Total laryngectomy: A new lateral cervical approach
Department of Otolaryngology – Head & Neck Surgery, Regina Elena National Cancer Institute, Rome, Italy
F. Ferreli, Department of Otolaryngology – Head & Neck Surgery, Regina Elena National Cancer Institute, Rome, Italy.
Nowadays, total laryngectomy is primarily performed for advanced
laryngeal cancers with involvement of the laryngeal skeleton and/or
extending outside the larynx, hypo or oropharynx. Another field of
application is represented by salvage surgery following chemo-radia-
tion therapy failure. In both these situations, laryngectomy is
achieved by therapeutic or elective neck dissection.
dure is carried out by adopting an open trans cervical approach.
Transoral total laryngectomy performed with minimally invasive
approach has recently been proposed to preserve as much tissue as
These techniques require dedicated instruments and the
need of staged neck dissection. The idea of a new lateral surgical
approach for the treatment of both the larynx and the neck nodes
through the same skin incision allows a minimally invasive technique
using standard equipment, avoiding any delay of neck treatment
involving the removal of the larynx and nodes during the same
After orotracheal intubation, the patient is placed in the neck exten-
sion position with elevation of shoulders. Nasogastric feeding tube is
A mono/bilateral 6-8 cm skin incision is made along the medial
border of the sternocleidomastoid muscle in line with the side of
neck dissection. A myocutaneous flap including anterior cervical skin,
subcutaneous tissue, platysma muscle, anterior jugular veins, ster-
nohyoid and homohyoid muscles is harvested. The limits of the
myocutaneous flap elevation include the following: the hyoid bone,
cranially; the sternal notch, caudally; and the lateral margin of the
controlateral sternohyoid muscle, laterally. Positioning of the retrac-
tors creates a space between the myocutaneous flap and the thyro-
hyoid and the sternothyroid muscles (Figure 1). In the case of
bilateral neck dissection, this space becomes a tunnel, allowing the
bilateral approach to reach the larynx. The superior insertion of the
thyrohyoid muscle and the inferior insertion of the sternothyroid
muscle are transected.
If a selective neck dissection (level II-IV) is performed, the ante-
rior margin of the sternocleidomastoid muscle is the lateral limit of
the dissection; while, a post-erolateral flap is elevated through the
skin, and subcutaneous tissue and platysma muscle are elevated
from the sternocleidomastoid muscle when a V level dissection is
After completing the neck dissection, the thyroid gland is
released from the trachea on both sides sectioning the isthmus when
there is no suspicion of anterior spread of the tumour; otherwise,
the emithyroid with tumour involvement is left attached to the lar-
ynx and is removed with it.
The superior laryngeal artery and vein are identified at the level
of the thyrohyoid membrane and bilaterally sectioned. Superior con-
strictor muscles are exposed and incised at the insertion on the pos-
terior border of the thyroid cartilage; thus, the superior cornu is
skeletonised, consequently releasing the larynx.
The hyoid bone is cranially identified, preserving the insertion of
the sternohyoid muscle on it. The hyo-thyro-epiglottic space is
FIGURE 1 Myocutaneous tunnel is harvested to allow a bilateral
approach of the neck and the larynx
Accepted: 14 June 2017
© 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/coa Clinical Otolaryngology. 2018;43:784–785.