I. GENERAL CONSIDERATIONS
II. PREOPERATIVE CONSIDERATIONS
III. NURSING CONSIDERATIONS
IV. ANESTHESIA CONSIDERATIONS
V. OPERATIVE PROCEDURE
A. Table is turned 180° (Mayfield headrest
helpful in selected cases, not routinely).
B. Shoulder roll is needed.
C. Incision
1. Skin incision may be made with
electrocautery (on blend of 20/20 cut/coag) from
inferior to mastoid tip, similar location on opposite
side if bilateral neck dissections to be done; may
make “apron flap” smaller if full radical or
comprehensive neck dissections not required.
2. Lower border of incision will be upper aspect of
tracheostoma (about 2 to 4 cm above sternal
notch).
3. Alternatively tracheostoma may come out of lower
flap separate from apron incision. Should leave
adequate distance between these incisions to retain an
adequate blood supply to the intervening skin.
D. Flap elevation should be in the subplatysmal plane,
immediately above anterior and external jugular
veins.
E. Transect strap muscles inferiorly (hemostat
dissection/monopolar cautery on cutting).
F. Divide thyroid isthmus, oversew and dissect thyroid
gland away from the trachea (may remove ipsilateral lobe
along with larynx).
G. Trim 2 to 4 cm in half-moon shape from inferior
skin flap and remove subcutaneous fat in preparation for
maturing lower border of tracheostoma. With 3-0 vicryl,
suture anterior tracheal wall in 3 to 5 sites to under
surface of inferior flap to begin formation of a mature
tracheostoma.
H. Clean soft tissue off anterior tracheal wall and
incise between second and third rings (lower if concern
for subglottic extension exists).
1. Continue incision superolaterally to bevel
lateral tracheal walls superiorly to enlarge
tracheostoma.
2. One method to remove the endotracheal tube
without requiring anesthetist to come to head of table
to withdraw tube: After puncturing balloon of
endotracheal tube, in a “hand-over-hand
fashion” with 2 large hemostats, pull tip of tube
out of tracheotomy. Advance the tube inferiorly
through the glottis and cut with heavy scissors,
allowing the upper two-thirds remnant to retract
superiorly, still attached to tape at the mouth.
3. Inspect subglottis from below to ensure adequate
margin has been obtained.
4. Place new flexible endotracheal tube into the
trachea and secure to anterior tracheal wall or chest
with suture, attach to sterile anesthesia tubing, and
resume ventilation through the neck.
I. Be prepared to perform a radical or modified
radical neck dissection if previously unrecognized neck
disease becomes apparent after flap elevation (see
Cervical Lymphadenectomy: General
Considerations)
1. Bilateral Levels II, III, and IV neck
dissections are commonly employed for cN0
neck disease.
2. If irradiation is clearly indicated
postoperatively as an adjunct to laryngectomy (based
on tumor characteristics as the primary site),
elective neck dissection (for cN0 necks) is
not necessary.
3. Comprehensive radical or modified radical neck
dissection is done for clinically N-positive
disease.
J. Isolate the inferior pedicle of ipsilateral thyroid
lobe and ligate vessels.
1. Good practice but not essential to
identify and preserve pedicled inferior parathyroid
2. Also good practice but even less essential to
identify the recurrent laryngeal nerve prior to its
transection
K. Detach constrictor muscles from the thyroid ala
with cautery or scalpel blade. The mucosa of the pyriform
sinus on uninvolved side may be mobilized medially with a
sponge, Kitner, or Freer elevator.
L. Dissect suprahyoid musculature off of superior
border of hyoid bone with monopolar dissection staying in
the midline well away from the hypoglossal nerves. Grasp
the midline of the hyoid with an Allis clamp.
1. Heavy Mayo scissors dissection laterally
to isolate greater cornu of hyoid bilaterally
2. Hug corner of greater cornu to avoid hypoglossal
nerve; if neck dissection done, the hypoglossal nerves
will be under direct vision
M. Entry into the larynx from above
1. Should enter larynx as far from tumor as
possible: choices include the vallecula or pyriform
sinus on side opposite tumor or from below; most
commonly enter from the vallecula.
2. With finger palpation of vallecula, insert
Army-Navy retractor through the mouth with end of
retractor now palpable through the neck immediately
above hyoid.
3. This maneuver keeps the surgeon out of the
pre-epiglottic space.
4. Cut with cautery down to the Army-Navy retractor
that will now appear into the neck wound.
5. Dissect laterally from point of entry to expose
supraglottis.
6. May place Allis clamp on epiglottis for
retraction to help gain full visualization of
tumor.
N. Heavy scissors cuts (Mayo or Metzenbaum) may be
made on less involved side along lateral pharyngeal wall
to “open pharynx like a book.”
1. On less involved side, cuts may be made to
hug arytenoids and cricoid to preserve pyriform sinus
mucosa.
2. Superior laryngeal neurovascular pedicle will be
encountered with these cuts and should be ligated.
O. With the excellent exposure now available, the
involved side of the larynx is separated from
posterolateral wall mucosa also with scissors cuts. This
allows good visualization to obtain adequate margins.
P. Final separation of the larynx is performed from
below with scalpel incision of posterior tracheal wall to
identify the gray line (avascular plane between esophagus
and trachea).
Larynx removed from patient with upward traction on
the larynx permitting inspection of surgical margin,
esophageal introitus, and trachea as final cuts are
made.
Q. Pharyngeal Closure
1. Place NG Corpak feeding tube before
closure.
2. T-shaped closure with 3-0 vicryl or 4-0 vicryl
in running modified Connell or true Connell technique
for first layer
3. Second layer of interrupted 3-0 vicryl to ensure
the deeper running layer is imbricated
4. Third layer with interrupted 3-0 vicryl to
loosely approximate constrictor muscles (overly tight
closure may lead to narrowing with subsequent
dysphagia or failure of TEP speech may choose to avoid
third layer)
R. Tracheostoma
1. Take bilateral “cookie bites”
out of sternal head of sternocleidomastoid (SCM) to
allow room for tracheostoma; may tack thyroid remnant
laterally under SCM.
2. Remove 2 to 4 cm elliptical segment from upper
skin flap above tracheostoma.
3. Suture undersurface of upper and lower flaps
(dermis, 2 to 3 mm from skin edge) to cartilage of
trachea with 0 or 00 chromic or 3-0 vicryl.
4. Approximate skin of flaps to mucosa of trachea
(covering exposed cartilage) with 4-0 chromic.
S. Suction drains (3 or 4)
1. Bilaterally placed active suction drains
to both “gutters” (along internal jugular
veins)
2. Third drain placed horizontally just above upper
aspect of tracheostoma
3. Consider fourth drain across submental area
T. Platysma closed with 3-0 vicryl and the skin is
stapled.
VI. POSTOPERATIVE CARE
VII. CPT CODING
VIII. SUGGESTED READING