Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 468 - файл

The concept of the reconstructive ladder (Table 8.1) is well established within the reconstructive literature and describes a spectrum of reconstructive options that may be applied to a particular defect, ranging from healing by secondary intention to microvascular free tissue transfer (MVFTT). Selecting a reconstructive modality is a complex decision that depends on a variety of factors, including the patient’s anatomy, anticipated extent of the defect, and medical comorbidities. Depending on the extent of resection, the size of the defect may vary dramatically from small pharyngotomies in mucosa-sparing laryngectomy to total laryngopharyngectomy with total glossectomy or esophagectomy. There have been numerous algorithms described to guide pharyngeal reconstruction, and approaches are highly surgeon and institution-dependent. Ideally, the reconstruction would minimize risk of post­operative pharyngocutaneous stula and stenosis, allowing for as close to normal function as possible while minimizing donor site morbidity and operative complex­ity. A variety of techniques ranging from primary closure, skin grafting, local muco­sal ap, pedicled aps, abdominal-based enteric aps, and microvascular free tissue transfer (MVFTT) have been described.

The primary goal of pharyngeal closure is to obtain a water-tight, tension-free closure with care taken to avoid excessive tension resulting in strangulation of the mucosa. Multiple different suture techniques, including Lembert, Cushing, Connell, and Gambee sutures, have been utilized and are shown in Fig.8.2 [18]. The choice of suture technique varies greatly among surgeons and institutions, and there is little data to suggest superiority of one technique over another, though some studies have suggested that continuous sutures may have lower rates of pharyngocutaneous s­tula than interrupted suture [19, 20]. Meticulous technique is imperative as any gaps or tears in the mucosa can lead to a salivary leak and PCF.There is also considerable variation based on institutional and surgeon preference in the orientation of the closure (vertical, horizontal, or “T”-shaped). Due to its orientation, horizontal clo­sure may reduce likelihood of stricture and improve postoperative dysphagia and dysphagia-related quality of life, though this may not be suitable for larger defects [21]. The “T” closure is typically accomplished with a vertical suture line along the medial pyriform mucosa with a horizontal cross-bar at the base of tongue [22]. The “T”-shaped closure has been shown to reduce the incidence of pseudo-diverticula (pseudo-vallecula) separated from the neopharynx by a scar band (pseudoepiglot­tis); this has been suggested to reduce postoperative dysphagia in some studies although this relationship has not been consistently demonstrated [22–24]. While the trifurcation of the “T”-shaped closure represents a theoretical weak point, which may increase the risk of pharyngocutaneous stula, there is limited data to support this assertion and retrospective studies have had mixed results [25, 26].