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
Thank you
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