Total laryngectomy

Total laryngectomy is the gold standard for the surgical treatment of advanced laryngeal tumors: is the standard against which the cure rates of other treatment modalities must be compared. The main indication for total laryngectomy is locally advanced tumors of the larynx or hypopharynx that are not suitable for open or endoscopic partial laryngectomy. Salvage total laryngectomy has an important role in nonsurgical organ preservation protocols. Prior to surgery, the patient must understand the indication and sign an informed consent, including realistic understanding of the total laryngectomy state and lifestyle modifications after surgery. The surgeon must have a very precise knowledge of the extension of the tumor prior to surgery (via fibroscopy, endoscopy, computed tomography/magnetic resonance imaging). This information can indicate the best way to remove the larynx and obtain free margins. For hypopharyngeal and subglottic primaries, unilateral or subtotal thyroid gland and paratracheal node resection may be necessary. Three main ways to remove the larynx can be used: above-downward approach, below-upward approach, and lateral approach. For every tumor, the surgeon must analyze the best way to remove the larynx. For endolaryngeal tumors, it is to use the above-downward approach; for extensions to valecula or when a mechanical closure of the pharynx, the best approach is below-upward; and for extensions to the piriform sinus the best approach is the lateral one. Obtain frozen section specimens of the margins if there is any doubt, especially in cases of salvage surgery after radiotherapy. There are many ways to reconstruct the pharynx. Surgeons should be familiar with primary closure of the defect and free flap recon-struction. The status of the quality of life after total laryngectomy is highly personal and subjective. In general, survivors have the perception of a good quality of life and most have a high level of satisfaction with their decision to undergo total laryngectomy. © Springer-Verlag Berlin Heidelberg 2010.