DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the supraglottis.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the supraglottis.
OPERATIONS PERFORMED:
1. Total laryngectomy.
2. Bilateral modified radical neck dissection, type 1.
3. Indirect laryngoscopy with esophagoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General via tracheostomy tube.
ESTIMATED BLOOD LOSS: 200 mL.
DESCRIPTION OF OPERATION: Once the patient was appropriately identified, general anesthesia was administered via the previously placed tracheostomy tube. Once under general anesthesia, the patient’s bed was rotated 90 degrees away from the anesthesia machine and the patient placed on a shoulder roll and covered with sterile fields in standard fashion. A Dedo rigid laryngoscope was used to perform a laryngeal examination and examination of the oral cavity, oropharynx and oropharyngeal cavity. The location of the tumor was confirmed on direct laryngoscopy, involving the right false vocal folds and vallecula. Direct rigid esophagoscopy was then performed to evaluate for the possibility of synchronous lesions and no lesions were found on esophagoscopy.
Thus, the decision was made to proceed with total laryngectomy and bilateral modified radical neck dissection. The apron-type incision was marked out with a marking pen incorporating the tracheostomy stoma with peristomal skin excision site. Lidocaine 1% with epinephrine 1:100,000 was used to inject the premarked incision site. A total of 10 mL was used. Once this was done, the patient’s neck was prepped with Betadine solution and sterile fields were done in standard fashion.
An incision was made along the previously marked lines and carried out through the subcutaneous layers below the platysma. Once this was performed, a skin flap was elevated in the subplatysmal plane to the level of the hyoid bone and down to the level of the clavicle. Once this was performed, the operation proceeded to modified selective neck dissection which incorporated levels 2, 3 and 4. The dissection started on the patient’s right side. The sternocleidomastoid fascia was grasped and retracted medially off the sternocleidomastoid muscle towards the carotid sheath. As dissection proceeded toward the carotid sheath, the spinal accessory nerve was identified and carefully isolated from surrounding fascial attachments. Once the nerve was freed up, level 4 dissection started by identifying the omohyoid muscle. The omohyoid muscle was freed of fascial covering and retracted inferiorly exposing the carotid sheath at level 4. Fibrofatty tissue around that area was carefully dissected off the fascia overlying the anterior scalene muscles and bluntly dissected forward towards the carotid sheath and superiorly. It was then dissected off the carotid sheath and the previously identified plane with blunt and sharp dissection using electrocautery.
Attention was paid to preserving the phrenic nerve, vagus nerve, brachial plexus and cervical sensory rootlets. Once the fibrofatty tissue was released along the entire carotid sheath, it was brought up superiorly where it was completely dissected off the carotid sheath and submitted to the pathology department. Prior to submission, level 2 of the neck dissection was marked with a 2-0 silk for proper orientation. Once the dissection was completed, attention was turned to the patient’s left side where dissection was performed in a similar fashion incising the sternocleidomastoid fascia and releasing it off the muscle. Once this was performed, the spinal accessory nerve was identified in the medial portion of the sternocleidomastoid muscle and released from overlying fibrofatty tissue. Once that was performed, the omohyoid muscle was identified lower in the neck and was dissected off surrounding fascia and retracted inferiorly, exposing level 4 of dissection. Fibrofatty tissue was bluntly and sharply dissected off the carotid sheath and the floor of the neck and brought out the superior medial fascia. Once dissection was completed, the fibrofatty tissue was submitted to the pathology department with a marking stitch at level 2 neck dissection.
Upon completion of the neck dissection, attention was turned to total laryngectomy. The trachea was identified along the midline and a transverse incision was made at the level below the previously created tracheostomy stoma. The incision was carried in a slightly oblique direction posteriorly to provide an adequate size stoma. Once incision was made into the trachea, a 2-0 silk suture was placed through the tracheal cartilage down to skin to prevent retrosternal retraction of the trachea. The tracheostomy and 8.0 reinforced endotracheal tube was placed in the newly created tracheal stoma and secured to the chest with 2-0 silk for ventilation. Once this was performed, the tracheal incision was completed at the posterior aspect finding the fascial plane between the trachea and esophagus. Once that was performed, attention was switched to thyroid isthmusectomy. The thyroid isthmusectomy was previously performed during tracheostomy procedure and thus the scar tissue was excised from the midline tracheal wall and the left thyroid gland was carefully dissected off the trachea where the right thyroid gland was incorporated into the specimen due to predominantly right-sided lesion.
Hemostasis was achieved and the vasculature to the thyroid gland was identified and ligated to free up the thyroid gland. Once this was performed, the dissection proceeded in a superior direction along the plane between the trachea and esophagus, releasing the trachea off the esophagus to the level of the cricopharyngeus muscle. Once this was completed, attention was switched to separating the larynx superiorly. An incision was made with the Bovie along the body of the hyoid bone through the strap muscles down to the mucosa of the vallecula and epiglottis. Once the body of the hyoid was released, it was grasped with a Lahey clamp and retracted inferomedially exposing the greater horn of the hyoid. The incision was completed along the greater horn of the hyoid, releasing all fascial and ligamentous attachments in close proximity to the bone to avoid damage to the hypoglossal nerve.
Once the greater horn of the hyoid was released on the right side, dissection proceeded toward the left side. In a similar fashion, the hyoid bone was rotated medially, inferiorly exposing the greater horn of the hyoid bone on the right side, and the soft tissue was released off the bone. Once that was performed, attention was turned to the thyroid cartilage. The inferior constrictors were released off the left side of thyroid cartilage and greater horn of thyroid cartilage and piriform mucosa was carefully dissected off the inner portion of the thyroid cartilage.
The decision was made to enter the oropharyngeal cavity through the left vallecula. The mucosa of the vallecula was excised and opened and the epiglottis noted and grasped and retracted inferiorly. Exposure of the larynx was then obtained on the left side and tumor was also visualized on the left side. Mucosal cuts were made behind the larynx and along the medial walls of piriform sinuses with direct visualization of the lesion to avoid the positive margins. Once the mucosal cuts were made, the rest of the specimen was released from surrounding muscular and ligamentous attachments.
Once released, the specimen was submitted to pathology for evaluation. Due to significant redundancy of piriform mucosa, about 1 cm margins were obtained circumferentially and also submitted for frozen section. Once frozen section confirmed the absence of positive margins, 3-0 Vicryl sutures were placed along the most inferior, middle and superior portions of the piriform mucosa. The mucosa was pulled up and the articular linear stapler was used to staple the mucosal edges together. There was a small area at the tongue base where the stapler could not get to. Thus, inverted 3-0 Vicryl stitches were placed along the base of tongue in interrupted fashion to provide a watertight closure. Once this was completed, the oropharyngeal cavity was irrigated with the bulb irrigator and a watertight closure was assured. Once this was completed, the mucosal closure of the neopharynx was reinforced with closure of the inferior constrictor muscles without excessive tension. Once this was performed, the total laryngectomy portion of the procedure was completed.
The neck was thoroughly irrigated. Hemostasis was achieved using bipolar cautery. Four #10 JP drains were placed in the patient’s neck, 2 in the lateral aspect of the neck bilaterally with a drain placed underneath the sternocleidomastoid muscle and 2 along the medial portion of the neck in the area of anastomosis. They were carried out through separate stab incisions in the skin. The skin flap then was laid down and stomal stitches using 3-0 Vicryl were placed to create a widely patent stoma. Half mattress stitch technique was utilized to have the edges of the skin encroach and cover the top of the cartilage. This was done under intermittent apneic episodes with close monitoring. Once the stomal stitches were placed, the skin was closed in the platysmal layer with interrupted 3-0 Vicryl. The skin incision was closed with stainless steel staples along the entire incision. The incision was covered with antibiotic ointment. Drains were placed to suction. The patient was turned over to Anesthesia for withdrawal of the general anesthesia. When the patient was able to be maintained on ventilation, the endotracheal tube was withdrawn from the patient’s newly-created laryngectomy stoma and he was transferred to the recovery room in guarded condition.
