Total Laryngectomy: A Review of Surgical Techniques

Abstract

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end. Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

Keywords: neopharynx; pharyngeal fistula; salvage laryngectomy; surgical technique; total laryngectomy; voice rehabilitation.

Figure 1. Schematic illustration of the eight different types of neck incisions.

(A) Midline vertical incision, (B) T-shaped incision, (C) horizontal double-Y incision, (D) trap-door incision, (E) double trap-doors, (F) apron incision (separate tracheostoma), (G) apron incision (tracheostoma-incorporated), and (H) extended apron incision.

Figure 2. The mucosal layer of the neopharynx.

(A) The defect after total laryngectomy with partial hypopharyngectomy and (B) the T-shaped closure.

Figure 3. Schematic illustration of commonly used suture patterns in mucosal layer repair.

(A) The Lambert and Gambee interrupted-suture techniques and (B) the Cushing and Connell continuous-suture techniques. The Cushing and Lambert techniques penetrate only the submucosa, while the Connell and Gambee techniques pass through the lumen.

Figure 4. Schematic illustration of the reconstruction of the neopharynx.

(A) Traditional three-layer closure, (B) three-layer closure with myotomy, (C) non-closure of the pharyngeal musculature, (D) half-muscle closure technique, (E) horizontal closure, and (F) crossover zigzag neopharyngoplasty. In horizontal closure, the pharyngeal constrictors are stitched to the tongue base muscles.

Figure 5. Schematic illustration of different stoma-fashioning techniques.

(A) Straight transection, (B) beveled transection, (C) wide triangular stoma, (D) interposed lower skin flap, and (E) Y-shaped, interposed superior skin flap.