return to protocol: Supracricoid Laryngectomy with Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP)
73 yo male who 9 1/2 years previously underwent a planned endoscopic laser resection of a T3N2aM0 supraglottic SCC converted intraoperatively to a supracricoid laryngectomy with CHP based on extension to the anterior commissure (March 2000). Right comprehensive neck dissection done concurrently with 1/47 nodes positive. PORT administered; 6440 cGy tumor bed; 5040 cGy regional nodes (right neck 5940 cGy) (completed June 22, 2000). PEG removed November 2000.
9 1/2 year followup after supracricoid laryngectomy
Modified Operative Note
Procedure: Supracricoid laryngectomy with right modified radical neck dissection sparing cranial nerve XI following effort at endoscopic laser resection of T2aN1 squamous cell carcinoma of the supraglottic larynx.
Postoperative Diagnosis: T3-N2a squamous cell carcinoma of the supraglottic larynx.
Description of Operation:
The patient was brought into the room. General anesthesia was administered by the anesthesiologists using a laser safe 6.0 endotracheal tube. The patient was turned 90 degrees and prepped and draped in the usual fashion for laser supraglottic laryngectomy. The Weerda supraglottic laryngoscope was inserted into the mouth, opened and then suspended so that the supraglottic mass on the laryngeal surface of the epiglottis could be visualized. There was some difficulty visualizing the entire lesion, therefore, the procedure was begun by debulking a portion of the suprahyoid epiglottis using the laser on a setting of 8 watts super-pulse mode. Dissection then proceeded to remove the epiglottic mass using the laser on a setting of 10 watts super-pulse mode. The tumor was removed in a piece-meal fashion. Dissection proceeded into the pre-epiglottic space up to the inner-perichondrium of the thyroid lamina. As dissection proceeded inferiorly to the anterior commissure and the anterior true vocal cords were visualized, there was some irregularity noted of the true vocal folds bilaterally. Therefore, a biopsy was taken of the left and right anterior true vocal cords and sent for frozen section analysis. During this time the right false vocal fold was removed. The lateral most portion of this excision still showed evidence of cancer growth on gross inspection. At this time the frozen section analysis had returned positive for squamous cell carcinoma, therefore, it was deemed necessary to perform a supracricoid laryngectomy and the laser resection was abandoned. The microscope and laser were removed from the field. The laser safe endotracheal tube was changed to an 8.0 cuffed endotracheal tube by the Anesthesiology Service. The patient was turned another 90 degrees and prepped and draped in the usual fashion for a neck dissection, laryngeal surgery and tracheotomy.
The planned incision was marked down to the skin which was then incised with subplatysmal flap was then elevated inferiorly to the level of the clavicles, to the sternal notch and posteriorly to visualize the trapezius muscle. During this elevation of the posterior portion of the flap, the cranial nerve XI was identified and dissected from its surrounding tissues. A superior subplatysmal skin flap was then elevated to the level of the mandible. During this dissection the marginal mandibular nerve was identified and preserved and reflected superiorly with the skin flap. The neck dissection was begun from a medial to lateral direction, beginning with dissection of the submandibular gland from the surrounding tissue. The gland was released from the surrounding tissue. The facial artery was ligated twice along with the facial vein. The lingual nerve was identified and preserved with division of the submandibular ganglion. The hypoglossal nerve was also identified inferior to the submandibular gland and preserved. The fascia was brought up off of the digastric muscle and retracted laterally with the neck dissection specimen. Dissection proceeded in this medial plane until the omohyoid muscle. The dissection proceeded along this muscle inferiorly in a lateral direction reflecting the contents of the neck laterally. Dissection proceeded medially until the entire submandibular gland was completely free from the surrounding structures. Attention was then turned posteriorly and the entire free edge of the trapezius muscle was identified. Once this was completed, the spinal accessory nerve was dissected out from the surrounding tissues in level V to its entrance into the sternocleidomastoid muscle. The nerve was then dissected out from this muscle from a lateral to medial direction. Branches to the sternocleidomastoid muscle were cut. Dissection proceeded medially until the internal jugular vein was identified. Attention was then turned inferiorly as the omohyoid passed underneath the sternocleidomastoid approximately 1 cm superior to the clavicle. The sternocleidomastoid muscle was divided sharply until the internal jugular vein could be seen underneath the muscle. Now that the medial, superior, inferior and posterior portions of the neck dissection had been identified, the neck contents were elevated off the fascial carpet from an inferior to superior direction. Once the internal jugular vein was sufficiently exposed, it was doubly ligated superiorly with 2-0 silk, doubly ligated inferiorly with 2-0 silk and then suture ligated with 3-0 silk. It was then cut and this was brought up along with the neck contents. Care was taken to ensure that the carotid artery and vagus nerve were identified and not ligated along with the internal jugular vein. While lifting this specimen off the fascial carpet, the phrenic nerve was identified and preserved. Dissection continued in a superior direction up to the level of the large level II neck mass. The internal jugular vein was further exposed superiorly and then ligated in a similar fashion as below. The entire neck contents were then elevated off the fascial carpet from the medial to lateral direction taking care to take the fascia off of the vagus and carotid artery leaving a small amount of fascia over the carotid artery. Once the contents had been removed, they were divided on the back table into the appropriate levels. The entire levels I through V were taken out in an en bloc fashion along with the internal jugular vein and sternocleidomastoid muscle preserving the spinal accessory nerve.
At this point attention was turned to the supracricoid laryngectomy. The strap muscles were identified and then divided in the midline and retracted slightly laterally. This was done from the level of the hyoid inferiorly to the sternal notch. The trachea was then exposed from the cricoid down into the mediastinum until the innominate artery could be palpated. Once this was completed, the thyroid isthmus was clamped, divided and then suture ligated. The thyroid lobes were then elevated slightly off of the trachea until the anterior 180 degrees could be easily seen. The strap muscles and pharyngeal constrictors were then elevated off of the thyroid cartilage using a combination of cautery and a No. 15 blade until the superior cornu, inferior cornu and posterior edge of the thyroid cartilage were all easily seen. The cricothyroid joint was then divided sharply taking care to stay very close to the cartilage to preserve the recurrent laryngeal nerve. The superior cornu was exposed taking care to preserve the hypoglossal nerve and the superior laryngeal nerves as much as possible. Once the supracricoid larynx had been adequately exposed for resection, the thyrohyoid space was entered in the midline. Initially dissection proceeded superficially into into the vallecula in order to avoid epiglottic tumor. Once the vallecula was entered, the entire thyrohyoid space was opened and the tumor could be seen along the thyroid lamina. Putting the larynx on traction, the piriform mucosa was then incised freeing the thyroid cartilage first on the right side. The entire thyroid lamina on the right side was now free. The cut was then made on the left side. On both sides the cut went through the true vocal fold just anterior to the vocal process leaving the arytenoids intact. The cricoid cartilage was left intact. An incision was made in the cricothyroid membrane taking care to preserve the cricoid cartilage. The supracricoid larynx was removed. Frozen sections were taken. The wound was thoroughly irrigated. Frozen sections returned negative.
0-Vicryl sutures were placed first in the midline through the cricoid and then around the hyoid bone submucosally. Similar sutures were then placed 1 cm laterally to this on both sides. Placing the sutures on traction, approximating the hyoid and the cricoid, the approximate site of the tracheotomy was found. An incision was made into the skin and placed over the trachea which corresponded with approximately the fourth tracheal ring. This ring was then marked for excision. It was excised and the inferior portion of the stoma was sutured to the sub-dermis of the tracheotomy incision. Once this was completed, an anode tube was placed through the skin and into the trachea. The subdermal to tracheal sutures were then repeated on the superior portion of the stoma. Once the tracheotomy was completed attention was redirected to the laryngeal remnant with vicryl sutures were placed just lateral to the vocal process and then brought forward onto the cricoid just lateral to the midline. This was performed on both sides and loosely tied thereby tilting the arytenoids anteriorly.
The 0-Vicryl sutures were then tied into position, approximating the cricoid and the hyoid. The pharyngeal mucosa that was redundant on both sides was then sutured towards the midline using Vicryl sutures. The strap muscles were then approximated to the superior portion of the defect re-suspending them. The thyroid lobe was then tacked over the superior portion of the stoma in order to prevent air leak through this site. Once this was completed, the wound was thoroughly irrigated. Hemostasis was achieved. Suction drains were placed, two on the right side and one on the left and secured to the skin. The deep layer was then closed with Vicryl sutures and the skin was closed with staples. At the end of the case the anode tube was removed, a Shiley tube was placed and secured to the skin with silk sutures. The patient was then returned to anesthesia. He was awakened and taken to the recovery room in good condition. He tolerated the procedure well.
Summary of Findings:
Carcinoma on initial pathologic review with frozen section identifying involvement at the anterior commissure.
Large right level II mass, probably metastatic disease representing N2a disease.
Initially T2 squamous cell carcinoma of the supraglottic but identified as T3 supraglottic (pre-epiglottic space involvement).