Download Surgical technique illustrated in the anatomy laboratory

OPERATIVE TECHNIQUES
This article supplements the Operative Techniques video presentation, which can be viewed online on Head & Neck’s home page at
http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1097-0347/homepage/video_archive.htm.
Supracricoid partial laryngectomy with cricohyoidoepiglottopexy: Surgical technique
illustrated in the anatomy laboratory
F. Christopher Holsinger, MD,1* Chafeek Tomeh, MD,1 Michael W. Moore, MD,3 Wang Yan, MD,1 Crystal Chen, MA,1 Ollivier Laccourreye, MD2
1
Division of Head and Neck Surgery, Department of Otolaryngology – Head and Neck Surgery, Stanford University, Stanford, California, 2Department of Otorhinolaryngology –
Head and Neck Surgery, University de Paris V-Descartes, H^opital Europeen Georges Pompidou, Assistance Publique des H^opitaux de Paris, Paris, France, 3Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.
Accepted 24 October 2014
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23921
C 2014 Wiley Periodicals, Inc.
Background.Methods.Results.Conclusion. V
Head Neck 37: 906–908, 2015
KEY WORDS: supracricoid partial laryngectomy, laryngeal
preservation, partial laryngectomy, laryngeal cancer, glottic cancer
INTRODUCTION
in the central portion of this incision later in the
procedure.
A subplatysmal flap is then raised to 2 cm above the
hyoid bone and the inferior flap is extended just caudal to
the sternal notch. The sternohyoid and sternothyroid
muscles are then identified and separated along the midline raphe. Central compartment lymphatics from the
hyoid bone to the thyroid isthmus are removed. This dissection includes superficial lymphatics in this region as
well as Delphian lymph nodes. The thyroid isthmus is
then divided and the thyroid lobes are elevated laterally
to expose the anterior tracheal wall. Inferior to the thyroid, the pretracheal fascial plane is gently finger dissected, and a cervicomediastinal release of the trachea is
performed. This release is extended down to the level of
the carina taking care to stay in the midline of the
trachea.
At this point, the larynx should be released from all its
attachments in the neck. The sternohyoid and thyrohyoid
muscles are divided along the superior edge of the thyroid
cartilage. Next, the sternothyroid muscles are divided at
their oblique line insertions. The larynx is now rotated
exposing the constrictor muscles. The pharyngeal constrictors are then incised along the lateral thyroid cartilage
lamina, from the superior cornu to the inferior cornu. The
inner perichondrium of the pyriform is subsequently
deflected away from the thyroid ala for preservation of
pyriform sinus mucosa. If there is concern of hypopharyngeal involving on a particular side, elevation of the
inner perichondrium of the thyroid ala should not be performed on that side. This should be delayed until the
resection is completed under direct visualization with the
larynx open. Next, the cricothyroid joint is disarticulated
1
Despite its first introduction by Majer and Rieder in
1959 and its widespread implementation by French surgeons, supracricoid partial laryngectomy (SCPL) only
started to be discussed in the English literature in the
early 1990s. The procedure has been used for decades as
a partial laryngectomy that preserves laryngeal function,
such as speaking, swallowing, and breathing. SCPL is
similar to an extended supraglottic laryngectomy; however, while the glottis remains intact with a supraglottic
laryngectomy, a neolarynx is recreated in the SCPL using
the fundamental elements of the cricoarytenoid unit. In
SCPL with cricohyoidoepiglottopexy (CHEP), a pexy is
created between the cricoid cartilage below and the preserved epiglottis and hyoid bone above. Remarkably, but
reliably, this reconstruction recreates the airway and
improves swallowing to the point where even 1 arytenoid
can be removed.
With the bed turned 180 degrees from anesthesia, the
patient is placed in the supine position and the neck is
slightly extended using a shoulder roll. The procedure
begins with a U-shaped apron incision beginning 2-cm
cephalad to the sternal notch and extending laterally
about midway between the lower neck and mastoid tip. If
a concurrent neck dissection is planned, the incision on
that side can be extended to the mastoid tip to create a
standard “utility” flap. The tracheostomy will be included
*Corresponding author: F. C. Holsinger, Division of Head and Neck Surgery,
Department of Otolaryngology – Head and Neck Surgery, Stanford University,
875 Blake Wilbur Drive, Stanford, CA 94305-5820.
E-mail: [email protected]
906
HEAD & NECK—DOI 10.1002/HED
JUNE 2015
SUPRACRICOID
FIGURE 1. Rotating the thyroid cartilage after incising the inferior
constrictor muscle. Needle driver points to the cricothyroid joint,
which is disarticulated just caudal to the inferior cornu. [Color figure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]
just caudal to the inferior cornu. Care is taken at this
point not to injure the underlying recurrent laryngeal
nerve by direct visualization of the nerves in this area.
With the larynx completely mobilized, the endolarynx
is now entered by a horizontal cricothyroidotomy, performed at the superior edge of the cricoid cartilage. At
this point, the endotracheal tube can be inserted through
the cricothyroidotomy after inspection of the inferior
extent of the cricoid, although complete visualization of
the inferior extent may be limited because of the inflexibility of the thyroid and cricoid cartilages. Once the laryngotomy has been completed, improved visualization
will allow for complete inferior visualization. Next, a
transepiglottic laryngotomy at the superior border of the
thyroid cartilage is performed via a horizontal incision
through the preepiglottic space. With the surgeon now at
the head of the bed, the incision is extended through the
upper part of the aryepiglottic fold, the false vocal cord
just anterior to the body of the arytenoid cartilage, and
last, the thyroarytenoid muscle anterior to the vocal process of the arytenoid. In performing this incision, the scissors should follow the lateral edges of the epiglottis to
FIGURE 2. Anterior view of completed resection. [Color figure can
be viewed in the online issue, which is available at wileyonlinelibrary.com.]
PARTIAL LARYNGECTOMY WITH CRICOHYOIDOEPIGLOTTOPEXY
FIGURE 3. Posterior view of resection. Note complete resection of
thyroid cartilage along with glottic and supraglottic structures. In
this case, both arytenoid units were preserved. [Color figure can
be viewed in the online issue, which is available at wileyonlinelibrary.com.]
ensure preservation of the superior laryngeal nerves.
Next, the vertical incision is connected to the horizontal
cricothyroidotomy along the superior border of the cricoid
cartilage transecting both the cricothyroid muscles and
infraglottic mucosa. The thyroid cartilage can now be
grasped and fully opened allowing the tumor to be perfectly visualized. The surgeon can now use this intraoperative tumor assessment to make a decision on arytenoid
resection on the tumor-bearing side. While at least 1 cricoarytenoid unit is preserved with this procedure, the
bilateral paraglottic spaces are resected. Care must be
taken to preserve the interarytenoid muscle and posterior
arytenoid mucosa for neoarytenoid construction. Under
direct visualization, a nasogastric tube is inserted if a
feeding tube is not already present. At this point in the
procedure, the tracheostomy is performed in conjunction
with removal of the intubation tube. Ideally, the tracheostomy is placed as far away from the impaction site as
possible in order to minimize or ideally eliminate chondritis and potential breakdown of the impaction site. This
incision is generally placed more caudally in the trachea,
such as between tracheal rings 5 and 6, compared to routine tracheotomy. One must ensure there is adequate
length above the carina, although this is usually not an
issue.
Reconstruction begins with repositioning of the arytenoids to a more anterior position. A Vicryl 3-0 stitch is
placed through the anterior arytenoid cartilage above the
vocal process, which is then tied to the cricoid cartilage.
If both arytenoids are spared, this tie can be placed laterally on the cricoid. If 1 arytenoid is resected, the suture
for the remaining cartilage should be placed in the anterior cricoid to move the arytenoid more medial. For the
CHEP, the remaining portion of the epiglottis as well as
the hyoid bone are both impacted to the cricoid cartilage.
With 1-0 Vicryl suture on a 65-mm curved needle, 3
stitches are placed at the midline as well as 5 to 10 mm
apart from the midline on each side. The stitches are
passed inferior to superior, submucosally around the cricoid cartilage and then to the epiglottis and hyoid. At
HEAD & NECK—DOI 10.1002/HED
JUNE 2015
907
HOLSINGER ET AL.
impaction, care must be taken to ensure proper cricoidhyoid alignment.
Before closure of the skin flaps, placement of the skin
incision for the tracheostomy tube is variable, based on
anatomy and surgeon preference, as well as a history of
radiation or chemoradiation. Although some surgeons prefer to place the tracheostomy tube through the midline of
the neck incision, others prefer to create a separate midline incision both caudal to the neck incision and cranial
to the manubrium. Separation of the incisions may reduce
microbial contamination from the tracheostomy tube to
the pexy site, particularly in patients with compromised
microvascular flow, such as in the setting of prior radiation or chemoradiation.
The constrictor muscles are reattached anterolaterally to
the neolarynx to restore the physiologic position of the
constrictors for preservation of swallowing function. This
is accomplished by placing 2 Vicryl 3-0 stitches in the
fascia of the released inferior constrictor muscles. These
stitches from the bilateral constrictors are then tied anteriorly to its contralateral stitch after the compaction is completed. Two #10 JP drains are placed to counteract air
908
HEAD & NECK—DOI 10.1002/HED
JUNE 2015
leak from the tracheostomy and provide negative pressure. Finally, the incision is closed in layers. The infrahyoid strap muscles should be used to close over the
impaction side. Next, the platysma is reapproximated followed by careful closure of the skin.
SCPL with CHEP is a reliable surgical technique that
provides excellent oncologic results for patients with
intermediate to advanced staged laryngeal cancer. Furthermore, meticulous surgical technique and an understanding of the internal anatomy of the laryngeal
framework will optimize functional outcomes and promote restoration of laryngopharynx function.
REFERENCES
1. Majer EH, Rieder W. Laryngectomy technique for keeping the respiratory
permeability, “the crico-hyo€ıdo-pexy” [in French]. Ann Otolaryngol Chir
Cervicofac 1959;76:677–681.
2. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal
procedure for glottic carcinoma. Ann Otol Rhinol Laryngol 1990;99(6 Pt
1):421–426.
3. Holsinger FC, Laccourreye O, Weinstein GS, Diaz EM Jr, McWhorter AJ.
Technical refinements in the supracricoid partial laryngectomy to optimize
functional outcomes. J Am Coll Surg 2005;201:809–820.