Laryngectomy - Total

Considerations

• • Indications

    • Advanced laryngeal carcinoma

    • tumors with cartilage destruction and anterior spread outside the larynx

    • posterior commissure or bilateral arytenoid joint involvement

    • circumferential submucosal disease

    • subglottic extension with extensive invasion of the cricoid cartilage

    • Surgical salvage after failed radiation or partial laryngectomy 

    • Extralaryngeal cancer that invade the larynx

    • Atypical laryngeal cancer, such as adenocarcinoma, which is less radiosensitive 

    • Radiation necrosis 

    • Severe aspiration 

• Contraindications

  • Extensive primary tumor than cannot be resected 

  • Distant metastasis

    • Second primaries

• Lines of tumor resection

  • • Use imaging and palpation to determine the extent of the primary tumor and imagine the resection margins 

• Neck dissection

  • T1 or T2 glottic cancer - Routine elective neck dissection (levels 2-4) is not required

  • Supraglottic cancers, hypopharyngeal cancers, and T3 or T4 glottic cancers - Perform elective neck dissection for the clinically N0 neck

    • Advanced unilateral glottic

      • Perform ipsilateral levels 2-4

    • Advanced supraglottic, hypopharyngeal, bilateral glottic

      • Perform bilateral level 2-4 

      • Perform  level 6, for cancer of the subglottis or pyriform recess

  • Thyroid 

    • Remove the ipsilateral thyroid

  • Reconstruction - regional and / or free flap closure is necessary when

  • Primary closure is not possible

  • The hypopharynx is compromised, especially near or at the cricopharyngeus 

  • Salvage larygnectomy is performed, to reduce fistula rate 

  • Voice and swallow rehabilitation

    • Complete pre-operative Speech and Swallow Therapist counseling 

    • Optimize swallowing outcome during the TL

      • Cricopharyngeal myotomy

      • eMedicine - Cricopharyngeal Myotomy

      • Pharyngeal neurectomy

      • 2003: Comparison of pharyngoesophageal segment pressure in total laryngectomy patients with and without pharyngeal neurectomy

    • Options 

      • TEP - Primary vs secondary

      • 2016: Primary tracheoesophageal puncture and cricopharyngeal myotomy in stapler-assisted total laryngectomy

      • Electrolarynx

      • Esophageal speech

  • Pre-operative labs 

  • Ca, PTH, TSH if concerned or status post radiation 

    • Prealbumin, Albumin for nutritional assessment 

  • Peri-operative antibiotics

    • Administer pre-incision antibiotics for broad-spectrum, including anaerobic, coverage and continue for 24 hours post-op

Preparation

• • Communicate with anesthesia regarding the airway plan

    • If needed, prepare for awake tracheostomy to start the case

    • Otherwise, regular ETT

  • Positioning 

    • Supine with shoulder roll

    • Rotate bed 180 degrees 

  • Lines

    • Foley

    • A-line

  • Nerve monitoring

    • For planned neck dissections, monitor the MMN and SAN

  • Mark the incision

    • Plan the horizontal tracheostomy incision

    • Plan the apron incision

  • Note on the incision design

    • • Some include the tracheostomy incision in the apron incision while other keep the separate

      • If keep separate, place the trach incision 1.5 cm inferior to the apron incision

      • The trach incision may be placed about 2 fingerbreadths inferior to the cricoid 

      • Some prefer a linear incision while others (Dr. Wang) design a semi-circle skin excision 

    • Articles

    • 2015: Neck incision planning for total laryngectomy: A finite element analysis

    • 2016: Neck Incision Planning for Total Laryngectomy with Pharyngectomy

• Local anesthesia

  • • Infiltrate the planned incision with 1% Lidocaine with 1:100,000 Epinephrine 

• Equipment 

• • DL, bronchscopy, esophagoscopy tray and camera with Hopkins rod

    • Setup the computer for recording photos into the chart 

  • Head and neck major tray 

  • Micro tray x 2, if harvesting a free flap for reconstruction

  • Foley catheter, large and small syringe (to inflate foley balloon and instill the methylene blue)

  • 12 Fr dobhoff feeding tube

  • If using stapler technique

    • Covidien 60 mm x 3.5 mm TA stapler with DST series technology

  • Prep and drape

  • Sterilize entire anterior neck, mentum to sternum 

    • Sterilize the chest if a pec flap is possible 

  • Standard draping of the bilateral neck towels and staples

Procedure

• • Mindset - Think "it's OK to go fast"

    • The majority of the extirpation can be done quickly with sharp and / or electrocautery dissection 

    • Structures to mind and slow down for

      • Hypoglossal nerve

      • Lingual artery

      • STA on the side of thyroid preservation

      • Paraythryoid glands on the side of thyroid preservation

      • Pyriform mucosa, especially on the "normal" side, away from the cancer

      • Vessels: EJV and Facial vessels, given these may be used for anastomoses for any free flap reconstruction 

• Recommended: Repeat triple endoscopy to double check accurate staging and judge your lines of resection

  • • Key: Know the tumor's boundaries; Be particular about the vallecula, pyriform recess, and post-cricoid areas

• Perform a tracheostomy

• • Optional: Perform awake, especially if the tumor obstructs the airway significantly 

  • Make the apron flap incision

  • Perform a subplatysmal dissection of the flap

    • Superiorly, elevate above the level of the hyoid to expose bilateral SCM

    • Inferiorly, elevate to the sternum and clavicles 

    • Retract the flaps with Lone Stars or sutures 

  • Divide the superficial layer of the deep cervical fascia starting 1 cm posterior to the anterior edge of the SCM

• Divide the anterior jugular veins

• • Expose the sternocleidomastoid muscle by incising its fascia superiorly and inferiorly

  • Dissect the “outer tunnels”

    • Bluntly dissect between the SCM and strap muscles to the free the medial contents of the neck

    • Identify the carotid sheath and laryngotreacheal complex 

  • Incise the strap muscles and elevate them off the thyroid gland

    • The strap muscles are usually divided at the level of the tracheostomy stoma 

  • Approach the thyroid gland from its lateral aspect

    • Identify its pedicle, the STA

  • Divide the thyroid isthmus and free the thyroid lobe to be preserved

    • Free the contralateral thyroid lobe and preserve its vascular pedicle

      • Sweep it off the trachea making effort to preserve the associated parathyroids

    • Leave the ipsilateral thyroid lobe attached to the specimen

  • Bluntly dissect the "inner tunnels" between the carotid sheath and larynx along the prevertebral fascia

  • Identify the superior laryngeal neurovascular bundle, which penetrates the thyrohyoid membrane  

  • Divide the superior laryngeal artery, vein, and nerve superior to the level of greater cornu of the hyoid 

  • Expose and free the body and greater cornu of the hyoid bone

    • Grasp the hyoid with a tenaculum or Allis clamp

    • Leave the hyoid attached to the thyrohyoid membrane and strap muscles 

    • Release the central hyoid first, then lateral cornua 

    • Pull the lateral cornua away from the hypoglossal nerve and lingual artery

    • Free the cornu by dividing by dividing its attachments on the bone

      • Some do this bluntly with a Freer or the handle of a Metz versus using a Bovie

      • The key is to avoid coming off the bone and injuring the hypoglossal nerve and / or lingual artery

  • Rotate the thyroid cartilage using a hook under the lateral aspect of the ala

• Divide the constrictor muscles along the lateral border of the thyroid cartilage

• • Elevate the pyriform mucosa and superior cornu from thyroid cartilage using a Freer

    • Preserve the mucosa unless the ipsilateral pyriform is involved 

  • Divide the trachea transversely between the second and third ring (or, take as many rings as needed to ensure adequate surgical margins)

    • Stapler technique (YouTube (15:49) - 25-YEAR EXPERIENCE OF USING A LINEAR STAPLER IN LARYNGECTOMY)

      • Once the trachea is incised and the distal trachea is re-cannulated with armored tube, then one surgeon scrubs out to do a DL to visualize the epiglottis

      • The assistant surgeon stays sterile and through the lumen of the trachea, use a single prong skin hook to grasp the epiglottis and evert it into the larynx under direct visualization. 

      • Maintain cephalad traction of the entire specimen while retaining the epiglottis retracted

        • Alternate "semi-closed" method: Make a mini-median pharyngotomy along the vallecula epiglottica through which the apex of the epiglottis is identified and everted and sutured to the specimen and then the stapler is engaged

        • 2007: Linear stapler closure of the pharynx during total laryngectomy: a 15-year experience (from closed technique to semi-closed technique)

      • Insert the Covidien TA stapler (60 mm x 3.5 mm) along the posterior surface of the specimen and take care to ensure the epiglottis is with the specimen

      • Engage the stapler and deploy staples

      • Use 15 blade to incise the specimen off the superior aspect of the stapler

      • Release stapler

      • Inspect wound closure (consider further locking running suture as back up) and specimen to ensure epiglottis is with specimen

        • if epiglottis is accidentally left behind, then may need to resect it with TLM and TLM accessory tray using a bovie under direct visualization through the mouth

      • Proceed as below regarding checking your seal

      • Other articles

      • 2013: Comparison of complication rates associated with stapling and traditional suture closure after total laryngectomy for advanced cancer

      • 2014: Efficacy of stapler pharyngeal closure after total laryngectomy: A systematic review

    • Optional: Bevel the cut posteriorly and superiorly using Mayo scissors 

      • vs. straight incision at the level of the cartilage posteriorly 

  • Identify the party wall

    • Free the larynx up to the level of the postcricoid mucosa

  • Open the pharynx through the vallecula, piriform sinus, or postcricoid mucosa

    • Choose the option that allows the best exposure and remains oncologically sound

    • Entering the vallecue is fastest

    • Optional: Place a metal Yankauer suction or Deaver retractor through the oral cavity and into the vallecula

      • Identify the hyoepiglottic ligament and follow it posteriorly under the tongue muscles

      • Incise the mucosa to enter the vallecula on the previously placed suction or Deaver

      • Identify the epiglottis and grasp it with an Allis clamp

• Excise the tumor under direct vision with adequate gross margins (>1 cm) while preserving as much piriform sinus mucosa as possible

• Examine the specimen

• Perform frozen section analysis of the margins

• Irrigate 

• Obtain hemostasis 

• Change gloves and use only "fresh" instruments 

• • Insert and suction the stomach using a nasogastric tube

  • Insert and secure a feeding tube (Dobhoff tube, DHT) 

    • Secure to the membranous septum using 3-0 Silk; First to an air-knot loosely, then tie a surgeon's knot around the feeding tube (DHT)

  • Perform cricopharyngeal myotomy

    • Divide the constrictor muscles along the posterior aspect of the pharynx

    • Optional: Denervate the pharyngeal muscles 

  • Divide the sternal heads of the SCM from their sternal attachments 

  • Optional: Perform primary TEP

  • Close the pharynx via a vertical, horizontal, or T closure with an inverting suture

    • Perform a Connell inverting suture (true or modified) with 3-0 Vicryl (Polysorb) to approximate the mucosa

      • True Connell suture pattern

        • Starts with Lembert’s suture pattern

        • After knotting the bites are taken parallel to wound edges alternately through the tissue, the suture runs parallel to the wound edges and the exposed part of the suture runs perpendicular to the wound edges

        • Unlike Cushing’s suture, it penetrates the mucosa layer

    • 2015: Modified Continuous Mucosal Connell Suture for the Pharyngeal Closure After Total Laryngectomy: Zipper Suture

    • Do not close the constrictors

• Optional: Perform regional or free flap reconstruction

• • The pectoralis major myocutaneous flap offers the advantage of multi-layered closure and additional tissue bulk

• Irrigate the wound and test the pharynx for leaks using Methylene Blue or Betadine dyed solution or H202/saline 

• Reinforce any leaks with additional 3-0 Vicryl (Polysorb) 

• • Place closed suction drains x 2-4

    • Some place one drain laterally and one drain medially on either side

  • Mature the permanent tracheostoma (laryngectomy stoma) remembering to bevel the trachea (Wang preference) and “walk the skin” to limit stomal stenosis

    • Optional: Excise a semi-circle of skin inferiorly to enlarge the stoma (Wang preference) 

    • Use 2-0 or 3-0 Polysorb and 5-0 Fast 

    • Options: Buried simply interrupted versus half-mattress sutures 

    • "Walk the skin" means travelling larger distances on the skin side than on the tracheal side during closure

• Approximate the platysma and skin 

  • • 3-0 Polysorb to approximate both the platysmal and deep dermis layers 

    • 5-0 Fast to approximate the epidermis 

• • Dress with Bacitracin 

• Replace the ETT with the appropriate tracheostomy or laryngectomy tube (with HME) 

Sample operative report

Post-op

• • Admit to ICU

    • Airway

      • RT consultation

      • RN and RT education re airway and HME, if present 

      • Constant humidified air, unless HME is present 

      • Post critical airway sign

    • Confirm NGT placement on CXR

    • Continue peri-operative antibiotics x 24 hours

    • Post op labs

    • PTH and serial Ca, if needed  

    • TSH if concerned or status post radiation 

      • Prealbumin, Albumin for nutritional assessment 

• Speech consult, if needed, to initiate voice rehabilitation, usually starting with electrolarynx 

  • Nutrition

    • Tube feed vis NGT until POD 7-21, depending on the patient and type of closure

• Complications

  • Surgical

    • Seroma

    • Hematoma

    • Dehiscence

    • Infection

    • Fistula

    • Stomal stenosis

  • Medical

    • 1990: Medical Complications in Total Laryngectomy: Incidence and Risk Factors

Pearls & Pitfalls

• • Pearls

    • Visualize and mentally map the tumor's margins so that you anticipate where to enter the airway and what to resect 

  • Pitfalls

    • Injury to CN 12

    • Sacrificing arteries / veins needed for possible microvascular anastomosis reconstruction

High-Yield

• • An involved Delphian node suggests a high likelihood of recurrence post laryngectomy

  • In subglottic SCC status post laryngectomy, metastasis to the superior mediastinum is associated with stomal recurrence

  • What is considered "good" pulmonary function as a requirement for laryngectomy? 

    • FEV 1 / FVC > 50-60% 

Links

• eMedicine - Total Laryngectomy

• eMedicine - Laryngectomy Rehabilitation

• Iowa Protocols - Total Laryngectomy 

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - TOTAL LARYNGECTOMY

• YouTube (4:14) - Cushing and Connell Suture Patterns

• YouTube (11:14) - Total Laryngectomy

  • YouTube (14:22) - Total laryngectomy - well done instructional 

• YouTube (27:32) - Total Laryngectomy Dr M. Garni (INSTRUCTIONAL CADAVER)

• YouTube (39:23) - Laryngectomy by Dr Majid Ahmed Talikoti