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Total Laryngectomy

Total Laryngectomy

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This book describes the surgical procedure total laryngectomy, its indications, surgical steps and complications.
This book describes the surgical procedure total laryngectomy, its indications, surgical steps and complications.

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Published by: Dr. T. Balasubramanian on Dec 07, 2009
Copyright:Attribution Non-commercial

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03/29/2013

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Total Laryngectomy
ByDr. T. Balasubramanian
 
Historical perspectives:History credits Patrick Watson for having performed totalLaryngectomy. This happened way back in 1866. Careful study of PatrickWatson’s description of the case has revealed that he performed atracheostomy on a live patient and performed an autopsy Laryngectomy onthe same patient. Ironically the patient died of syphilitic laryngitis. It wasBillroth from Vienna who performed the first total Laryngectomy on apatient with growth larynx. This happened on December 31 1873.Bottini of Turin documented a long surviving patient following totalLaryngectomy (10 years).Gluck critically evaluated total Laryngectomy patients and found thatthere were significantly high mortality rates (about 50%) during early postoperative phases. This prompted him to perform total Laryngectomy in twostages. In the first stage he performed tracheal separation, followed bytotal Laryngectomy surgery two weeks later. This staging of procedureallowed for healing of tracheocutaneous fistula before the actualLaryngectomy procedure.In 1890’s Sorenson one of the students of Gluck developed a singlestaged Laryngectomy procedure. He also envisaged the current popular incision Gluck Sorenson’s incision for total Laryngectomy.Indications:With the current focus on organ preservation procedures, totalLaryngectomy is slowly falling out of favor. The strategies for organpreservation surgery include horizontal partial and vertical partialLaryngectomy. Currently supracricoid partial Laryngectomy and near totalLaryngectomy are slowly gaining ground.1. Total Laryngectomy is still indicated in advanced laryngealmalignancies with extensive cartilage destruction and extralaryngealspread of the lesion.2. Involvement of posterior commissure / bilateral arytenoidinvolvement3. Circumferential submucosal disease associated with / withoutbilateral vocal fold paralysis4. Subglottic extension of the tumor mass to involve cricoid cartilage5. Completion procedure after failed conservative Laryngectomy /irradiation6. Hypopharyngeal tumors originating / spreading to post cricoid area7. Radiation necrosis of larynx unresponsive to antibiotics andhyperbaric oxygen therapy8. Severe aspiration following partial / near total Laryngectomy9. Massive nodal metastasis – In these patients total Laryngectomyshould be accompanied by block neck dissection
 
 Patient selection:Enumerated below are the patient requirements for a successful totalLaryngectomy.a. Patient should be medically fit for general anesthesia.b. Patient should be adequately motivated for post Laryngectomy lifec. Patient should have adequate dexterity of hands / fingers to managethe Laryngectomy tubesd. Positive biopsy proof is a muste. Screening for metastasis – This should include CT imaging of neckf. Evidence of second primary should be sought in all these patientsbefore surgery.g. Airway assessment by anesthetist is a must. In patients withobstructed airway tracheostomy should be performed beforeintubation. This preliminary tracheostomy can be performed under local anesthesia. Care should be taken to site the skin incision at theintended site of tracheostomy stoma. This helps to avoid theBipedicled Bridge of skin between the skin flap and tracheostomysite.Procedure:Total Laryngectomy is performed under general anesthesia. Patient isusually positioned with a mild extension of the neck. This can be achievedby placing a small sand bag under the shoulder of the patient. If availablethe patient can be placed over a table with head holder. This allows for thehead of the patient to be cantilevered with adequate head support. Ryle’stube should be introduced before the commencement of surgery.Incision:The following points should be borne in mind before deciding the type of incision to be used.1. Whether patient has been irradiated or not2. Whether block neck dissection is planned / notCommon incision used to perform total Laryngectomy is the GluckSorenson’s incision. This is actually a “U” shaped incision withincorporation of stoma into the incision line. The major advantage of thisincision is that there is minimal intersection with the pharyngeal closureline. The vertical limbs of the incision is sited just medial to thesternomastoid muscle. The upper limit of the incision is the mastoid

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precise and informative.
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very nice
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