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H. E. Eckel and M. Quer
and/or chronic pulmonary disease. Endoscopy of the larynx
in the awake patient is done to assess laryngeal function, and
additional panendoscopy under general anaesthesia may be
useful to assess the extent of the tumour with regard to inltration of the base of the tongue, the hypopharynx and the
oesophagus. Standard imaging will typically involve CT or
MRI scanning of the neck and CT scanning (or PET-CT) of
the lung to rule out distant metastasis.
37.3 Preoperative Checklist,
Considerations andAnaesthesia
The following checklist should be worked through prior to
surgery:
• Obtain informed consent from the patient
• Perform transnasal laryngoscopy to assess vocal cord
mobility, phonation and swallowing
• Obtain and read CT or MRI scans of the neck
• Rule out distant spread of the disease
• Obtain relevant laboratory studies
• Obtain lung function tests
• Obtain a formal recommendation for surgery from the
interdisciplinary tumour board
not permitted during the rst 3–5days after surgery, a nasogastric feeding tube is inserted, and the correct positioning is
veried. Alternatively, a central venous catheter can be used
to feed the patient during this period. Local antiseptics are
used to sterilise the neck area, and sterile draping is applied,
taking care to leave access to the mouth for the anaesthetist.
Local antiseptics should also be used to disinfect the oral
cavity and the pharynx. Intravenous antibiotics are given
according to local protocols. Anatomical landmarks such as
the sternocleidoid muscles, hyoid bone, thyroid notch, cricoid and suprasternal notch are identied by palpation.
37.4.2 Incision
In most cases, bilateral neck dissection will be performed in
conjunction with total laryngectomy. In these cases, an apron
incision is done, extending from both mastoid processes to
approximately the level of the cricoid arch (Fig.37.1). The
tracheostomy can later be placed at the lower end of the ap,
or a separate incision can be used for the tracheostomy,
3–4cm below the inferior end of the ap. If no neck dissection is planned, then a narrower incision may be used.
Although total laryngectomy reportedly has been performed under local anaesthesia, the procedure generally
requires general anaesthesia with intubation of the airway
[7]. The transoral or transnasal tube will be removed during
the procedure, to be replaced by a second tube to be introduced directly into the trachea immediately before the denitive separation of the larynx from the trachea. This step of
the operation is crucial for maintaining a reliable airway and
should be discussed beforehand with the anaesthesiologist in
charge. In patients with preoperative airway obstruction, a
tracheostomy under local anaesthesia should be performed
in the rst place. General anaesthesia will then be induced
after intubation of the trachea, and the tube will remain in
place throughout the entire procedure.
37.4 Surgical Technique
Further illustration of the technique of total laryngectomy
can be found in books cited in the References [2, 7, 8].
37.4.1 Positioning andPreoperative Measures
The patient is placed in a supine position with the neck
extended, using a pillow underneath the shoulders; the head
is stabilised on a head ring in the midline. As oral intake is
Fig. 37.1 Proposed incision lines, with surface markings of the thyroid
and cricoid cartilages, and the tracheostomy site. After adequate surgical skin preparation and sterile draping, key neck structures and the
incision site are marked. In this case, the dark ‘V’ mark points to the
thyroid notch, and the dark square marks the cricoid cartilage level. The
incision site is usually marked halfway between the cricoid cartilage
and the suprasternal notch. Inltration using local anaesthetic with
adrenaline solution is performed at the incision site
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Alternatively, a transverse incision at the level of the thyroid
cartilage, with a separate incision for the tracheostomy, gives
adequate exposure in many cases. The planned incision is
injected with 1% lidocaine with 1:100,000 epinephrine. The
incision is made with a scalpel or electrocautery device on
cut mode.
The upper skin ap is retracted superiorly with hooks or
clamps and is elevated upward in the subplatysmal plane.
The dissection is carried superiorly for 3–4cm beyond the
upper margin of the hyoid bone in the middle.
37.4.3 Neck Dissection
If total laryngectomy is done for previously untreated cancer
of the larynx or hypopharynx, a unilateral or bilateral neck
dissection will invariably be an integral part of the surgical
concept. In these cases, the neck dissection is accomplished
prior to the mobilisation of the larynx. Details of performing
a neck dissection will be covered separately in this book and
shall not be discussed here.
37.4.4 Mobilisation oftheLarynx
andResection oftheHyoid Bone
After completing neck dissection on one or both sides of the
neck, the prelaryngeal muscles are identied at the level of
the hyoid and then transected superiorly and inferiorly.
Monopolar electrocautery is used for this division, to limit
troublesome bleeding. The hyoid bone is then identied in
the midline. Its body is grasped with a clamp and retracted
antero-inferiorly, exposing the superior surface (Fig.37.2).
The hyoid is then released and removed by detaching the
mylohyoid muscle, the geniohyoid muscle, the digastric
sling and the hyoglossus muscle from medial to lateral
(Fig.37.3). Care must be taken to avoid injuring the lingual
artery or hypoglossal nerve when detaching the hyoglossus
Fig. 37.2 Dissection and removal of the hyoid bone
Fig. 37.3 Dissection and removal of the hyoid bone
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H. E. Eckel and M. Quer
muscle. The hyoid bone can be removed separately in most
cases. In advanced supraglottic cancer, however, it should be
left in continuity and removed with the larynx.
37.4.5 Dissection oftheThyroid
andTracheotomy
The thyroid gland is dissected, and the isthmus is clamped on
both sides and transsected or removed (Fig. 37.4). In
advanced anterior laryngeal cancer with thyroid cartilage
inltration and in most tumours of the pyriform sinus, the
ipsilateral thyroid lobe remains attached to the larynx and
will later be moved. In these cases, the superior and inferior
thyroid vessels are divided and ligated. In all other cases,
both thyroid lobes will be freed from the larynx and the trachea, taking care to leave the inferior blood supply to the
gland intact. The cervical trachea can now be opened between
the second and third tracheal rings, or more caudal as needed
for subglottic tumours. Before dividing the larynx from the
trachea, it is recommended to suture the anterior aspect of
the trachea to the skin in order to avoid troublesome reintubation in case the tube gets loose during surgery. The
endotracheal tube is now removed from the mouth and
replaced by a second tube inserted directly into the trachea
through the surgical eld. Care must be taken to maintain
aseptic conditions during this manoeuvre.
37.4.6 Removal oftheLarynx
The superior cornu of the thyroid cartilage is exposed and
divided bilaterally. The larynx is rotated laterally with a hook
to expose the contralateral superior neurovascular bundle of
the larynx (Fig.37.5). It will next be ligated and cut on both
sides.
Blunt dissection at the inner lateral and superior aspect of
the thyroid is used to free the pyriform sinus, if appropriate
(Fig.37.6). Next, the pharynx is to be opened (Fig. 37.7).
This can be done from the vallecula glosso-epiglottica
between the base of the tongue and the lingual aspect of the
epiglottis by means of transverse incision with the monopolar cautery for glottic and subglottic lesions. Once the pharynx is opened in the midline, the free edge of the epiglottis is
grasped and the plica glosso-epiglottica is cut bilaterally.
Incisions along the medial wall of the epiglottis bilaterally
are united in the postcricoid region, leaving the oesophageal
inlet intact. In case of a pre-existing tracheotomy, it is safe to
completely excise the tracheostoma with the surrounding
skin in order to reduce the risk of peristomal recurrence.
N. hypoglossus
GI.
submandibularis
M. digastricus
M. stylo-hyoideus
Os hyoideum
M. sternohyoideus
M. thyrohyoideus
M. omohyoideus
Ramus cricoideus
V. jugularis interna
M.
nocleidomastoideus
Fig. 37.4 Anatomical situation after dissection of the larynx, removal of the hyoid bone and transection of the thyroid isthmus
Ramus marginalis
A. u. V. facialis
A. facialis
GI. parotis
V. jugularis interna
N. vagus
A. carotis interna
A. lingualis
A. carotis externa
A., V. u. N. laryngea
superior
A. carotis communis
A. thyroidea superior
GI. thyroidea
Tr uncus
thyrocer
A. subclavia
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Fig. 37.5 Identication, transection and ligation of the superior neurovascular pedicle of the larynx. Dissection and removal of the hyoid bone
377
Fig. 37.6 Blunt dissection at the inner lateral and superior aspect of
the thyroid is used to free the pyriform sinus before entering the
pharynx
Once the trachea is open and after looking into the subglottic
space to make sure there is a sufcient inferior surgical margin, the trachea is intubated with a new, cuffed endotracheal
tube that is inserted into the distal trachea for control of the
airway. Only then is the tracheal division completed, with an
incision in the posterior tracheal wall that should curve
upward slightly at its midpoint to optimise the mucosa
remaining for tracheostomy. The larynx can now be removed
after blunt dissection separating the posterior wall of the cricoid complex and the trachea from the anterior wall of the
hypopharynx and the oesophagus (Fig.37.8). For tumours
extending to the vallecula or the base of the tongue, it is recommended to open the pharynx after separating the posterior
Fig. 37.7 Sharp dissection of the pharyngeal muscles at the lateral
aspect of the thyroid cartilage
wall of the larynx from the oesophagus and the pharynx,
entering the pharyngeal lumen at the level of the interarytenoid plane. In every case, it is essential to preserve as much
of the pharyngeal mucosa and muscle as possible without
risking inadequate removal of the tumour. Frozen sections
are harboured from the base of the tongue and the mucosal
margins of the pyriform sinuses and the postcricoid region to
ensure complete removal of the tumour or to guide additional
resection. Once the removal is completed, the wound should
be irrigated, and meticulous haemostasis is performed.
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Fig. 37.8 The trachea has been transected completely, and the larynx is freed from the underlying oesophagus and pharynx
H. E. Eckel and M. Quer
37.4.7 Cricopharyngeal Myotomy andClosure
ofthePharynx
Prior to closing the pharynx, a cricopharyngeal myotomy
should be carried out. This is a prerequisite for successful
voice restoration with voice prostheses, and it facilitates
swallowing. With one nger inside the oesophageal lumen,
the cricopharyngeal muscle is cut dorsally in the midline or
in a paramedian plane down to the mucosa. This requires
meticulous dissection to avoid mucosal tears. Closure of the
pharynx using inverting sutures can then be achieved in a
T-shaped manner (Fig. 37.9), or with a straight suture line
from the caudal to the cranial edge of the pharyngeal
opening.
Pharyngeal closure also can be achieved by using a
mechanical stapling device [9]. Essentially, this technique is
applicable in purely endolaryngeal tumours. The advantages
of the mechanical closure in the closed technique are simple
and rapid application, watertight closure with good haemostasis, prevention of eld contamination and lower stula
rates. The main drawback of the technique is that the tumour
itself is not visualised during resection, with the potential for
oncologic compromise if the technique is applied in unsuitable cases. Tumours that are not entirely endolaryngeal are
evidently at risk for compromise with this technique.
In patients with previous radiotherapy of the larynx and
pharynx, reinforcement of the pharyngeal suture line with a
pectoralis major myofascial or myocutaneous ap has
become the standard of care in recent years, owing to the
Fig. 37.9 T-shaped suturing of the pharynx
high rates of pharyngo-cutaneous stula and wound infection after simple closure of the pharynx (Fig.37.10) [10]. In
advanced hypopharyngeal cancer requiring partial or total
pharyngectomy, additional surgical procedures will frequently be required to reconstruct the pharynx and an alimentary tract. These reconstructions will usually encompass
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Fig. 37.10 Reinforcement of the pharyngeal suture line with a pectoralis major muscle ap, covered with a meshed split-thickness skin graft
379
local or regional aps, free aps or gastric pull-up procedures. The details of pharyngeal reconstruction are dealt
with elsewhere in this book.
37.4.8 Creation oftheTracheostoma
andWound Closure
One or two suction drains are placed through separate stab
incisions, being careful not to place the drains directly over
the pharyngeal closure. These drains are secured in place
using nylon sutures. The distal tracheal stump, which had
been previously secured to the inferior skin ap using two or
three nylon stitches, is then circumferentially joined to the
skin of the lower and upper skin aps or the dedicated skin
incision created for the tracheostomy (Figs. 37.11 and
37.12). The neck is then closed in layers bilaterally using
nylon sutures or staples. Finally, the endotracheal tube is
removed and replaced with a cuffed tracheotomy tube of
appropriate size, which will be xed around the neck once
the wound dressing is completed (Fig.37.13).
37.4.9 Recent Surgical Innovation
In 2013, Lawson etal. from Belgium were the rst to describe
the use of transoral robotic surgery (TORS) for performing
total laryngectomy [11]. In brief, the procedure starts with an
open standard tracheostomy. With the use of a surgical robot
and a dedicated retraction system, a transoral incision is
placed along the superior aspect of the arytenoid mucosa.
The epiglottis is released from retraction, and the vallecula
incision is made along the lingual surface of the epiglottis in
the direction towards the superior border of the thyroid cartilage. Multiple clips are placed on the superior laryngeal vessels. Dissection is continued caudally until the thyroid
cartilage is encountered, keeping the hyoid bone retracted
underneath the intraoral retractor blade. The instruments are
directed along the external thyroid cartilage perichondrium
(Fig.37.14). Dissection continues caudally until the larynx is
freed from its attachments and the larynx can be delivered
orally. The technique has not yet found wide acceptance, and
its inherent advantages and improved surgical robots may
promote this approach in the future.
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Fig. 37.11 (a–c) Epithelialisation of the
tracheal cartilage by drawing the skin over
the denuded cartilage rim
H. E. Eckel and M. Quer
ab
c
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ab
cd
381
e
Fig. 37.12 (a–e) Closure of the wound by approximation of the apron ap to the trachea
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Fig. 37.13 Situation at the end of the procedure
H. E. Eckel and M. Quer
Fig. 37.14 Transoral robotic
surgery total laryngectomy:
specimen release and delivery.
(a) The sagittal view displays
the direction of transoral
extra-laryngeal dissection.
Piercing the thyrohyoid
membrane, dissection
separates the external thyroid
perichondrium from the
overlying strap muscles. Note:
The use of the retraction
sutures is instrumental in
reaching the caudal aspect of
dissection. (b) With the larynx
completely dissected, the
specimen is delivered
trans-orally. (Reprinted with
permission from Lawson etal.
[11])
a
b
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37.5 Post-operative Care
37.5.1 Complications
Post-operative bleedings usually occur on the day of surgery
and require wound revision with evacuation of the blood and
ligation of bleeding vessels. They are usually indicated by
excessive blood ow to the drains or by a swelling of the
neck and require immediate revision. Wound dehiscence is a
rare event. It may occur with excessive tension on the skin
closure. Local wound care should allow the wound to heal by
secondary intention. A regional or free ap such as a pectoralis major ap may be necessary if the carotid artery
becomes exposed.
Fever, erythema or swelling can indicate a wound infection. Empiric antibiotic therapy should be initiated until the
results of swabs allow for more specic antibiotic therapy. In
these cases, radiographic swallowing studies should be
obtained, because local wound infections usually occur secondary to pharyngeal leakage. Such leakage will usually
progress to clinically overt pharyngo-cutaneous stulae. As a
rule of thumb, early stulae should best be treated by surgical revision and secondary re-closure of the pharynx. Fistulae
that occur after a longer period (more than 5–7 days after
surgery) can usually be treated with a nonoral diet, local
wound care and watchful waiting, because spontaneous closure can be expected [12]. Patients with prior radiation therapy, poor nutritional status, hypothyroidism, diabetes,
smoking and positive surgical margins are at higher risk for
development of a stula [13]. Initially, stula packing with
sterile saline-soaked gauze and a pressure dressing may lead
to closure. More advanced stulas usually require a pedicled
regional ap, such as a pectoralis major or trapezius ap
[12].
37.5.2 Post-operative Care
Drains are removed when output is below 20mL/day. The
tracheostomy tube should be changed daily for the rst couple of days, as well as the dressing. It is desirable to go without a tube as soon as possible, provided the stoma is stable
and not shrinking excessively.
Oral intake is usually started on the fourth to seventh postoperative day in nonirradiated patients if there is no sign of
pharyngo-cutaneous stula or wound infection [14]. In previously irradiated necks, it is advisable to wait until the 12th
to 14th day post-operatively, to allow a longer healing time
for the pharyngeal repair. Some authors have encouraged
oral intake started on the rst postoperative day, avoiding
temporary nasogastric tube feeding, but this is not the general practice. Because most radiographic leakages are clini-
cally silent and not all clinically apparent stulas are
radiographically visible, the role of routine post-operative
radiographic swallowing studies in the absence of clinical
signs or stula remains unclear.
The stomal sutures are removed on the tenth day, and the
nonirradiated patient is discharged on that day if there are no
residual problems such as a fever, ap tenderness or
discharge.
All patients with partial or total thyroid removal (and all
patients after radiotherapy) require repeated assessment of
thyroid and parathyroid function during the post-operative
period.
References
1. Lefebvre JL.The impact of a total laryngectomy on the patients’
quality of life. Eur Arch Otorhinolaryngol. 2011;268:1397–8.
2. Quer M, Eckel HE.Total laryngectomy. In: Remacle M, Eckel HE,
editors. Surgery of the larynx and trachea. Berlin: Springer; 2010.
p.229–44.
3. Rosenthal DI, Mohamed AS, Weber RS, Garden AS, Sevak PR,
Kies MS, etal. Long-term outcomes after surgical or nonsurgical
initial therapy for patients with T4 squamous cell carcinoma of the
larynx: a 3-decade survey. Cancer. 2015;121:1608–19.
4. Maddox PT, Davies L.Trends in total laryngectomy in the era of
organ preservation: a population-based study. Otolaryngol Head
Neck Surg. 2012;147:85–90.
5. Theunissen EA, Timmermans AJ, Zuur CL, Hamming-Vrieze O,
Paul de Boer J, Hilgers FJ, etal. Total laryngectomy for a dysfunctional larynx after (chemo)radiotherapy. Arch Otolaryngol Head
Neck Surg. 2012;138:548–55.
6. Hutcheson KA, Alvarez CP, Barringer DA, Kupferman ME, Lapine
PR, Lewin JS.Outcomes of elective total laryngectomy for laryngopharyngeal dysfunction in disease-free head and neck cancer survivors. Otolaryngol Head Neck Surg. 2012;146:585–90.
7. Nauman HH. Surgery of malignant tumors of the larynx. In:
Naumann HH, editor. Head and neck surgery, vol. 4. Stuttgart:
Georg Thieme Verlag; 1984. p.148–238.
8. Shah JP.Head and neck surgery. London, Baltimore: Mosby-Wolfe;
1996.
9. Aires FT, Dedivitis RA, Castro MA, Bernardo WM, Cernea CR,
Brandao LG.Efcacy of stapler pharyngeal closure after total laryngectomy: a systematic review. Head Neck. 2014;36:739–42.
10. Guimaraes AV, Aires FT, Dedivitis RA, Kulcsar MA, Ramos DM,
Cernea CR, etal. Efcacy of pectoralis major muscle ap for pharyngocutaneous stula prevention in salvage total laryngectomy: a
systematic review. Head Neck. 2016;38:E2317–21.
11. Lawson G, Mendelsohn AH, Van Der Vorst S, Bachy V, Remacle
M. Transoral robotic surgery total laryngectomy. Laryngoscope.
2013;123:193–6.
12. McLean JN, Nicholas C, Duggal P, Chen A, Grist WG, Losken A,
etal. Surgical management of pharyngocutaneous stula after total
laryngectomy. Ann Plast Surg. 2012;68:442–5.
13. Erdag MA, Arslanoglu S, Onal K, Songu M, Tuylu
AO. Pharyngocutaneous stula following total laryngectomy:
multivariate analysis of risk factors. Eur Arch Otorhinolaryngol.
2013;270:173–9.
14. Aires FT, Dedivitis RA, Petrarolha SM, Bernardo WM, Cernea CR,
Brandão LG.Early oral feeding after total laryngectomy: a systematic review. Head Neck. 2015;37:1532–5.
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