This presentation discusses the topic Total laryngectomy

1. Total Laryngectomy an overview
Dr T Balasubramanian

2. Actually
History
Performed
tracheostomy
● 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Position
● Supine
● Mild extension of
neck
● Ryles tube to be
inserted prior to
surgery

11. Incision choice
● Whether pt has been irradiated / not
● Whether block neck dissection has been
planned along with total laryngectomy

12. Types of incision
● Gluck Sorenson
● Vertical
● Double horizontal
● Crile Y incision
● Low neck horizontal

13. 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

14. 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

15. 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

16. Flap sutured

17. 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

18. Loose areolar compartment
Boundaries
● Laterally sternomastoid muscle and carotid
sheath
● Medially – visceral compartment of neck
containing pharynx and larynx

19. Division of strap muscles
● Muscles are divided
close to their sternal
margins
● Division of strap
muscles exposes
thyroid gland

20. Thyroid
● Total / hemithyroidectomy
● Massive midline / bilateral tumors – Total
thyroidectomy preferred
● Unilateral laryngeal tumors –
Hemithyroidectomy is preferred

21. Total thyroidectomy
● Middle thyroid vein secured
● Both superior and inferior thyroid vascular
pedicles
● Parathyroid glands should be preserved

22. 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

23. Thyroid mobilization

24. Middle thyroid vein

25. Recurrent laryngeal nerve and inf
pedicle

26. Parathyroid

27. 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

28. Suprahyoid dissection

29. 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

30. Epiglottis delivery
High pharyngeal
entry is made
avoiding
preepiglottic space.
Epiglottis is
visualized
Surgeon moves to
head end and
grasps the epiglottis
with a forceps

31. Head end dissection

32. 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

33. 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
st
rings (between 1
and 2nd )

34. Pharyngeal defect

35. 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

36. Connel suture

37. T – shaped closure

38. 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

39. Complications
● Drain failure
● Hematoma
● Skin flap infection
●
Pharyngocutaneous fistula -after 2 nd week.
Common in irradiated pts
● Flap necrosis
● Tracheal stenosis
● Oesophageal stenosis
● Hypothyroidism / Hypoparathyroidism

40. Thank you