What are the surgical steps for a bilateral selective neck dissection and total laryngectomy (removal of the larynx)?

From the Guidelines

A bilateral selective neck dissection and laryngectomy is a complex surgical procedure that requires meticulous technique to achieve complete oncologic resection while preserving vital structures and function, and the surgical steps involve patient positioning, prepping the surgical field, making an apron incision, and methodically removing lymph node groups at risk for metastasis, followed by laryngectomy and reconstruction. The surgery begins with patient positioning in neck extension and prepping the surgical field from the lower face to the upper chest. An apron incision is made across the neck, creating skin flaps that are elevated to expose the underlying structures. For the selective neck dissection, the surgeon identifies and preserves critical structures including the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle while methodically removing lymph node groups at risk for metastasis (typically levels II-IV) 1. The dissection proceeds from lateral to medial, with careful identification and ligation of vessels and preservation of non-lymphatic structures. For the laryngectomy portion, the surgeon separates the larynx from surrounding structures, divides the suprahyoid muscles, transects the pharynx above the larynx, separates the larynx from the trachea, and removes the entire specimen. The pharynx is then reconstructed, a permanent tracheostoma is created, and the neck is closed in layers with drains placed to prevent fluid collection. This procedure requires meticulous technique to achieve complete oncologic resection while preserving vital structures and function, with postoperative care focusing on wound healing, voice rehabilitation, and swallowing therapy. The decision to perform a bilateral selective neck dissection is based on the tumor's location and extent, with tumors at or near the midline or with bilateral drainage often requiring bilateral dissection 1. The type of neck dissection (comprehensive or selective) is determined by the preoperative clinical staging and the surgeon's discretion, with selective neck dissection often recommended for N0 disease and comprehensive neck dissection recommended for N3 disease 1.

Some key points to consider in the surgical procedure include:

• The importance of preserving critical structures, such as the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle, to minimize morbidity and improve functional outcomes 1.
• The need for meticulous technique and careful identification and ligation of vessels to prevent complications, such as bleeding or nerve damage 1.
• The importance of postoperative care, including wound healing, voice rehabilitation, and swallowing therapy, to improve functional outcomes and quality of life 1.
• The consideration of tumor location and extent in determining the need for bilateral selective neck dissection, with tumors at or near the midline or with bilateral drainage often requiring bilateral dissection 1.

Overall, a bilateral selective neck dissection and laryngectomy is a complex surgical procedure that requires careful planning, meticulous technique, and attention to detail to achieve complete oncologic resection while preserving vital structures and function.

From the Research

Surgical Steps for Bilateral Selective Neck Dissection and Laryngectomy

The surgical steps for a bilateral selective neck dissection and laryngectomy involve several key procedures:

• Preoperative evaluation and planning, including imaging studies to assess the extent of the tumor and potential lymph node involvement 2
• Intraoperative management, including the use of surgical instruments and techniques to minimize complications and ensure complete removal of the tumor and affected lymph nodes 3, 4
• Bilateral selective neck dissection, which involves the removal of lymph nodes from levels II-IV on both sides of the neck 4, 2
• Laryngectomy, which involves the removal of the larynx and surrounding tissues 3, 5

Key Considerations

Some key considerations for bilateral selective neck dissection and laryngectomy include:

• The risk of occult metastases, which can be higher in certain types of tumors, such as supraglottic laryngeal cancer 4, 5
• The potential for postoperative complications, such as wound infections and bleeding, which can be higher with bilateral neck dissection 3, 5
• The importance of careful preoperative planning and intraoperative management to minimize complications and ensure complete removal of the tumor and affected lymph nodes 2

Lymph Node Involvement

Lymph node involvement is an important consideration in bilateral selective neck dissection and laryngectomy:

• The incidence of occult cervical metastases can be significant, even in patients with clinically negative necks 4, 5
• The distribution of lymph node metastases can vary depending on the location and extent of the primary tumor 6
• The use of imaging studies and other diagnostic tools can help identify patients who are at high risk for lymph node involvement and may benefit from bilateral selective neck dissection 2