Total laryngeal, laryngopharyngeal, esophagectomy, pectoralis major myocutaneous flap repair

Laryngeal, hypopharyngeal, esophageal cancer resection has a long history. As early as 1877, Czerny used the cervical approach to remove the 6cm long cervical esophagus, and the distal esophagus and neck skin were sutured, and the esophagus was maintained to maintain nutrition. 15 months, died of tumor recurrence. In the future, people have been studying improved methods, the purpose of which is to completely remove the tumor and to restore the laryngeal function by one-stage reconstruction. In recent years, effective repair methods include cervical and thoracic flaps and organ transplantation: the whole larynx, hypopharynx, and esophagus are replaced by organs instead of esophagus or thoracic triangle flaps and pectoralis major flaps instead of cervical esophagus. Treatment of diseases: throat cancer, laryngeal cancer Indication Total laryngeal, hypopharyngeal, esophagectomy, pectoralis major myocutaneous flap repair is applicable to: 1. Cancer invades all or most of the throat and throat mucosa. 2. Throat and throat cancer invades the esophageal entrance, or the upper esophagus does not exceed 2 to 3 cm. 3. Piriform fossa cancer T3 and T4 involve the glottic region. 4. Piriform fossa cancer involves the posterior annulus or the posterior wall of the hypopharynx beyond the midline. 5. Laryngeal cancer T3 and T4 involve most of the pear-shaped fossa. 6. Laryngeal cancer radiotherapy failed and the glottis, glottis (T3), or tongue roots. 7. Laryngeal squamous cell carcinoma and one side cervical lymph node metastasis (concurrent cervical lymph node dissection). Contraindications 1. The tumor is too large and the musculocutaneous flap is insufficiently repaired. 2. Tumors involving the cervical esophagus more than 3cm. 3. Laryngeal carcinoma has a mediastinal metastasis or extensive metastasis of bilateral cervical lymph nodes, lymph nodes have been fixed or have worn through the lymph node capsule. 4. Aged, infirm, and severe organs with serious diseases. Preoperative preparation 1. General preparation for the same laryngectomy. 2. Prepare the skin on the neck and chest. 3. Swallow X-ray or photographic examination of the throat and esophagus to determine the extent of the tumor. 4. The neck is palpated to check the cervical lymph nodes. 5. Fiber laryngoscopy to check the throat, throat and esophagus. 6. CT scan of the esophagus in the neck and throat. Surgical procedure 1. After the complete laryngeal, hypopharyngeal and cervical esophagectomy and lymph node dissection are completed, the wound is flushed, and the surgical gown and gloves are changed. 2. The chest incision is cut according to the incision line drawn in advance with methylene blue, and the skin on one side of the chest is a rectangular (or paddle-shaped) incision. The width of the incision is 5 to 8 cm, and the size of the flap is determined as needed. Another oblique incision extends from the ankle to the fourth intercostal space parallel to the clavicle to the outer upper corner of the rectangular incision, deep to the pectoralis major. 3. Separate the musculocutaneous flap and suture the pectoralis major sarcolemma and the skin margin with the No. 0 silk thread to avoid the separation of the muscle and the skin during the separation process. Continue to separate from the pectoralis major to the crotch and cut the pectoralis major. The pleural rib fiber attachment and the lateral muscle fibers form a musculocutaneous island. 4. Formation of muscle vascular pedicles to identify the blood vessels of the vascular pedicle during the separation of the superior clavicle and ankle. This blood vessel is mainly the chest branch of the thoracic and aortic peak arteries. It can be seen by the naked eye that there is a blood vessel under the pectoralis major muscle which is inclined from the outside to the inside and can be palpated by hand. The width of the vascular pedicle is about 4 cm. 5. Separate the subcutaneous tunnel under the skin of the clavicle and form a wide tunnel with the neck wound to facilitate the passage of the myocutaneous flap. The size of the tunnel is such that there is no tension through the flap, and the muscle vascular pedicle is not subject to pressure. 6. Reconstruction of the laryngeal and cervical esophagus, such as the laryngeal mucosa, has a partial retention in the middle, which can face the skin surface of the skin island to the laryngeal and pharyngeal cavity, and the outer edge and the laryngeal mucosal margin are intermittently sutured, and the upper edge of the skin island is The tongue is sutured, the periphery of the oropharynx is sutured, and the lower edge of the island is sutured with the esophagus margin. If the laryngeal mucosa is not preserved, the skin island can be placed in the laryngeal and pharyngeal defect area, and the upper part and the oropharyngeal cutting edge can be circularly sutured. After the nasal feeding tube is placed, the tubular suture can be made, that is, the laryngeal esophagus can be made. 7. Rinse the wound and place the drainage tube to fully stop the bleeding, rinse the wound with saline, and insert the drainage tube under the skin. 8. Stitching the incision tracheostomy has completed the suture, suture the skin subcutaneously, skin, and suture the chest skin incision, and place the drainage strip. 9. Exchange the tracheal cannula After the patient is awake, remove the anesthesia catheter and place the common tracheal cannula in the trachea. 10. Wrap the chest incision and place the sterile dressing with a bandage. Place the neck incision with a sterile gauze and gently pressurize the dressing. complication 1. There is fresh blood flowing out in the trachea or in the mouth or in the drainage tube. It should be cut open in time to check the bleeding. 2. In the hematoma surgery, hemostasis or improper pressure bandage may cause hematoma in the chest donor area, and severe cases may be secondary infection. 3. Patients who have undergone radiotherapy before pharyngeal surgery are more likely to occur, and the principle of treatment is the same as that of general laryngeal surgery. 4. Muscle flap necrosis, poor blood supply to the vascular pedicle or severe infection of the wound after surgery can cause skin flap necrosis and cause surgery failure. 5. Anastomotic stenosis is a late complication requiring stenosis.