When tumors occur at the junction between the lower larynx and the trachea and involve both organs, a conservative laryngeal sparing approach seems appropriate. Benign neoplasms such as granular cell tumor, chondroma, and paraganglioma can be effectively removed in conservative fashion, with a portion of larynx, accepting a narrow margin of normal tissue around the tumor. Some malignant tumors, especially of limited aggressiveness, may be similarly removed, but patients must be closely followed. Reconstruction varies uniquely with size and location of the tumor.16
Table 25-1 Laryngotracheal Anastomosis with Posterior Mucosal Flap:
1. Place midlateral traction sutures (2-0 Vicryl) deeply in the lamina of the cricoid, above and through the wall of the trachea below (see Figure 25-4A).
2. Place four fixation sutures (4-0 Tevdek) from the inferior margin of the posterior cricoid plate to the base of the membranous tracheal flap. Sutures do not penetrate the mucosa (see Figures 25-4A,B).
3. Place anastomotic sutures (4-0 Vicryl) between the posterior mucosa of the larynx (over the upper posterior cricoid plate) and the membranous wall flap of the trachea. Knots will lie beneath the mucosa (see Figures 24-4B,C).
4. Place anastomotic sutures (4-0 Vicryl) from the lateral lamina of the cricoid and laryngeal mucosa to the full thickness of the lateral tracheal wall, posterior to the midlateral traction sutures.
5. Place one or two additional anastomotic sutures on both sides, anterior to the midlateral traction sutures.
6. Flex the neck as necessary. Tie traction sutures, approximating the airway posteriorly and laterally.
7. Tie Tevdek fixation sutures posteriorly. Cut off excess of each suture as tied.
8. Tie Vicryl posterior mucosal flap anastomotic sutures inside the larynx.
9. Tie lateral anastomotic sutures posterior to the traction sutures.
10. Place anterior anastomotic sutures (4-0 Vicryl, with occasional midanterior 3-0 or 2-0 Vicryl suture, as needed) (see Figure 25-4D).
11. Advance the endotracheal tube from the larynx into the trachea.
12. Tie all sutures anterior to the lateral traction sutures, working from both sides toward the center. The surgical assistant crosses the next suture to assist in the approximation.
An anteriorly located tumor that involves the cricoid is removed by excision of the anterior subglot-tic larynx, employing individualized modifications of the technique of laryngotracheal resection described for resection of benign anterolateral subglottic stenosis (see Figure 25-2). For posterior midline tumors, a membranous tracheal wall flap is advanced for reconstruction. In some cases, the mucosa and submucosa overlying the posterior plate of the cricoid alone need to be resected (see Figure 7-14 in Chapter 7, "Primary Tracheal Neoplasms"). In others, various amounts and depths of cricoid must be resected to obtain suitable margins. If the tumor is limited enough to permit a larynx conserving operation, usually enough posterior cricoid cartilage remains below and between the arytenoids to serve as a bridge, which preserves laryngeal stability. When a posterior laryngeal resection alone is necessary, adequate exposure for posterior mucosal anastomosis is obtained by vertical midline division of the cricoid, essentially a limited laryngofissure (Figure 25-5). An example of excision of a posterior centrally located tumor is shown in Figures 25-5A—F. The technical steps are explained in the legends.
In other cases with unilateral involvement, an appropriate margin is obtained by resection of portions of the lower larynx, tailoring the trachea to fit the laryngeal gap created.16,17 A major application of such tailoring procedures, following partial resection of the lower larynx for the tumor, has been for differentiated carcinomas of the thyroid (follicular, papillary, and mixed types).17,18 Undifferentiated thyroid cancer most often, but not universally, invades too aggressively for conservative surgery to be applied. If any surgical treatment is applicable in these patients, en bloc resection of larynx and trachea may be required (see Chapter 34, "Cervicomediastinal Exenteration and Mediastinal Tracheostomy"). For differentiated thyroid cancer, for benign tumors, or for tumors of lesser malignancy, the objective is to remove the local tumor and prevent airway obstruction, while preserving laryngeal function. This is achieved by carefully circumscribing the tumor,
figure 25-5 Excision of a central posterior tumor involving the subglottic larynx and trachea. A, The trachea is transected at an appropriate level below the tumor (horizontal dashed line). A midline vertical incision divides the anterior wall of the subcricoid segment of the trachea and continues up as a limited laryngofissure across the midpoint of the cricoid cartilage and the cricothyroid membrane to the thyroid cartilage. Exposure is further improved by dividing the trachea from beneath the cricoid horizontally on either side (dotted line), working posteriorly toward the tumor. The glottic level is also indicated. B, Lateral view showing the level of tumor and lines of incision. The recurrent nerves are carefully spared by keeping dissection close to the tracheal wall and not dissecting out the nerves. C, The Alm expandable retractor facilitates anterior exposure through the laryngofissure.
with a sufficient margin of subglottic larynx so that the tumor is locally excised (Figure 25-6). The larynx on the side opposite from the tumor is transected horizontally beneath the lower border of the remaining cricoid cartilage, very carefully preserving that recurrent laryngeal nerve. If a recurrent laryngeal nerve must be excised, it is usually one that has already been paralyzed by tumor invasion or is inseparable from the tumor. Distally,
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