Special Surgical Procedures II
LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery
Section IV: THROAT, TONGUE, AND NECK SURGERY
1-44
1-44. TOTAL LARYNGECTOMY
a. General. This procedure involves the complete removal of the cartilaginous larynx, the hyoid bone, and the strap muscles-connected to the larynx and possible removal of the pre-epiglottic space with the lesion. The tumor may have produced immobility of the vocal cords, or be in the extrinsic larynx and hypopharynx where there is greater danger of metastasis. The lymphatics are often removed.
b. Psychological Aspects. Laryng-ectomy presents many psychological problems. The loss of voice that follows this procedure is a most tragic event for the patient and his family. The patient may be taught to talk either by using esophageal voice or with an artificial larynx. Esophageal voice is produced by the air contained in the esophagus rather than by that in the trachea. Speech requires a sounding air column. With instruction and practice, the patient is able to control the swallowing of air into the esophagus and re-introduction of this air into the mouth-with phonation. The sounding air column is then transformed into speech by means of the lips, tongue, and teeth.
c. Patient Preparation.
(1) The patient is placed on the table in a dorsal recumbent position with his neck extended and shoulders raised by a rubberized block or folded sheet. The table is slanted downward to elevate the upper part of the body for the convenience of the surgeon.
(2) An endotracheal anesthetic is administered. An effective suction apparatus is most essential.
(3) The proposed operative site--including the anterior neck region, lateral surfaces of the neck down to the outer aspects of the shoulders, and the upper anterior chest region--is cleansed in the usual manner.
d. Operative Procedure.
(1) A tracheostomy may be performed to control the airway.
(2) A midline incision is made from the suprasternal notch to just above the hyoid bone. Skin flaps are undermined on each side. The sternothyroid, sternohyoid, and omohyoid muscles (strap muscles) on each side are divided by means of curved hemostats and a knife.
(3) The suprahyoid muscles are severed from the portion of the hyoid to be divided. The hyoid bone is divided at the junction of its middle and lateral thirds with bone-cutting forceps. Bleeding vessels are clamped and ligated.
(4) The superior laryngeal nerve and vessels are exposed and ligated on each side, using long curved fine hemostats and fine chromic gut or silk ligatures.
(5) The isthmus of the thyroid gland is divided between hemostats. Each portion of the thyroid gland-is dissected from the trachea, using fine dissection with Stevens and Metzenbaum scissors and fine tissue forceps. The superior pole of the thyroid is retracted in a Greene retractor. The superior thyroid vessels are freed from the larynx by a sharp dissection.
(6) The larynx is rotated. The inferior pharyngeal constrictor muscle is severed from its attachment to the thyroid cartilage on each side.
(7) The endotracheal tube is removed. The trachea is transected just below the cricoid cartilage over a Kelly or Crile hemostat previously inserted between the trachea and esophagus. The upper resected portion of the trachea and the cricoid cartilage are held upward with Lahey forceps. A balloon-cuffed tube (endotracheal) or a Foley catheter is inserted in the distal trachea.
(8) The larynx is freed from the cervical esophagus and attachments by sharp and blunt dissection. A moist pack is placed around the endotracheal tube to help prevent leakage of blood into the trachea.
(9) The pharynx is entered. In most cancers of the intrinsic larynx, the pharynx is entered above the epiglottis. The mucosal membranous incision is extended along either side of the epiglottis; the remaining portion of the pharynx and cervical esophagus is dissected well away from the tumor by means of fine-toothed tissue forceps, Metzenbaum scissors, knife, suctioning, and fine hemostats. The specimen is removed en massa.
(10) A nasal feeding tube is inserted through one nares into the esophagus; closure of the hypopharyngeal and esophageal defect is begun, using continuous inverting fine sutures of chromic gut #3-0. The nasal tube is guided down past the pharyngeal suture line.
(11) The pharyngeal suture line is reinforced with interrupted sutures; the suprahyoid muscles are approximated to the cut edges of the inferior constrictor muscles.
(12) The diameter of the tracheal stoma is increased by means of a knife and heavy straight scissors. The two portions of the thyroid behind the tracheal opening are approximated with interrupted silk sutures, thereby obliterating dead space posterior to the upper portion of the trachea.
(13) A small Penrose drain or catheter is inserted through two separate stab wounds on each side of the neck just below the pharyngeal suture line. If a closed suction system is used, catheters connected to a suction apparatus are used.
(14) The edges of the deep cervical fascia and the platysma are closed separately with interrupted fine silk sutures. When a great amount of the fascia and platysma has been removed, the wound edges are approximated with silk sutures.
(15) A laryngectomy tube is inserted into the tracheal stoma; a pressure dressing is applied to the wound and neck.
