Total Laryngectomy

Description:

Total laryngectomy involves the removal of the entire larynx, from the vallecula to the superior trachea, including the hyoid bone and the thyroid and cricoid cartilages. A tracheoesophageal puncture may be done concomitantly to enable post-laryngectomy speech. The pharynx is then closed and the trachea is circumferentially secured to the skin of the anterior neck, forming a permanent tracheostoma. This procedure separates the digestive tract from the airway. Concurrent neck dissection may also be indicated; technique for this procedure is covered in a separate chapter. Several less extensive procedures exist for resection of laryngeal tumors amenable to less than total removal of the larynx; these include transoral endoscopic and open approaches, all of which avoid a permanent tracheostoma.

Indications for Surgery:

  • Advanced (T3 or T4) laryngeal tumors not amenable to partial resection due to presence of any of the following characteristics:
    • Thyroid cartilage destruction and anterior extralaryngeal spread
    • Circumferential submucosal involvement
    • Involvement of the posterior commissure or bilateral arytenoid/cricoarytenoid joints
    • Subglottic extension with invasion of the cricoid cartilage
  • Hypopharyngeal tumors involving the postcricoid mucosa
  • Direct invasion of the larynx from an adjacent neck metastasis or highly invasive resectable thyroid malignancy
  • Recurrence or persistence following prior irradiation, chemoradiation, or partial laryngectomy (endoscopic or open)
  • Refractory laryngeal radiation necrosis
  • Intractable aspiration or non-functioning larynx (as may occur after prior chemoirradiation or with some neurological disorders)

Contraindications to Surgery:

  • Medical comorbidities that would preclude surgical or anesthesia risk
  • Unresectability, such as involvement of the common carotid artery or posterior invasion through the prevetebral fascia
  • Presence of distant metastases precludes surgery for curative intent, but palliative surgery may sometimes be indicated

Pre-Operative Evaluation:

  • Biopsy confirmation of malignancy and evaluation for medical co-morbidities
  • Computed tomography (CT) or MRI to assess for invasion of local structures and cervical metastases
  • Positron emission tomography (PET)-CT scan to evaluate for distant metastases

Anesthesia:

General endotracheal

Surgical Technique:

  1. The patient is placed supine on the operating table. If the airway is adequate and the patient can be adequately mask ventilated, general anesthesia is induced and the patient is intubated. If there is concern about the airway, an awake tracheostomy is performed.
  2. Direct laryngoscopy may be performed to confirm the extent of disease.
  3. A low transverse neck incision is made and carried superolaterally on both sides as needed. Subplatysmal flaps are elevated to a level superior to the hyoid and inferior to the clavicles. Neck dissection(s) may be done, if indicated.
  4. The cervical fascia is dissected along the anterior border of the sternocleidomastoid (SCM) muscles bilaterally.
  5. The carotid sheath is separated from the larynx and pharynx.
  6. The superior laryngeal artery and superior thyroid artery are divided, avoiding injury to the superior parathyroid glands.
  7. The strap muscles are divided.
  8. The thyroid isthmus is divided and suture ligated. The left and right hemithyroid glands (pedicled on the superior and inferior thyroid arteries and veins) are dissected from the trachea and lateralized. A lobe of the thyroid may be resected if extralaryngeal spread to it is present.
  9. The inferior constrictor muscles are incised along the posterior border of the thyroid ala.
  10. The superior edge of the hyoid bone is dissected. The digastric tendon is separated from the lesser cornu, and the greater cornu dissected free, taking care to avoid entry into the pyriform sinus and to avoid injury to the hypoglossal nerve and lingual artery. Dissection is continued superiorly between the hyoid and the base of tongue following the course of the hyoepiglottic ligament so that the preepiglottic fat is included in the resection.
  11. The trachea is divided at an appropriate level inferior to the cricoid. The tracheostoma is made by suturing the anterior tracheal wall to the neck skin, maximizing the size of the stoma. Anesthesia is converted to a new endotracheal tube inserted into the stoma as the initial endotracheal tube is withdrawn.
  12. The vallecula is entered, usually in the midline where there is redundant mucosa. The mucosal limits of the resection are delineated, preserving as much pyriform sinus and hypopharyngeal mucosa as possible.
  13. The superior portion of the trachea and the larynx are dissected from the esophagus in a superior-to-inferior fashion and the final mucosal cuts completed as the specimen is removed en bloc.
  14. A tracheoesophageal puncture (TEP) is generally done at this time, with placement of a speaking valve.
  15. A nasogastric feeding tube is inserted prior to closure.
  16. The pharyngeal mucosal defect is closed with inverting running or interrupted sutures or an endoscopic stapler. An inverting second layer is done, followed by partial reapproximation of inferior constrictor muscles. A flap reconstruction may occasionally be needed if a large amount of pharyngeal mucosa is resected. If resection will result in a circumferential defect, reconstructive options include a tubed flap (such as a radial forearm free flap reinforced with a pectoralis major flap), jejunal interposition free flap, or gastric pull-up.
  17. The wound is irrigated and checked for leaks. Drains are placed.
  18. The posterior tracheostoma is completed by suturing the inferior edge of the skin flap to the posterior trachea (where there is no cartilage), and the skin is closed in layers laterally.
  19. Ventilatory support is weaned as appropriate. The anesthesiologist and surgeon will have decided whether an intensive care unit is needed postoperatively.

Post-Operative Care

  • The patient is fed solely via the nasogastric tube for an appropriate time, often at least 7 days. A barium swallow may be considered prior to resumption of oral feeding to ensure that no leak is present before advancing diet to clear liquids.
  • Drains are removed when they are no longer draining much fluid, often around postoperative day 3.
  • It is critical that the patient, caregiver, or skilled nursing facility understand and be facile in tracheostomy care prior to discharge.
  • Initial speech production will likely be via an electrolarynx, with use of the speaking valve placed via TEP delayed until adequate wound healing has occurred.

Complications:

  • Bleeding/hematoma
  • Wound dehiscence, flap necrosis, or wound infection
  • Pharyngocutaneous fistula
  • Tracheostoma obstruction or stenosis, resulting in airway compromise
  • Pharyngoesophageal stenosis, resulting in dysphagia
  • Hypothyroidism or hypoparathyroidism
  • Medical complications resulting from prolonged surgery and recovery (such as pneumonia, deep venous thrombosis or pulmonary embolism, pressure ulcers)






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