Total laryngectomy: Technique
TOTAL LARYNGECTOMY: TECHNIQUE HARVEY M. TUCKER, MD
Total laryngectomy is the baseline procedure against which all less radical resections for cancer of the larynx must be measured. Key points in its performance are: the use of an apron flap; a posterior "tongue" of mucous membrane to increase cross-sectional area of the stoma without exposing cartilage; removal of the larynx from below upward to preserve maximal mucous membrane while providing adequate exposure of tumor; and "vest over pants" suturing of skin margins to the stoma to provide coverage and allow retraction of the stoma into the mediastinum after complete healing. KEY WORDS: Baseline procedure/mucosal preservation/inferior approach/ovoid stoma.
Total laryngectomy remains the baseline procedure against which all other conservation or subtotal resections for laryngeal cancer must be measured. Any malignancy of the larynx that cannot be adequately removed by this approach is, by definition, unresectable. The basic technique1,2 is virtually unchanged since 1900, when the essentials of the modern procedure had been developed by Solis-Cohen and Sorenson.
PROCEDURE PLANNING INDICATIONS 1. Lesions too extensive for adequate removal by subtotal procedures. 2. Lesions otherwise appropriate for subtotal resection, but medical status, age, or personal preference do not permit acceptance of the added risks and complications that more often accompany conservation procedures. 3. Salvage surgery after failed radiation (although some radiation failures are still amenable to conservation procedures). 4. Palliative local control of disease.
CONTRAINDICATIONS 1. Lesions too extensive for complete resection of local disease. 2. Unacceptable medical risk. 3. Patient refusal.
TECHNIQUE Although many incisions may be employed, an apron flap provides excellent exposure with no trifurcations. Moreover, the stoma may be placed in the lower portion From the Department of Otolaryngology and Communicative Disorders, the Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to H.M. Tucker MD, Chairman, Department of Otolaryngology and Communicative Disorders, Desk A-71 , Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. © 1990 by W.B. Saunders Company. 1043-1810/90/0101-0001$5.00/0
42
of the flap and the flap can be readily shifted or extended to either side if radical neck dissection is required (Fig 1). Once the flap has been elevated in the plane deep to the platysma muscle to expose the hyoid bone, neck dissection can be performed, if indicated. The strap muscles are transected at or below the level of the anticipated stoma and the great vessels are mobilized and displaced laterally. Next, the thyroid isthmus is mobilized and either fransected if the gland is to be left intact or removed in continuity with the lobe to be resected with the laryngeal specimen (Fig 2). On the involved side, the inferior thyroid vessels are identified and transected, and the gland is mobilized from lateral to medial, leaving it in contact with the upper trachea to be resected. On the side to be preserved, it is mobilized off the trachea from medial to lateral and left with its blood supply intact. At a point below the second tracheal ring or, if necessary to gain clearance of subglottic extension, as low as individual anatomy will permit the trachea can then be transected to establish the stoma. Rather than cutting the trachea on the bevel to provide a greater cross-sectional area of stoma, the surgeon may divide it horizontally between adjacent rings just to the point where the tracheal cartilages join the membranous posterior portion of the lumen. At this point, a tongue-like superior projection of the membranous wall can be designed to increase stomal area without cutting or exposing cartilage (Fig 3). The anterior distal tracheal wall can now be anchored to the midline skin of the lower flap (Fig 4) with interrupted sutures of 2-0 silk, as placed in Fig 5. This technique not only covers the exposed edges of the transected trachea with skin, but permits eventual retraction of the suture line down into the upper mediastinum in order to minimize exposure, crusting, and irritation of the mucosa. The oral endotracheal tube is removed and replaced with a sterile one in the partially completed stoma. The remaining posterior stomal wall closure is accomplished at the time of return of the apron flap. The hyoid bone is skeletonized by releasing the suprahyoid muscles from its upper surface, usually with a cutting cautery (Fig 6). The greater cornua are identified and undercut toward the lesser cornua, during which maneuver the superior neurovascular bundle is usually encountered and can be suture ligated and divided. The thyroid cartilage is skeletonized by dividing the fibers of the inferior and middle constrictor muscles along both peste-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 1 (MARCH), 1990: PP 42-44
FIGURE 2. Strap muscles are transected low in the neck. Thyroid isthmus may be divided in the midline or to either side as required by extent and location of laryngeal disease. FIGURE 1. Apron flap is preferred for total laryngectomy. It may be shifted laterally when radical neck dissection is indicated.
FIGURE 4. Anterior wall of stoma is anchored to lower neck skin with interrupted 2-0 silk sutures.
FIGURE 3. Trachea is transected between cartilages and a "tongue" ,of posterior wall is left to increase cross-sectional area of StO•..3.
~
FIGURE 5. Modified vertical mattress sutures draw skin over cut edge of cartilage and permit retraction of suture line into upper mediastinum to minimize exposure of mucosa. TUCKER
43
FIGURE 6. Hyoid bone is freed from suprahyoid muscles with cutting cautery. FIGURE 7. Total laryngectomy from below upward. Note that party wall between the posterior aspect of the trachea and esophagus is maintained.
rll l.~'~~ ./1
,I ~.~~ Iii I, ,~"--=-"m
FIGURE 8. Transection of base of tongue attachments anterior to epiglottis and above the freed hyoid bone. This approach permits maximal preservation of hypopharyngeal mucosa.
is reached to enter the hypopharynx, usually at the lower border of the cricoid cartilage . At this point, a transverse incision is made in the mucosa of the hypopharynx to enter the lumen. Scissors are used to divide the remaining mucosal attachments, by placing one blade in and one blade out. The blades are directed superiorly, hugging the posterior margins of the thyroid alae first on one side and then on the other. In this manner, the larynx is gradually opened towards the epiglottis. When this structure can be visualized and grasped, it is inverted and further scissor dissection is directed across the base of the tongue attachment, anterior to the epiglottis and inferior to the hyoid bone (Fig 8). Closure is begun after inspection and frozen section margins reveal no residual tumor. A nasogastric tube is passed and the mucosa of the pharynx is closed using a Connell-type of running, 3-0 chromic catgut suture. Although a simple horizontal or vertical suture line would be desirable, most often a Y-shaped closure results. The muscular layer should not be closed as this may interfere with development of a good vibratory segment should a "duck-bill" prothesis be used for restoration of voice.
f Ir:
DISCUSSION rior margins from the greater to the lesser cornua. If tumor involves the pyriform sinus, skeletonization is avoided on that side. The larynx can now be entered in any of several ways . The inferior approach permits maximal preservation of pharyngeal mucosa and an approach to most tumors under direct vision from an uninvolved area, except in those relatively uncommon cases wherein there is postcricoid involvement. The loose areolar tissue of the party wall between the trachea and esophagus is entered just superior to the upper end of the stoma (Fig 7). By placing an index finger or retractor into the proximal tracheal lumen, traction can be applied to permit blunt dissection of the entire party wall from below upward. The anterior wall of the esophagus is preserved until the appropriate level
44
Total laryngectomy remains a necessary procedure in the treatment of a majority of carcinomas of the larynx, particularly when radiation for cure has been tried and failed. With the advent of prosthetic restoration of voice, this procedure need not be a terrible detriment to a full and productive life after cure of laryngeal cancer. Attention to details of technique and proper selection of patients can result in good cure rates, and minimize postoperative complications.
REFERENCES 1. Tucker HM: The Larynx, Thieme, New York, NY, 1987 2. Silver CE: Surgery for Cancer of the Larynx, Churchill Livingston e, New York, NY, 1981
TOTAL LARYNGECTOMY
Total laryngectomy is the baseline procedure against which all less radical resections for cancer of the larynx must be measured. Key points in its performance are: the use of an apron flap; a posterior "tongue" of mucous membrane to increase cross-sectional area of the stoma without exposing cartilage; removal of the larynx from below upward to preserve maximal mucous membrane while providing adequate exposure of tumor; and "vest over pants" suturing of skin margins to the stoma to provide coverage and allow retraction of the stoma into the mediastinum after complete healing. KEY WORDS: Baseline procedure/mucosal preservation/inferior approach/ovoid stoma.
Total laryngectomy remains the baseline procedure against which all other conservation or subtotal resections for laryngeal cancer must be measured. Any malignancy of the larynx that cannot be adequately removed by this approach is, by definition, unresectable. The basic technique1,2 is virtually unchanged since 1900, when the essentials of the modern procedure had been developed by Solis-Cohen and Sorenson.
PROCEDURE PLANNING INDICATIONS 1. Lesions too extensive for adequate removal by subtotal procedures. 2. Lesions otherwise appropriate for subtotal resection, but medical status, age, or personal preference do not permit acceptance of the added risks and complications that more often accompany conservation procedures. 3. Salvage surgery after failed radiation (although some radiation failures are still amenable to conservation procedures). 4. Palliative local control of disease.
CONTRAINDICATIONS 1. Lesions too extensive for complete resection of local disease. 2. Unacceptable medical risk. 3. Patient refusal.
TECHNIQUE Although many incisions may be employed, an apron flap provides excellent exposure with no trifurcations. Moreover, the stoma may be placed in the lower portion From the Department of Otolaryngology and Communicative Disorders, the Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to H.M. Tucker MD, Chairman, Department of Otolaryngology and Communicative Disorders, Desk A-71 , Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. © 1990 by W.B. Saunders Company. 1043-1810/90/0101-0001$5.00/0
42
of the flap and the flap can be readily shifted or extended to either side if radical neck dissection is required (Fig 1). Once the flap has been elevated in the plane deep to the platysma muscle to expose the hyoid bone, neck dissection can be performed, if indicated. The strap muscles are transected at or below the level of the anticipated stoma and the great vessels are mobilized and displaced laterally. Next, the thyroid isthmus is mobilized and either fransected if the gland is to be left intact or removed in continuity with the lobe to be resected with the laryngeal specimen (Fig 2). On the involved side, the inferior thyroid vessels are identified and transected, and the gland is mobilized from lateral to medial, leaving it in contact with the upper trachea to be resected. On the side to be preserved, it is mobilized off the trachea from medial to lateral and left with its blood supply intact. At a point below the second tracheal ring or, if necessary to gain clearance of subglottic extension, as low as individual anatomy will permit the trachea can then be transected to establish the stoma. Rather than cutting the trachea on the bevel to provide a greater cross-sectional area of stoma, the surgeon may divide it horizontally between adjacent rings just to the point where the tracheal cartilages join the membranous posterior portion of the lumen. At this point, a tongue-like superior projection of the membranous wall can be designed to increase stomal area without cutting or exposing cartilage (Fig 3). The anterior distal tracheal wall can now be anchored to the midline skin of the lower flap (Fig 4) with interrupted sutures of 2-0 silk, as placed in Fig 5. This technique not only covers the exposed edges of the transected trachea with skin, but permits eventual retraction of the suture line down into the upper mediastinum in order to minimize exposure, crusting, and irritation of the mucosa. The oral endotracheal tube is removed and replaced with a sterile one in the partially completed stoma. The remaining posterior stomal wall closure is accomplished at the time of return of the apron flap. The hyoid bone is skeletonized by releasing the suprahyoid muscles from its upper surface, usually with a cutting cautery (Fig 6). The greater cornua are identified and undercut toward the lesser cornua, during which maneuver the superior neurovascular bundle is usually encountered and can be suture ligated and divided. The thyroid cartilage is skeletonized by dividing the fibers of the inferior and middle constrictor muscles along both peste-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 1 (MARCH), 1990: PP 42-44
FIGURE 2. Strap muscles are transected low in the neck. Thyroid isthmus may be divided in the midline or to either side as required by extent and location of laryngeal disease. FIGURE 1. Apron flap is preferred for total laryngectomy. It may be shifted laterally when radical neck dissection is indicated.
FIGURE 4. Anterior wall of stoma is anchored to lower neck skin with interrupted 2-0 silk sutures.
FIGURE 3. Trachea is transected between cartilages and a "tongue" ,of posterior wall is left to increase cross-sectional area of StO•..3.
~
FIGURE 5. Modified vertical mattress sutures draw skin over cut edge of cartilage and permit retraction of suture line into upper mediastinum to minimize exposure of mucosa. TUCKER
43
FIGURE 6. Hyoid bone is freed from suprahyoid muscles with cutting cautery. FIGURE 7. Total laryngectomy from below upward. Note that party wall between the posterior aspect of the trachea and esophagus is maintained.
rll l.~'~~ ./1
,I ~.~~ Iii I, ,~"--=-"m
FIGURE 8. Transection of base of tongue attachments anterior to epiglottis and above the freed hyoid bone. This approach permits maximal preservation of hypopharyngeal mucosa.
is reached to enter the hypopharynx, usually at the lower border of the cricoid cartilage . At this point, a transverse incision is made in the mucosa of the hypopharynx to enter the lumen. Scissors are used to divide the remaining mucosal attachments, by placing one blade in and one blade out. The blades are directed superiorly, hugging the posterior margins of the thyroid alae first on one side and then on the other. In this manner, the larynx is gradually opened towards the epiglottis. When this structure can be visualized and grasped, it is inverted and further scissor dissection is directed across the base of the tongue attachment, anterior to the epiglottis and inferior to the hyoid bone (Fig 8). Closure is begun after inspection and frozen section margins reveal no residual tumor. A nasogastric tube is passed and the mucosa of the pharynx is closed using a Connell-type of running, 3-0 chromic catgut suture. Although a simple horizontal or vertical suture line would be desirable, most often a Y-shaped closure results. The muscular layer should not be closed as this may interfere with development of a good vibratory segment should a "duck-bill" prothesis be used for restoration of voice.
f Ir:
DISCUSSION rior margins from the greater to the lesser cornua. If tumor involves the pyriform sinus, skeletonization is avoided on that side. The larynx can now be entered in any of several ways . The inferior approach permits maximal preservation of pharyngeal mucosa and an approach to most tumors under direct vision from an uninvolved area, except in those relatively uncommon cases wherein there is postcricoid involvement. The loose areolar tissue of the party wall between the trachea and esophagus is entered just superior to the upper end of the stoma (Fig 7). By placing an index finger or retractor into the proximal tracheal lumen, traction can be applied to permit blunt dissection of the entire party wall from below upward. The anterior wall of the esophagus is preserved until the appropriate level
44
Total laryngectomy remains a necessary procedure in the treatment of a majority of carcinomas of the larynx, particularly when radiation for cure has been tried and failed. With the advent of prosthetic restoration of voice, this procedure need not be a terrible detriment to a full and productive life after cure of laryngeal cancer. Attention to details of technique and proper selection of patients can result in good cure rates, and minimize postoperative complications.
REFERENCES 1. Tucker HM: The Larynx, Thieme, New York, NY, 1987 2. Silver CE: Surgery for Cancer of the Larynx, Churchill Livingston e, New York, NY, 1981
TOTAL LARYNGECTOMY