Total Laryngectomy with Free Flap Reconstruction: Surgical Steps and Critical Neurovascular Structures
Total laryngectomy with free flap reconstruction is a complex procedure that requires careful attention to neurovascular structures to minimize complications and optimize functional outcomes.
Preoperative Considerations
- Pretreatment voice and swallowing assessments should be performed to establish baseline function and help predict postoperative outcomes 1
- Multidisciplinary evaluation is essential to determine suitability for the procedure and to plan reconstruction 1
- Advanced imaging should be used to precisely stage tumors and assess extent of disease 1
Surgical Steps for Total Laryngectomy
1. Patient Positioning and Preparation
- Position patient supine with neck extended
- Prepare and drape from face to chest and upper arms (for potential flap harvest)
- Mark incision lines for both laryngectomy and flap donor site 2
2. Incision and Exposure
- Create a U-shaped or apron incision at the level of the thyroid cartilage
- Raise subplatysmal flaps superiorly to the hyoid bone and inferiorly to the clavicles
- Identify and preserve great vessels of the neck (carotid artery, jugular vein) 1
3. Neck Dissection (if indicated)
- Perform appropriate level neck dissection based on nodal status
- Preserve non-involved structures (spinal accessory nerve, internal jugular vein, sternocleidomastoid muscle) when oncologically appropriate 1
4. Laryngeal Dissection
- Divide strap muscles at the level of the hyoid bone
- Identify and ligate superior laryngeal vessels and preserve superior laryngeal nerve if possible
- Separate larynx from pre-vertebral fascia posteriorly 1
5. Pharyngeal Entry
- Enter pharynx through vallecula or pyriform sinus
- Complete circumferential dissection of larynx
- Divide trachea below the level of the tumor 1
6. Closure of Pharyngeal Defect
- For primary closure: close pharyngeal mucosa in vertical or T-shaped fashion
- For free flap reconstruction: prepare recipient vessels (typically facial or superior thyroid artery and external jugular or facial vein) 2
Free Flap Reconstruction
1. Flap Selection
- Radial forearm free flap: most commonly used for pharyngeal reconstruction due to thin, pliable tissue and long pedicle 3
- Anterolateral thigh flap: alternative option for larger defects
- Ileocolic free flap: option for extensive defects involving total laryngopharyngectomy with glossectomy 4
2. Flap Harvest and Preparation
- Harvest appropriate flap based on defect size
- For tubed reconstruction: create a tube from the flap to restore pharyngeal continuity
- For patch reconstruction: use flap to reinforce primary pharyngeal closure 2
3. Microvascular Anastomosis
- Perform end-to-end or end-to-side anastomosis of flap vessels to neck vessels
- Ensure adequate arterial inflow and venous outflow
- Use operating microscope for precision 5
4. Flap Inset and Closure
- Secure flap to remaining pharyngeal mucosa with absorbable sutures
- Create watertight closure to prevent fistula formation
- Place closed suction drains 2
Critical Neurovascular Structures to Protect
1. Vascular Structures
- Carotid artery system: Common, internal, and external carotid arteries must be identified and preserved 1
- Jugular venous system: Internal jugular vein should be preserved when possible 1
- Facial vessels: Often used as recipient vessels for free flap reconstruction 5
- Superior and inferior thyroid vessels: May be used as recipient vessels or may need to be ligated 2
2. Neural Structures
- Vagus nerve (CN X): Recurrent laryngeal branches will be sacrificed with the specimen, but main trunk should be preserved 1
- Hypoglossal nerve (CN XII): Critical for tongue mobility; must be identified and preserved 1
- Spinal accessory nerve (CN XI): Important for shoulder function; should be preserved during neck dissection 1
- Phrenic nerve: Located on the anterior scalene muscle; damage can cause diaphragmatic paralysis 1
- Sympathetic trunk: Located in the prevertebral fascia; injury can cause Horner's syndrome 1
Postoperative Considerations and Complications
- Pharyngocutaneous fistula: Free flap reconstruction reduces major fistula complications (29% vs 30% overall rate) but doesn't eliminate all fistulas 2
- Stricture formation: Can occur in up to 42% of patients with free flap reconstruction 2
- Wound infections: More common in primary closure compared to free flap reconstruction in total laryngectomy patients 6
- Voice rehabilitation: All patients should receive some method of functional speech restoration (electrolarynx, esophageal speech, or tracheoesophageal voice restoration) 1
Benefits of Free Flap Reconstruction
- Provides vascularized tissue to reinforce pharyngeal closure 2
- Reduces major wound complications compared to primary closure 5
- Allows for better management of salvage laryngectomy after failed organ preservation 5
- Enables successful functional rehabilitation with good quality of life outcomes 2
- Reduces hospital stay when fistula is prevented (7 days vs 19 days with fistula) 5