DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic aspiration and amyotrophic lateral sclerosis.
POSTOPERATIVE DIAGNOSIS: Chronic aspiration and amyotrophic lateral sclerosis.
OPERATION PERFORMED: Total laryngectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Less than 50 mL.
FINDINGS: There were no significant findings.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with a history of amyotrophic lateral sclerosis, who is having difficulty handling her own secretions. The concern is that she would start showing signs of aspiration pneumonia. The patient is currently aspirating with coughing and choking on her own saliva. She is currently G-tube dependent and does no oral feedings. The decision was made with the family to perform a laryngotracheal separation. This will be performed by doing a total laryngectomy with creation of a stoma. The risks and benefits of the procedure were explained to the patient, and the patient decided to go ahead with the procedure.
DESCRIPTION OF OPERATION: The patient came to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned, and the patient was prepped and draped in the sterile fashion.
A transverse incision, approximately two fingerbreadths above the clavicle, was made in a horizontal fashion, extending from the sternocleidomastoid muscles bilaterally. The incision was carried down through the skin with Bovie cautery. This was taken down to just below the platysma muscle. A flap was then elevated superiorly in a simple platysmal plane up to the level of the hyoid bone.
At that point, the strap muscles were dissected with Bovie cautery in the midline to reveal the cricoid cartilage and the trachea. The thyroid isthmus was dissected free and cut. The ends of the thyroid isthmus were cross clamped and tied with 3-0 silk suture. The medial wall of the thyroid glands was then dissected free from the trachea with Bovie cautery. This allowed approximately 270 degrees around the trachea. The dissection was then carried superiorly along the lateral borders of the cricoid cartilage.
At that point, the midline was then dissected free over the thyroid cartilage. The overlying strap muscles were dissected free from the underlying thyroid cartilage to the lateral border of the thyroid cartilages bilaterally. The tissues adhering to the superior border of the thyroid cartilage again were dissected free with Bovie cautery down to the level of the thyrohyoid ligament.
A 15 blade was then used to incise between the third and fourth tracheal rings. The endotracheal tube was removed. The creation of the stoma was then carried superiorly through one tracheal ring to the third tracheal ring. An endotracheal tube was then placed through the stoma opening for general anesthesia and respirations. A knife was used to dissect the posterior wall of the trachea preserving the underlying esophagus and pharynx.
Dissection was carried superiorly to the undersurface of the thyroid cartilage. The mucosa was gently dissected free from the posterior larynx. The pyriform sinuses were dissected free from the lateral posterior laryngeal wall. The mucosa was followed up superiorly up to the thyrohyoid ligament. This was dissected free and cut with Bovie cautery.
At that point, the larynx was tethered from the underlying pharynx. A 60 mm stapler was then used to staple between the larynx and the pharynx. This was performed without difficulty. Bovie cautery was then used to excise the overlying larynx from the newly created neopharynx. The pharyngeal closure was then tested with full strength peroxide. The neopharynx showed good filling and flow with the peroxide with no evidence of leak. The trachea was then sewn to the inferior skin edge in half mattress with 3-0 Vicryl stitches.
The underlying strap muscles were then reapproximated with 3-0 Vicryl stitches. A #10 JP drain was then placed into the wound bed. The skin was reapproximated in two layers. The platysma layer was reapproximated with 3-0 Vicryl stitches. The skin edges were reapproximated with staples. The superior edge of the stoma was then approximated to the underlying tracheal ring with 3-0 Vicryl sutures in a half mattress fashion. The procedure was then completed. The patient was awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
