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figure 25-5 (continued) D, The tumor and posterior subglottic larynx are exposed, permitting resection to continue. The posterior mucosal division superior to the tumor is indicated by the dashed line. This will be connected laterally to the line of resection on either side just below the cricoid. A portion of posterior cricoid cartilage is excised, if involved by tumor. Laryngeal stability will be maintained if a bridge of posterior cricoid remains above the level of cartilage excision. In order to fashion a posterior membranous tracheal flap for reconstruction of the defect, even if resection included cartilage, additional tracheal rings are resected, as outlined in the trachea below (dashed line). An estimate of the total number of rings that will be removed should be made at the outset. Resection of cartilages should be performed conservatively and, if necessary, in stages in order not to shorten the trachea unnecessarily. The corners of the flap are shaped as needed. E, Reconstruction is commenced by anastomosis of the posterior mucosa and submucosa of the larynx to the posterior tracheal flap. Sutures are placed so that knots will lie submucosally. If a wide expanse of cartilage of the posterior cricoid plate is exposed below the cut edge of the posterior laryngeal mucosa and submucosa, it is sometimes advisable to fix the back of the flap to the lower edge of the cartilage, as shown in Figures 25-4A and 25-4B. The balance of the anastomosis will be of trachea (cartilage and mucosa together) to residual anterior and lateral cricoid, with its underlying laryngeal mucosa. F, After placement of all circumferential anastomotic sutures, the vertical cricothyroid membrane incision is sutured closed. A mattress suture is placed at the junction of the inverted T suture lines. The anastomosis is then completed. The usual midlateral Vicryl stay sutures (in the lateral cricoid laminae and in the trachea below) are omitted in the drawing for clarity, but are necessary the trachea is shaped after laryngeal excision, in such fashion that it will mortise into the defect created by the excision (see Figure 25-6). Suture lines are irregular and unique to each case, and often "bayonet" shaped. On occasion, a partial or even full thickness of esophageal wall must be resected to obtain a posterior margin (see Figure 25-6E). Generally, the length of resection is not so great that a problem of anastomotic tension results.

figure 25-6 Lateral laryngotracheal excision for tumor, such as differentiated thyroid carcinoma or low-grade chondrosarcoma. A, Initial tracheal division is made horizontally at an appropriate level below the tumor. The extent of tailoring which is necessary for reconstruction is not known at the outset. The dashed line represents the final tracheoplasty incision, which is completed later. Transection is made at the level of the horizontal tracheal incision line closest to the tumor. The dashed line of laryngeal excision above circumscribes the portion of larynx invaded by tumor. The laryngeal excision is commenced by incising horizontally beneath the cricoid, opposite to the side of tumor, to visualize the edge of the tumor intralaryngeally. If this does not provide clear visualization, then the tracheal segment, already divided transversely below the tumor, may be opened vertically up to the uninvolved cricoid, and the extent of the tumor in the larynx can then be observed directly. As the line of excision advances, the extent of tumor becomes increasingly evident. B, The anterolateral laryngeal defect will be repaired with trachea, fashioned by removing segments of tracheal rings on the side opposite to the laryngeal excision. Since the circumference of laryngeal defect is likely to be greater in length, only a lesser segment of trachea is removed, allowing cartilage to spread somewhat. Slight rotation of the trachea prior to anastomosis is permissible, further sparing cartilage in order to provide stability. The recurrent nerve has been carefully spared on the uninvolved side. The nerve is not dissected out. Instead, dissection is kept close to the larynx and trachea on this uninvolved side, with no more exposure of the inferior cricoid margin than is absolutely necessary. C, Anastomosis is accomplished in the usual way, using 4-0 Vicryl sutures and 2-0 lateral stay sutures.

Particular aspects of the technique applicable to resection of laterally located tumors are noted in the legends for Figure 25-6. Since the tissue beyond the tumor is normal, the difficulty caused by residual inflammatory thickening and narrowing, which is seen in similar surgery for inflammatory strictures, is not a factor. Repair following laryngotracheoplasty for tumor is therefore more likely to succeed without danger of a stenosis. Results of laryngotracheal resections for tumor and for inflammatory lesions are not comparable.

A conservative approach is applicable in a small number of patients with squamous cell carcinoma or adenoid cystic carcinoma of the uppermost trachea with impingement on the larynx.19 On occasion, a microscopically positive margin is accepted in such cases, just as in the case of an invasive thyroid carcinoma, in order to save the larynx. Full-dose irradiation follows. In thyroid carcinoma, radioiodine may be indicated if uptake occurs. Chondroma or low-grade chondrosarcoma, most often arising from the posterior cricoid plate, may be similarly treated, conserving a functional larynx.16,20 Other patients treated by conservative resection had mucoepidermoid and spindle cell tumors and pseudotumors. These patients must be followed in the long term for possible recurrence. Laryngotrachiectomy may later be possible for local recurrence, despite irradiation received (see Chapter 34, "Cervicomediastinal Exenteration and Mediastinal

figure 25-6 (continued) D, In this patient, a differentiated thyroid carcinoma invades the larynx, trachea, and esophagus. The left recurrent nerve is paralyzed. A similar "bayonet" excision of airway is performed as in the previous illustrated case. I elected to save the uninvolved right hemithyroid, further ensuring safety of the right recurrent laryngeal nerve. The lobe, however, is dissected free from the trachea and larynx medially. E, Invasion of the esophagus was limited to the muscularis, and the mucosa was saved. The esophageal muscle is sutured with a single layer of interrupted 4-0 Vicryl or silk Lembert sutures. If the esophageal mucosa must also be resected due to invasion, it is closed with interrupted inverting sutures of 4-0 Vicryl or silk, and the muscularis is closed in a second layer, as described. A pedicled sternohyoid muscle is sutured over the esophageal repair prior to airway reconstruction, in order to prevent fistulization. At most, the esophagus may require one or more dilations postoperatively. In many cases, no dilation is needed. F, The completed laryngotracheal reconstruction.

Tracheostomy"). Indeed, primary irradiation alone has been elected by some patients, where larynx sparing surgery was impossible. The use of the omentum in concert with resectional or reconstructive airway surgery is discussed in Chapter 42, "The Omentum in Airway Surgery and Tracheal Reconstruction after Irradiation." Patients often prefer to take risks in order to salvage laryngeal function for a considerable period of time, if not permanently. There is no way to estimate the hazard of metastasis from a residual but irradiated disease, in the interval.

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