Closed Laryngectomy Using the Automatic Linear Stapling Device

Although first described by Hoehn and Payne 1. in 1969 for pharyngeal repair after excision of a Zenker's diverticulum, the use of automatic stapling devices in head and neck surgery as a means to achieve closure of pharyngeal defects created during surgery has received only sporadic interest. 2.-7. When it is used during total laryngectomy, most reports describe application of stapling devices often in combination with traditional suture techniques to repair open pharyngeal defects created after laryngeal resection. 2.-5. Application of the stapling device to the pharynx after laryngeal skeletonization just before resection of the larynx has been reported in only two previous published series. 6., 7. The senior author (d.e.s.), however, became interested in this technique after favorable results reported by Bedrin et al. (personal communication, 1998) and Greenberg et al. (personal communication, 1998) at the Second International Symposium in Israel on Head and Neck Surgery and Oncology in Jerusalem in 1998. The latter method, which describes a “closed” technique of total laryngectomy, theoretically minimizes wound contamination by pharyngeal secretions while simultaneously effecting rapid pharyngeal repair. Potential benefits of such an approach include decreased operative time as well as decreased perioperative morbidity with regard to wound infection resulting from salivary contamination. This study was undertaken to describe our initial experience with this approach in patients who have undergone total laryngectomy at this institution using this type of device. The charts of seven patients who underwent total laryngectomy from December 1998 to October 1999 in the Department of Otolaryngology—Head and Neck Surgery at Ohio State University using an automatic stapling device were reviewed. Data obtained included pertinent history, staging, endoscopic assessment, intraoperative course, surgical margins, and postoperative course including information pertaining to complications and swallowing ability. Panendoscopy is performed on all patients to verify tumor extent. After standard flap elevation, the larynx is systematically skeletonized in the usual fashion. The following points are emphasized. After detachment of the pharyngeal constrictors from the lateral borders of the thyroid ala and release of the hyoid bone from the suprahyoid musculature and its lateral attachments, the suprahyoid epiglottis, which can be appreciated in relief, is subsequently skeletonized along its lingual surface, thus preserving additional mucosa superiorly and further mobilizing the larynx along its superior aspect. Performance of this maneuver is critical and allows for adequate mucosa to be available superiorly for direct mucosal approximation and tension-free closure when the stapling device is later applied. Furthermore, the epiglottis itself can hinder application of the stapling device if not adequately mobilized. Care is taken throughout to avoid inadvertent entry into the pharynx. The trachea is then transected at an appropriate level and a formal separate stoma is created through the inferior flap, thus separating the airway from the wound. At this point, the larynx, now completely mobilized, is suspended above the pharynx, remaining connected only by its mucosal attachments (Fig. 1). Completely skeletonized larynx after transection of the trachea. Larynx is entirely suspended above pharynx, attached only by mucosa. The hyoid bone and pharyngeal constrictors have been released. The skeletonized epiglottis (arrowhead) can be seen in relief superiorly. The stapling device (Autosuture TA 90 long disposable stapler, United States Surgical Corp., Norwalk, CT) (Fig. 2) is then positioned between the larynx and pharynx. The device, positioned close to the larynx so that additional pharyngeal mucosa is not unnecessarily resected (Fig. 3), is then clamped and staples are applied by activating the trigger handle mechanism, after which the specimen is sharply transected (Fig. 4). After release of the device, the closure is checked manually to verify an intact staple line (Fig. 5). Primary tracheoesophageal puncture is then performed at this time. Although this most often involves the use of a long right-angled hemostat passed transorally by an assistant, occasionally other methods are employed (see results section) if this method proves difficult. Closure of the neck incision is carried out over closed suction drains. Autosuture TA 90 long disposable surgical stapler (titanium staples). Stapling device being positioned between larynx above and pharynx below. Stapler should be positioned close to larynx immediately before device activation to maximize preservation of normal mucosa. Transection of specimen after clamping of the device and activation of the trigger-handle stapling mechanism. Intact suture line after release of the pharynx from the jaws of the stapling device. After surgery, patients are restricted to a nonoral diet for 7 days, after which oral feeding is then initiated. Patients are typically discharged from the hospital within 24 hours of initiating oral nutrition. A summary of patient information is shown in Table I. As noted here, two patients had a history of prior therapeutic irradiation to the larynx. One patient had previously undergone a partial laryngeal resection. Skeletonization of the larynx and application of the stapling device was accomplished easily in all patients. In the patient who had previously undergone partial laryngeal resection, pharyngeal closure was found to be incomplete after application of the stapling device, necessitating additional suture placement. RT = radiation therapy; D/C = discharge. In five of the seven patients, tracheoesophageal puncture was accomplished by means of a long right-angled hemostat passed transorally by an assistant. In one patient a modified esophagoscope was passed transorally by an assistant to accomplish tracheoesophageal puncture. In one patient in whom esophageal instrumentation could not be accomplished transorally, a miniature pharyngotomy was performed to gain access to the cervical esophagus, which was then closed primarily. One patient with a history of prior radiation therapy to the larynx developed a pharyngocutaneous fistula on postoperative day 7, resulting in delayed initiation of oral feeding. All other patients demonstrated adequate oral intake before discharge. No other patients in this group experienced significant postoperative complications. Surgical margins were negative in all patients. A number of reasons make the use of an automatic stapling device an attractive option during head and neck surgery. These include the rapidity by which watertight closure of normally thin and friable pharyngeal mucosa can be accomplished, which can potentially decrease total operative time. In addition, by sealing off the pharynx just before resection of the larynx, wound contamination by pharyngeal secretions is minimized. Despite the lack of a comparative control arm of patients undergoing laryngectomy in the standard “open” fashion with traditional suture closure of the pharynx, as well as the relatively small number of patients in this group, some direct comparisons can be made based on historical data as well as subjective experience with this technique. The learning process using the automatic stapler is rapid. With attention to the specific technical details as mentioned previously with regard to closed laryngectomy, the initial operative technique is similar to that which occurs during standard total laryngectomy. After laryngeal skeletonization, the remainder of the procedure proceeds quickly, whereby subsequent resection and pharyngeal closure are accomplished simultaneously using the stapler. It is conceivable that use of the automatic stapler would, in theory, actually promote fistula formation because the mucosal edges of the pharynx are not inverted toward the pharyngeal lumen but actually everted with this technique. Experimental evidence in dogs undergoing staple closure of the hypopharynx by Sessions et al. 4. also lends some support to this theory. In our series however, only one patient developed a pharyngocutaneous fistula. Despite the absence of a control arm for direct comparison, ample historical data exist in this regard. The frequency of fistula occurrence in our group is within the lower range of fistula rates of 4% to 66% reported in the literature for patients undergoing total laryngectomy, 8.-11. with some reports of higher fistula rates in previously irradiated patients. 12., 13. Interestingly, the one case of fistula in this group occurred in a patient with prior history of laryngeal irradiation. In one of only two other series describing experience with this closed technique, no postoperative fistulae were reported in a group of 13 patients. 7. In the other series, the fistula rate was not reported. 6. Other series describing the use of automatic stapling devices during total laryngectomy, although using this device to repair open pharyngeal defects after resection, also report comparable fistula rates, with the majority of fistulae occurring in previously irradiated patients. 2.-5. It would thus seem that this concern regarding fistulization specific to this technique is largely theoretical in nature and thus far not borne out in actual practice—although granted the total number of reported patients is small. With regard to fistula formation, the factor of prior irradiation rather than type of closure used may be of more importance overall. Limitations, of course, also exist regarding this approach. Perhaps most important to consider is the fact that the tumor itself is not visualized during resection using this closed technique and thus harbors the potential for oncologic compromise if applied in inappropriately selected situations. Tumors that are not entirely endolaryngeal—for example those that extend significantly above the level of the false vocal folds involving the aryepiglottic folds, suprahyoid epiglottis, interarytenoid/postcricoid areas, or medial wall of the pyriform sinus—are clearly at risk for compromise with this technique. Furthermore, other than visual inspection of the resected specimen itself, use of frozen section analysis of margins to compliment assessment of adequacy of resection is difficult if not impossible with this technique. As such we would advocate that this approach not be used in settings where tumor involves these regions or if the entire extent of the tumor cannot be readily appreciated on endoscopy. All patients in this series had tumors confined entirely within the endolarynx and subsequently had negative pathological surgical margins. One additional aspect worthy of mention here relates to performance of primary tracheoesophageal puncture, which provides a route for direct alimentation in the early postoperative period as well as means for early speech rehabilitation. In standard cases of total laryngectomy, this is easily accomplished before pharyngeal closure. In cases using the automatic stapling device, however, access to the cervical esophagus must be accomplished by alternative means because the pharynx is not entered during actual resection. In most cases (6 of 7), puncture was accomplished by means of passing an instrument (hemostat or esophagoscope) transorally into the cervical esophagus. As mentioned, one patient required performance of a “mini” pharyngotomy to gain pharyngoesophageal access. Although this increased operative time only minimally, it diminished the theoretical advantage of avoiding pharyngeal entry in an effort to minimize soiling of the wound. This particular patient, nevertheless, experienced no adverse postoperative sequelae, and although this part of the procedure was more challenging in some patients in this series than in others, they all underwent successful primary tracheoesophageal puncture. All patients thus far have continued to demonstrate adequate swallowing function. In addition, those fitted with and able to use tracheoesophageal voice prostheses have demonstrated adequate speech production. From a functional standpoint, swallowing and speech results after staple closure of the pharynx appear to be quite satisfactory. The technique of closed laryngectomy using a linear automatic stapling device can be learned rapidly. The application of this device as described facilitates an essentially closed procedure with rapid, watertight pharyngeal closure and minimal wound contamination. Tracheoesophageal puncture can be accomplished primarily, although this may require employment of various methods. Overall perioperative morbidity is low with this technique and the functional results are acceptable.