return to: Total Laryngectomy

updated April 2024 by P Wenzel, BS and H Hoffman, MD 

Case - Near field laryngectomy for supraglottic cancer

Total laryngectomy done 5 years after a comprehensive neck dissection (sparing CN XI) and endoscopic laser resection of a supraglottic SCC with post-operative radiation. The limited disseciton for this T3N0 cancer was done due to extensive radiation change and the previous neck dissection which had sacrificed the IJV and SCM. Follow-up nine years after the total laryngectomy shows no recurrence.

Modified Operative Note

Operation: Near Field Total Laryngectomy   

The patient was taken to the main operating room and placed in the supine position. General endotracheal anesthesia was induced through a previous tracheostomy site. The neck was injected with 1 lidocaine with 1:100,000 epinephrine in the vertical incision line along the neck was injected. The patient was aseptically prepped and draped.

A vertical incision starting approximately 3 cm below the mandible was incised down to the level of the previous tracheostomy site leaving a small strip of skin superior to the tracheostomy site.

The incision was carried down through the level of the straps. The straps were preserved as they were separated and elevated off of the thyroid cartilage using monopolar cautery.

After they were elevated off the thyroid cartilage, the hyoid was identified and strap attachments to the hyoid were also dissected off using scissors and bipolar cautery. Resection of the hyoid was facilitated by transecting it in the midline and removing the two separate remnants by medial traction with an allys clamp and scissors dissection laterally hugging the bone.

When the hyoid and thyroid cartilage were completely free on either side, an incision was made sharply with a scissors between the first ring and the cricoid cartilage and the larynx was elevated from in site using scissors and dissecting between the esophagus and the cricoid cartilage. Once the piriform sinuses were entered, incision was made again with Metzenbaum scissors up along the piriform sinuses and the larynx was freed inferiorly.

Next superiorly a monopolar cautery was used to enter into the pre-epiglottic space and vallecula. Once this was entered, scissors was used to excise down along the mucosal edge of the lateral pharyngeal wall to the previous incision site.

At this point the larynx was completely free and removed from the field. Final hemostasis was obtained by using bipolar cautery.

With the larynx removed, a T type closure using a Connell stitch was used to close the mucosal surface. A second layer of closure using the straps and remaining constrictor muscles was completed using 3-0 simple interrupted Vicryl sutures.

The pharyngotomy site was closed (water tight) through this two-layered closure.

The remaining trachea was dissected free down to the previous tracheostomy site, and cuts were made laterally along the tracheal wall. The extra trachea was brought out through the tracheostomy site. Inferiorly the trachea was left attached in the tracheostomy site, and the superior portion of the trachea was sewn to the dermal layer of the skin after resecting a small amount of posterior tracheal wall.

The stoma was maturerd by sutures in place with 3-0 interrupted Vicryl sutures and matured with 4-0 running Chromics.

Once the tracheostomy site was matured, 2-0 Prolene stitches were placed through the strap muscles and brought out through the opposite side of the skin in a parachute type closure. Three parachute type closures were used for retention stitches to approximate the skin and strap muscles to the recently closed laryngectomy site.

Before tying the 'parachute sutures', a half inch Penrose was placed and brought out through the wound. These Prolenes were then tied over rubber shods.

A second layer of 3-0 Vicryls was used to close the deep layers of the skin and subcutaneous tissue together. Finally, the skin was closed with 5-0 running nylon suture.

The patient was then decannulated from the J Rousch tube at the end of the case.

The patient tolerated the entire procedure.

Intraop:

Intraoperative Closure:

Closure with 'parachute sutures':

Resected specimen:

Post-op Final Result:

References

Garvey C.M., Panje W.R., and Hoffman H.T.:  “The ‘Parachute’ Bolster Technique for Securing Intraoral Skin Grafts”.  Ear, Nose & Throat Journal 80(10):720-723, 2001.