DANIEL L. PRICE: Hi. My name is Dan Price. We'll be doing a total laryngectomy today. This is a patient with a T4 larynx cancer, never had any prior treatment. Preoperative evaluation includes office and operative endoscopy to understand the extent of the tumor and the extent of resection required. Patient has extralaryngeal extension, as can be seen here on the CT scan. Is not a candidate for laryngeal preservation surgery or therapy.
We try to make a separate neck incision from the stoma and have at least 3 centimeters of skin between these to preserve the blood supply to the skin between the neck incision and the stoma. This decreases the rate of fistulization. Flaps are elevated for the neck dissection. The hyoid bone is identified and palpated.
We divide all of the strap muscles. There's really no utility to preserving strap muscle for closure or reconstruction, and dividing these as close to their origins and insertions is helpful. Sternal hyoid and sternal thyroid muscles are divided inferiorly. With a subglottic tumor or extralaryngeal extension, least hemithyroidectomy on the side of the tumor should be performed.
One has to use caution not to injure the 12th cranial nerve. So the hypoglossal nerves should be identified on both sides. The vascular pedicles should be divided superiorly. This process is repeated on both sides. The omohyoid are divided inferiorly.
The pharyngeal constrictor should be divided off of the thyroid cartilage. You can preserve some of this musculature for your closure, as well as some of the periosteum, if there's not tumor involvement in these regions. So I will dissect down to the lateral aspect of the thyroid cartilage and then dissect in a subperichondrial plane.
Superiorly, the piriform sinus mucosa is surprisingly close to that superior thyroid cornu, and so taking some extra time to not create a pharyngotomy here is worthwhile, as you'll have to resect those areas if you create pharyngotomies. Otherwise, you increase your risk of fistulization.
So here the inner perichondrium is bluntly dissected off of the thyroid cartilage on the opposite side of the tumor. Because there's a significant amount of tumor on the contralateral side, a lot of this work will be done after we've visualized the tumor on the side of the tumor. At this junction, we perform the tracheotomy.
No Bjork flap should be performed. It's important to try to avoid performing a tracheotomy prior to surgery, as this increases the risk of recurrence. We performed laryngoscope and know the extent of the tumor inferiorly and perform the tracheotomy as high as possible, achieving a adequate surgical margin. This gets the endotracheal tube out of the way. We'll now dissect down to the hyoid bone and release the suprahyoid musculature. Again, awareness of the location of the hypoglossal nerves should be kept in mind here.
Similar to the thyroid cornu, when you take out the cornu of the hyoid bone, it can be tucked into the pharyngeal mucosa and you can make an incidental pharyngotomy. So you want to stay on the exterior surface or lateral surface of the hyoid bone as you dissect it out. And then as you work on the deep surface of the hyoid bone, stay in very close proximity to the bone.
Here you can see the shiny hyoepiglottic ligament. So we divide the hyoglossus muscle and enter into the vallecula. The mucosa of the vallecula contralateral to the tumor is entered so that cuts around the tumor can be made under direct visualization. Here you can see inserting the digit into the piriform sinus, and then under direct visualization cutting along the hyoepiglottic ligament, preserving as much of the normal mucosa as possible, which will allow you to have a linear pharyngotomy closure at the end of the procedure.
Between my index finger and thumb is the tumor as it extends out laterally, and these pharyngeal mucosa cuts are made under direct visualization, maintaining as many centimeters as possible around the tumor. You can see tumor in the postcricoid area here as well, and that mucosa should be resected. We then need to enter into the partition between the trachea and the esophagus. This can usually be done bluntly. Again, most of the postcricoid mucosa is normal, and so under direct visualization, we sharply divide that so that we maintain as much mucosa as is oncologically responsible to make for a tension-free, watertight closure.
Keeping my finger in the esophagus as we then elevate off the partition between the membranous trachea and the esophagus, delivering the laryngeal specimen. The specimen is inspected for any close margins. Margins are taken off the primary specimen, the tracheal or subglottic margin examined.
The stoma is then fashioned, again, a circular stoma about 2 centimeters in diameter, reserving 2 to 3 centimeters of skin between, so that skin is well vascularized. The stoma is matured with absorbable sutures. Here, I'm using VICRYL, although I'll often use chromic sutures, as I find the VICRYL sutures stay too long the patients get small abscesses around these, and chromics are perfectly adequate. The suturing is done to cover the edges of cartilage with a vertical mattress suture, bringing the suture around a ring of the trachea to secure it. This will help prevent infection as well as stenosis.
Cricopharyngeal myotomy is performed, inserting a digit into the esophagus. The cricopharyngeal muscle can be easily felt here. We cut it sharply, preserving the esophageal mucosa, avoiding a full thickness defect.
You can see that there's still constriction at the inferior aspect of my digit. You have to get this entire muscle. The patient may have speech problems post operatively. That optimizes their tracheoesophageal speech.
Ideally, the pharyngotomy is closed over a feeding tube in a linear fashion, avoiding a T closure, as the trifurcation is an area of weakness, most likely to break down. You want to invert the mucosa. This can be done with a variety of stitches. Here we do a stitch that is a running inverted stitch. You go through the muscle edge and out through the muscle, and then cross over to the other side, going through the muscle edge to invert and not have mucosa in your closure, which will increase your risk of a leak.
As you reach the most cephalad aspect, you then include the mucosa of the tongue base in the vallecula. Whenever possible, I will try to do a second layer of closure, using the pharyngeal constrictor muscles to bolster your mucosal closure. If the patient has had prior irradiation, they should get a pec flap, and this has been shown to decrease the rate of fistulization by nearly half.
Skin closure's then done in the standard fashion. Suction drains are placed. Patient is admitted for laryngectomy care and teaching. Postoperatively, we'll perform a swallow study, about 7 to 10 days in a primary patient.
Key points for total laryngectomy include performing endoscopy pre-operatively or interoperatively to understand the extent of tumor, doing a separate stomal incision from the neck dissection, incision creates a better stoma with less risk of salivary fistula. Preserving as much normal mucosa as possible allows for a tension-free, watertight closure and decreases your risks of a fistula.
Complete cricopharyngeal myotomy should be performed to maximize the patient's tracheoesophageal speech. And patients who have had prior chemoradiation therapy should have pectoralis flap or other free tissue coverage to decrease the risk of fistulization. Thank you for watching.
