Transoral ultrasonic total laryngectomy (TOUSS-TL): description of a new endoscopic approach and report of two cases

Abstract

The minimally invasive total laryngectomy avoids a wide surgical field and so it has the potential benefit of reducing the local morbidity, especially on radiated patients. This approach has been previously described on a robotic basis, the transoral robotic total laryngectomy (TORS-TL). We have designed a minimally invasive approach for total laryngectomy (TL) using the transoral ultrasonic surgery technique (TOUSS). TOUSS is a transoral, endoscopic, non-robotic approach for laryngeal and pharyngeal tumors, based on the ultrasonic scalpel as a resection tool. Two patients with a laryngeal squamous cell carcinoma with indication for total laryngectomy were surgically treated: one primary TL for a subglottic carcinoma and one salvage TL with partial pharyngectomy for a local relapse after chemoradiotherapy of a glottic carcinoma. The tumors were completely removed with free surgical margin in both patients. The functional recovery was satisfactory in terms of swallowing and speech (a tracheoesophageal puncture and voice prosthesis placement were done in the same procedure). No intraoperative complications were observed. The patient with previous chemoradiotherapy had a pharyngocutaneous fistula which closed spontaneously without additional surgery. We have demonstrated that transoral endoscopic approach to the larynx and pharynx is feasible without a robotic platform. TOUSS-TL can easily spread the transoral endoscopic philosophy as well as the benefits of a minimally invasive way to remove the entire larynx. Further research will show the advantages in terms of complications and functional outcomes.

Keywords: Minimally invasive surgery; TORS; TOUSS; Total laryngectomy; Transoral robotic surgery; Transoral surgery.

Fig. 1

Lateral view of the superior tunnel. The videoendoscope is introduced through the cervical incision, in the space under the sternohyoid muscle

Fig. 2

Endoscopic view of the superior tunnel. The endoscopic transection of the sternothyroid (1), omohyoid (2) and thyrohyoid (3) muscles is done close to their superior insertion by using the ultrasonic scalpel

Fig. 3

Lateral view of the inferior tunnel. The larynx is dissected up to the level of the arytenoid cartilages

Fig. 4

Endoscopic view of the inferior tunnel, and exposure of the posterior cricoarytenoid muscles

Fig. 5

Endoscopic transoral approach of the larynx. Section of the mucosa of the valleculae (1) is done with the ultrasonic scalpel. If mucosa of the lingual aspect of the epiglottis can be preserved, the section (2) should be incised with the monopolar electrode, as well as the posterior section of the mucosa (3)

Fig. 6

Lateral view of the transoral infrahyoid resection. The section of the preepiglottic space runs under the hyoid bone and enters the superior tunnel

Fig. 7

Pharyngeal closure. The pharynx is closed using a continuous suture

Fig. 8

Wide neopharynx and optimal swallowing in esophagogram

Fig. 9

No neck scars and optimal conditions of neck skin without local morbidity derived from flap elevation