TOTAL LARYNGECTOMY: TECHNIQUE

HARVEY M. TUCKER, MD

Total laryngectomy is the baseline procedure against which all less radical resections for cancer of the larynx
must be measured. Key points in its performance are: the use of an apron flap; a posterior "tongue" of mucous
membrane to increase cross-sectional area of the stoma without exposing cartilage; removal of the larynx from
below upward to preserve maximal mucous membrane while providing adequate exposure of tumor; and "vest
over pants" suturing of skin margins to the stoma to provide coverage and allow retraction of the stoma into the
mediastinum after complete healing.
KEY WORDS: Baseline procedure/mucosal preservation/inferior approach/ovoid stoma.

Total laryngectomy remains the baseline procedure
against which all other conservation or subtotal resec-
tions for laryngeal cancer must be measured. Any ma-
lignancy of the larynx that cannot be adequately removed
by this approach is, by definition, unresectable. The ba-
sic technique1,2 is virtually unchanged since 1900, when
the essentials of the modern procedure had been devel-
oped by Solis-Cohen and Sorenson.
PROCEDURE PLANNING
INDICATIONS
1. Lesions too extensive for adequate removal by sub-
total procedures.
2. Lesions otherwise appropriate for subtotal resec-
tion, but medical status, age, or personal preference do
not permit acceptance of the added risks and complica-
tions that more often accompany conservation proce-
dures.
3. Salvage surgery after failed radiation (although
some radiation failures are still amenable to conservation
procedures).
4. Palliative local control of disease.
CONTRAINDICATIONS
1. Lesions too extensive for complete resection of local
disease.
2. Unacceptable medical risk.
3. Patient refusal.
TECHNIQUE
Although many incisions may be employed, an apron
flap provides excellent exposure with no trifurcations.
Moreover, the stoma may be placed in the lower portion
From the Department of Otolaryngology and Communicative Dis-
orders, the Cleveland Clinic Foundation, Cleveland, OH.
Address reprint requests to H.M. Tucker MD, Chairman, Depart-
ment of Otolaryngology and Communicative Disorders, Desk A-71 ,
Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195.
© 1990 by W.B. Saunders Company.
1043-1810/90/0101-0001$5.00/0
of the flap and the flap can be readily shifted or extended
to either side if radical neck dissection is required (Fig 1).
Once the flap has been elevated in the plane deep to the
platysma muscle to expose the hyoid bone, neck dissec-
tion can be performed, if indicated.
The strap muscles are transected at or below the level
of the anticipated stoma and the great vessels are mobi-
lized and displaced laterally. Next, the thyroid isthmus
is mobilized and either fransected if the gland is to be left
intact or removed in continuity with the lobe to be re-
sected with the laryngeal specimen (Fig 2). On the in-
volved side, the inferior thyroid vessels are identified and
transected, and the gland is mobilized from lateral to me-
dial, leaving it in contact with the upper trachea to be
resected. On the side to be preserved, it is mobilized off
the trachea from medial to lateral and left with its blood
supply intact.
At a point below the second tracheal ring or, if neces-
sary to gain clearance of subglottic extension, as low as
individual anatomy will permit the trachea can then be
transected to establish the stoma. Rather than cutting the
trachea on the bevel to provide a greater cross-sectional
area of stoma, the surgeon may divide it horizontally be-
tween adjacent rings just to the point where the tracheal
cartilages join the membranous posterior portion of the
lumen. At this point, a tongue-like superior projection of
the membranous wall can be designed to increase stomal
area without cutting or exposing cartilage (Fig 3). The
anterior distal tracheal wall can now be anchored to the
midline skin of the lower flap (Fig 4) with interrupted
sutures of 2-0 silk, as placed in Fig 5. This technique not
only covers the exposed edges of the transected trachea
with skin, but permits eventual retraction of the suture
line down into the upper mediastinum in order to mini-
mize exposure, crusting, and irritation of the mucosa.
The oral endotracheal tube is removed and replaced with
a sterile one in the partially completed stoma. The re-
maining posterior stomal wall closure is accomplished at
the time of return of the apron flap.
The hyoid bone is skeletonized by releasing the supra-
hyoid muscles from its upper surface, usually with a cut-
ting cautery (Fig 6). The greater cornua are identified and
undercut toward the lesser cornua, during which maneu-
ver the superior neurovascular bundle is usually encoun-
tered and can be suture ligated and divided. The thyroid
cartilage is skeletonized by dividing the fibers of the in-
ferior and middle constrictor muscles along both peste-

42 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 1 (MARCH), 1990: PP 42-44
 FIGURE 2. Strap muscles are transected low in the
neck. Thyroid isthmus may be divided in the
midline or to either side as required by extent and
location of laryngeal disease.

FIGURE 1. Apron flap is preferred for total laryngectomy. It

FIGURE 4. Anterior wall of stoma is anchored to lower neck
may be shifted laterally when radical neck dissection is
skin with interrupted 2-0 silk sutures.
indicated.

FIGURE 3. Trachea is transected between cartilages and a

"tongue" ,of posterior wall is left to increase cross-sectional
area of StO•..3.

FIGURE 5. Modified vertical mattress sutures draw skin over

cut edge of cartilage and permit retraction of suture line into
upper mediastinum to minimize exposure of mucosa.

TUCKER 43
FIGURE 6. Hyoid bone is freed from suprahyoid muscles
with cutting cautery.
FIGURE 7. Total laryngectomy from below upward. Note
that party wall between the posterior aspect of the trachea
and esophagus is maintained.
rll l.~'~~
,I ~.~~
./1 Iii I, ,~"--=-"m
f Ir:
rior margins from the greater to the lesser cornua. If
tumor involves the pyriform sinus, skeletonization is
avoided on that side.
The larynx can now be entered in any of several ways .
The inferior approach permits maximal preservation of
pharyngeal mucosa and an approach to most tumors un-
der direct vision from an uninvolved area, except in those
relatively uncommon cases wherein there is postcricoid
involvement. The loose areolar tissue of the party wall
between the trachea and esophagus is entered just supe-
rior to the upper end of the stoma (Fig 7). By placing an
index finger or retractor into the proximal tracheal lumen,
traction can be applied to permit blunt dissection of the
entire party wall from below upward. The anterior wall
of the esophagus is preserved until the appropriate level
44
FIGURE 8. Transection of base of tongue attachments
anterior to epiglottis and above the freed hyoid bone. This
approach permits maximal preservation of hypopharyngeal
mucosa.
is reached to enter the hypopharynx, usually at the lower
border of the cricoid cartilage . At this point, a transverse
incision is made in the mucosa of the hypopharynx to
enter the lumen.
Scissors are used to divide the remaining mucosal at-
tachments, by placing one blade in and one blade out.
The blades are directed superiorly, hugging the posterior
margins of the thyroid alae first on one side and then on
the other. In this manner, the larynx is gradually opened
towards the epiglottis. When this structure can be visu-
alized and grasped, it is inverted and further scissor dis-
section is directed across the base of the tongue attach-
ment, anterior to the epiglottis and inferior to the hyoid
bone (Fig 8).
Closure is begun after inspection and frozen section
margins reveal no residual tumor. A nasogastric tube is
passed and the mucosa of the pharynx is closed using a
Connell-type of running, 3-0 chromic catgut suture. Al-
though a simple horizontal or vertical suture line would
be desirable, most often a Y-shaped closure results. The
muscular layer should not be closed as this may interfere
with development of a good vibratory segment should a
"duck-bill" prothesis be used for restoration of voice.
DISCUSSION
Total laryngectomy remains a necessary procedure in the
treatment of a majority of carcinomas of the larynx, par-
ticularly when radiation for cure has been tried and
failed. With the advent of prosthetic restoration of voice,
this procedure need not be a terrible detriment to a full
and productive life after cure of laryngeal cancer. Atten-
tion to details of technique and proper selection of pa-
tients can result in good cure rates, and minimize post-
operative complications.
REFERENCES
1. Tucker HM: The Larynx, Thieme, New York, NY, 1987
2. Silver CE: Surgery for Cancer of the Larynx, Churchill Livingston e,
New York, NY, 1981
TOTAL LARYNGECTOMY