total laryngectomy

In 1873, Billroth was the first to perform a total laryngectomy for a laryngeal cancer patient. At that time, due to serious complications such as postoperative bleeding, wound infection, aspiration pneumonia, sepsis, the success rate of surgery was low. In the early stage, 25 cases of laryngeal cancer were treated with total laryngectomy, and all died within 1 year after surgery. At the beginning of this century, with the improvement of surgical methods and anti-infective measures, the mortality rate of surgery has been significantly reduced, and it has become a safe and reliable method for the treatment of laryngeal cancer. Although the success rate of all laryngectomy is very high, it is a life-long disability because of the inability to speak after surgery. The ability to resume speech and speech after surgery is a problem that must be solved. In recent years, due to the general development of partial laryngectomy and laryngeal function reconstruction, all laryngectomy has a decreasing trend, but it is still a routine operation for the treatment of laryngeal cancer because of the wide range of indications. Treatment of diseases: throat cancer, laryngeal cancer Indication All laryngectomy is available for: 1. Glottis cancer 1T3 ~ T4; 2 vocal cords have been fixed; 3 epiglottic room with cancer and invasion of vocal cords; 4 invasion of thyroid cartilage or ring cartilage; 5 invasion of bilateral sacral cartilage; 6 out of the epiglottic space; 7 invasion of the epiglottis Tonggu root. 2. Glottic cancer 1 selective T3; 2T4; 3 invading the intercondylar region; 4 invading thyroid cartilage or ring cartilage; 5 extending to the subglottic. 3. Glottic carcinoma 1 extends to the glottis; 2 invades the cartilage. 4. Hypopharyngeal cancer 1T2 ~ T4; 2 piriform fossa and hypopharyngeal posterior wall were violated; 3 piriform fossa and posterior ring area were violated; 4 pear-shaped fossa and scorpion-like epiglottis were violated and one side vocal cord was fixed; 5 The throat was violated and the vocal cords were fixed. 5. Other 1 type of laryngeal cancer and hypopharyngeal carcinoma recurrence after radiotherapy; 2 thyroid cancer invades the throat; 3 other laryngeal malignant tumors; 4 glial closed incomplete long-term aspiration. Contraindications 1. A patient suitable for partial laryngectomy. 2. A distant transfer has occurred. 3. The tumor has worn out of the throat, the neck subcutaneously spread, invading the anterior fascia. 4. The general condition is extremely poor, with cachexia and severe cardiopulmonary dysfunction. Preoperative preparation 1. Ideological preparations The current operative mortality rate is very low, but the accidents that may occur in surgery, as well as the prognosis, especially the loss of vocal function after surgery, as well as the method of solving postoperative vocal speech, long-term wear of tracheal cannula should pay attention to the problem, Patients and their relatives should be clarified to resolve concerns and seek active cooperation. 2. Test blood routine, clotting time, blood pressure, electrocardiogram, chest X-ray (including esophageal barium meal) fluoroscopy, liver and kidney function, pay attention to distant metastasis. 3. Detailed examination of the local, using indirect laryngoscope, fiber laryngoscope, biopsy, laryngeal X-ray lateral slice and tomogram, if necessary, microscopic laryngoscopy, CT scan or MRI to determine the extent and size of the tumor . The neck was palpated and the lymph nodes were observed to be positive. If the palpation is positive, the location and size should be estimated. B-mode ultrasonography and CT scan are also feasible to determine the relationship between lymph nodes and peripheral blood vessels. 4. Local general preparation is the same as partial laryngectomy. Surgical procedure Type and choice of incision: Incision: There are many types of incisions, depending on the condition and the habits of the surgeon. Generally, vertical, T-shaped, horizontal I-shaped, U-shaped, etc. are used. The vertical incision is longitudinally cut in the midline of the neck, and the upper part of the lingual bone is cut from the midpoint of the lingual bone. The incision is narrow in the field and needs to be pulled out by the assistant. The T-shaped incision, the transverse incision parallels the hyoid bone to reach the large angle of the hyoid bone on both sides, and the longitudinal incision is connected from the central part of the hyoid bone to the transverse incision, and the upper sternal notch is obtained, and the surgical field is exposed to be spacious and clear. The lymph nodes around the internal jugular vein can be simultaneously explored. A transverse I-shaped incision is made on the basis of the T-shaped incision to extend the transverse incision of the plane of the hyoid bone along the lower edge of the lower jaw to the sides of the lower jaw to the mastoid tip. The other incision is at the lower end of the longitudinal incision and is transected to the outer posterior border of the sternocleidomastoid muscles on both sides. This incision is suitable for total laryngectomy and double neck dissection. The U-shaped incision runs from the lower side of the side of the mastoid tip to the medial line, reaching the midline of the plane of the ring of the nail, extending to the opposite side to the tip of the mastoid. This incision is clearly exposed and is suitable for all laryngectomy and neck dissection. The skin should be cut deep into the platysma, and the flaps should be covered with platysma and superficial veins to prevent skin flap necrosis. The choice of incision should be sufficient to achieve full exposure, consistent with the blood flow direction of the cervical flap (the blood flow of the neck and skin arteries is mostly vertical and vertical), the tension of the flap is small, and the requirement of leaving the dead space and protecting the carotid artery is not left. 1. The descending resection method removes the larynx from top to bottom. (1) Incision and separation of the flap: the skin, subcutaneous tissue, superficial fascia, and platysma are separately cut and separated, and the flap is retracted with a vascular clamp to expose the anterior cervical muscle. (2) Cutting the anterior ligament of the larynx: separating the sternohyoid muscle, the scapula and the thymus muscle, cutting it 1 cm below the hyoid bone, and cutting the sternum thyroid muscle at the attachment of the thyroid cartilage. The severed muscle can be re-sewed after the laryngectomy to strengthen the anterior pharyngeal wall. If the anterior larynx muscle has been invaded, it must be removed. (3) Cutting off the thyroid gland: Separate the thyroid isthmus to the lower edge along the anterior wall of the trachea with a curved hemostatic forceps, and then clamp the bilateral gland leaves with a forceps, cut in the middle, and then suture with a silk suture. The superior thyroid artery can be pulled together with the glandular lobes, without ligating and cutting. If the abnormality affects the exposed throat, it can be ligated and cut. If the glottic carcinoma is to be removed, the tracheal ring should be removed. The bilateral glandular lobes should be separated along the tracheal wall to ligate the lower thyroid artery. At the same time, the lateral gland leaves are removed. (4) loosening the laryngeal body: prior to the upper corner of the lateral thyroid cartilage of the thyroid ligament, separate the laryngeal artery, vein and ligation, and cut off the laryngeal nerve, cut the upper thyroid cartilage with bone scissors, along the thyroid cartilage wing The posterior edge of the plate cuts the incision and contraction muscles. At this point, attention should be paid to the ligament of the superior thyroid artery, and then the piriform fossa is separated from the posterior aspect of the thyroid cartilage. The thyroid cartilage is then cut down along the posterior inferior margin of the thyroid cartilage plate. (5) Resection of the hyoid bone: Separate and cut the muscles on the hyoid bone, and then remove the hyoid bone or the entire hyoid bone, which can completely remove the anterior epiglottis and reduce the tension when suturing the pharyngeal mucosa. (6) Incision of the ligament into the laryngeal and pharyngeal cavity: If the hyoid bone is left, the periosteum of the thyroid gland is cut horizontally on the upper edge of the thyroid cartilage, to the upper thyroid cartilage on both sides, and then the opaque mucosa is cut upward to enter the throat and throat. . Or cut from the hyoid bone to meet the pharyngeal mucosa into the throat and throat. At this point, you can see the episode, use the Allis tissue forceps to grasp the epiglottis, and pull forward. Continue to cut down the inner wall of the pear-shaped fossa on both sides of the epiglottis to see the lesions in the larynx. (7) Cut the trachea and take out the laryngeal body: cut off the trachea to the posterior wall of the trachea at the lower edge of the annular cartilage, and separate it along the tracheal esophageal wall, and the laryngeal body can be removed. If you want to retain the cartilage, you can cut it at the upper edge of the cartilage and then cut it horizontally. At the same time, the mucosa behind the posterior plate is connected with the incision on both sides of the piriform fossa. The laryngeal body can be removed. (8) Closing the throat and pharynx: the surgeon, the assistant replace the gloves and the surgical outer garment, check the surgical field, fully stop the bleeding and rinse the wound, suture the first layer of the laryngeal mucosa, use the No. 0 silk thread to make the suture under the mucosal margin, and close After the Y-shaped, the second layer is sutured to the submucosal layer, and the third layer of sublingual muscle can be sutured without muscle resection to strengthen the anterior wall of the throat and eliminate the dead space. (9) suture the end of the trachea: from the posterior wall of the trachea and the esophagus, until the trachea can be lifted and the surrounding skin is pulled without tension. The skin incision on both sides of the end of the trachea is to be semicircularly resected, and the size is determined according to the circumference of the trachea. The 2, 2-0 gut is used to suture the free end of the trachea to the sternum, and then the skin margin and the tracheal margin are sutured with silk. The skin edge is covered with the trachea to form a tracheostomy. (10) Place the drainage tube: insert two drainage tubes, and suture them from the skin on both sides of the neck to fix the lower part of the neck. The drainage tube is connected to the vacuum suction device. (11) suture the skin incision: suture the subcutaneous and skin incision in sequence. (12) Replace the tracheal cannula: After the patient's anesthesia becomes shallow, and the breathing is stable, fully remove the endotracheal secretions and remove the anesthesia catheter in the trachea, and put the tracheal cannula into the whole laryngectomy. (13) dressing: the neck wound is placed with sterile gauze, and the bandage is used to pressurize the neck to eliminate the dead space and achieve the purpose of stopping bleeding. 2. The ascending resection method removes the larynx from the bottom to the top. The surgical procedure before resection of the larynx is similar to that of the top-down resection, but it is removed from the lower edge of the annular cartilage and then removed from the bottom to the top. Apply in the opposite direction. (1) Resection of the larynx: When the larynx is free, the annular tracheal ligament is cut transversely at the lower edge of the annular cartilage. If the annular cartilage is retained, the ring is cut in the ring and the posterior plate of the cartilage is cut backward. The tissue cartilage was used to clamp the ring cartilage upwards, and the soft tissue in the posterior region of the ring was bluntly separated to reach the superior layer of the cartilage and the submucosa of the piriform fossa on both sides. The incision mucosa is cut transversely, and the epiglottis can be seen by opening the throat and the jaws are pulled down. According to the extent of the lesion, the incision is made from the anterior epiglottis, and the hyoid bone is removed together, or the hyoid bone is cut from the thyroplasty into the throat and pharynx, and the incision is connected with the intercondylar notch to remove the larynx. body. (2) Closing the wound: first close the throat and pharyngeal cavity, suture the muscle layer, subcutaneous, skin, suture the tracheostomy, place the drainage and the like. complication 1. Wound Infection Due to the advancement of aseptic technology and the wide application of antibiotics, wound infection has been greatly reduced compared with the past, but if improperly treated, it can cause delayed healing of local infection wounds, and can also develop into mediastinal inflammation, causing adverse consequences. In order to prevent intraoperative infection, after the opening of the throat and throat, the assistant should absorb the pharyngeal secretions at any time, or give atropine to reduce secretion. It can also fill the throat and throat with gauze, completely stop bleeding during operation, reduce dead space when closed, and lead to circulation. Can reduce the chance of infection. When the secretion is long, the extubation time can be extended. 2. Primary bleeding after hemorrhage, mostly due to improper hemostasis during operation, resulting in slippage of the ligature. Secondary bleeding is a wound infection, caused by erosion of the blood vessel wall. Postoperative bleeding is not timely, and there is a risk of death from hemorrhagic shock. It is required to completely stop bleeding during the operation and carefully check whether there is bleeding point in the surgical field. Larger blood vessels should be ligated or sutured to stop bleeding without electrocoagulation to stop bleeding. At the end of the operation, if fresh blood is poured from the drainage tube, the oral cavity, or the trachea, the wound should be reopened to stop bleeding. Bleeding caused by secondary infection is often difficult to control. First, pressure is applied to stop bleeding. If it is invalid, the wound is opened again to stop bleeding. At the same time, the wound should be fully drained, and active and effective anti-infective measures should be taken. 3. After the operation of pharyngeal fistula, saliva leaks from the wound, which is the formation of pharyngeal fistula. The reason may be due to improper suture of the laryngeal and pharyngeal mucosa, preoperative radiotherapy, surgical wound tissue is not easy to heal, wound infection, throat laryngeal mucosal suture split and other reasons. Under normal circumstances, the laryngeal and pharyngeal cavity is closed, the submucosal suture is sutured when the laryngeal mucosa is sutured, the alignment is neat, the mucosa is not turned to the operation side, and the submucosal soft tissue and the pharyngeal muscle are used to strengthen the suture, and it is generally difficult to form pharyngeal fistula. The anterior ligament of the larynx has been removed, and a large dead space is formed under the skin, which causes infection. The neck compression dressing and negative pressure drainage can eliminate the dead space and reduce the occurrence of pharyngeal fistula. When the pharyngeal fistula has been formed, the small pharyngeal fistula can be closed by itself. The diameter of the pharyngeal fistula is about 1~2cm. The butterfly-shaped adhesive tape is used to pull the skin on both sides. The pressure bandage is not difficult to heal. The big pharyngeal fistula has no closure tendency for more than 1 month. The suture is difficult to heal, and it is possible to form a hypopharyngeal stenosis. The skin around the mouth should be free to form a flap and double sutured. 4. The tracheostomy stenosis may be cut off due to the tracheal end of the trachea, the tracheal orifice is small; the skin around the stoma is resected too little, the stoma is infected; the trachea is not separated enough, the tension is large during suturing, resulting in tracheal constriction; The granulation of the mouth is formed; the skin and the trachea are not properly sutured, and the scar is formed. The methods to prevent stenosis include: strictly follow the operation of the operation, and try to keep the lower half of the ring cartilage as appropriate; cut the end of the trachea into a bevel to enlarge the tracheostomy; the skin around the stoma should be removed as much as possible, and the circumference of the stoma A slight tension can be used; after surgery, a large full-throat resection cannula is used to enlarge the stoma and prevent stenosis. If the stenosis has been formed, it is feasible to complete the surgery. 5. Tracheal cartilage necrosis and tracheal prolapse; tracheal cartilage may cause necrosis due to infection and poor blood supply, causing partial absorption and excretion of cartilage, separation of tracheostomy from surrounding skin, and tracheal downward prolapse. During the operation, the trachea should not be too much free. When suturing, try to reduce the damage of the suture to the tracheal cartilage ring. The bleeding around the trachea is sufficient to stop the bleeding, so as to reduce the chance of infection. Once the tracheostomy is found to have an inflammatory reaction, it should be taken. Effective anti-infective measures. The occurrence of tracheal prolapse can delay the repair operation. 6. Intrapulmonary infections Currently, all pepsia, atelectasis, and pulmonary suppuration have been rare after laryngectomy. However, those who have had lung disease before surgery and those who are old and infirm may have long-term postoperative tracheal endocrine and endotracheal secretion. Retention of the object, low body resistance caused by intrapulmonary infection.