Modular Approach to Open Partial Horizontal Laryngectomy: Step-by-Step Anatomic Dissection

Operative Technique

Open partial laryngectomies still play an important role in contemporary conservative management of laryngeal cancer. ¹ A comprehensive and systematic classification of open partial horizontal laryngectomies (OPHLs) was presented by the European Laryngological Society working committee in 2014. ² It represents a simple and organized scheme for the most widely used OPHLs and identifies 3 types of OPHL: type I (supraglottic laryngectomy), type II (supracricoid laryngectomy), and type III (supratracheal laryngectomy). Use of suffixes “a” and “b” in type II and III OPHLs reflects, respectively, sparing or removal of the suprahyoid epiglottis. OPHLs have been used extensively as a surgical option in early (I-II) ³ and intermediate stages (III) ⁴ ; they also provide excellent oncological and functional results as rescue procedures in radio-recurrent and laser-recurrent laryngeal cancer. ⁵

The aim of this video is to show the main surgical steps in OPHLs using a cadaveric dissection and to explain the modular approach for removal of laryngeal tumors (see Supplemental Video S1 in the online version of the article).

Ethics committee approval was not applicable (Exemption Comitato Etico delle province di Verona e Rovigo).

Preliminary Steps

After dissection of the subhyoid muscles, the larynx and hyoid bone are completely exposed in order to perform the subsequent surgical steps. Visualization of the superior laryngeal pedicle is mandatory; rotation of the larynx permits exposure of the pedicle in close proximity to the superior horn of the thyroid cartilage. The artery and vein are ligated and sectioned, while preservation of the nerve is fundamental for innervation of the piriform sinus. The superior horn of the thyroid cartilage is detached from the thyroid ligament using surgical scissors, and the constrictor muscles of the larynx are dissected. We then proceed with a meticulous and delicate detachment of the entrance of the piriform sinus from the thyroid cartilage. The inferior horn of the thyroid cartilage is always dissected from the side where the arytenoid must be retained in order to avoid accidental injury to the recurrent nerve. Finally, the thyroid cartilage is fractured to obtain a broader visualization of the laryngeal lumen during the subsequent surgical steps.

OPHL Type I

After detachment of the internal perichondrium of the thyroid cartilage, sectioning of the upper portion of the thyroid cartilage is performed along 2 symmetrical oblique lines.

OPHL Type IIA

After incising the cricothyroid membrane, cricothyroid muscle, and the elastic cone, the inferior limit of the resection passes immediately above the cricoid ring. The superior limit of the resection is represented by a perpendicular plane at the upper edge of the thyroid cartilage. The superior access to the laryngeal vestibule allows direct visualization of the arytenoids and epiglottis. The lateral resection always starts on the side not affected by the lesion. It passes anteriorly to the arytenoids, subsequently dissecting the insertion of the ventricular bands, the vocal process, the vocal fold and the lower paraglottic space, the cricothyroid membrane, and the elastic cone.

OPHL Type IIIA

In this illustrative video, we simulated the treatment of a laryngeal tumor that develops in the right hemilarynx and involves the focal fold, the subglottic space, and the arytenoid. The lower limit of the resection passes between the cricoid ring and the first tracheal ring. Incision of the mucosa is carried out medially in the posterior commissure and inferiorly until the lower limit of the resection is reached. It is imperative to perform a careful and meticulous detachment of the mucous membrane of the piriform sinus and of the retrocricoid region on the same side. During this step, the surgeon may find it helpful to enlarge the piriform sinus laterally by inserting an index finger and thus allowing dissection of the submucosa. The right cricoarytenoid unit must be removed together with the cricoarytenoid muscles. At the end of the resection, the left cricoarytenoid unit together with both piriform sinuses and the epiglottis is preserved. Before performing the tracheohyoidoepiglottopexy, it is mandatory to meticulously reconstruct the piriform sinus from the side of the sacrificed cricoarytenoid unit, suturing the mucous membrane of the arytenoid to the tracheal mucosa. The tracheohyoidoepiglottopexy is accomplished by means of 4 sutures (the central suture is a double suture, while the others are single sutures), which pass between the first and second tracheal rings inferiorly, cross the preepiglottic space and the subperichondrial plane of thyroid cartilage, and include superiorly the base of the tongue and the hyoid bone. The procedure ends with suspension of the thyroid gland over the tracheohyoidoepiglottopexy, after its mobilization from the airway.

As shown in this illustrative video, one of the main advantages of OPHLs is the possibility of using a modulated approach intraoperatively based on the tumor’s features. The 3 major categories of OPHLs can be combined and modulated with posterior or vertical enlargement, making them suitable for the management of most laryngeal cancers. ⁵