Second stage. The lateral aspect of the larynx is freely separated so that the attachment of the inferior constrictors is defined. The superior laryngeal artery is ligatured on each side, and divided, together with the internal laryngeal nerves. The thyreo-hyoid membrane is transversely divided, and the pharynx is opened so as to expose the upper limit of the growth; this may necessitate a transverse incision through the skin, or a vertical division of the hyoid bone in the middle line with retraction of its two halves. The larynx having been isolated above, below, and laterally, its removal can be completed according to the situation of the growth, in most cases from below. The lower end of the larynx is hooked forward, and dissected away from the œsophagus by means of scissors or a sharp scalpel (Fig. 262). While this is being effected, the extent of the growth must be constantly examined by inspection and palpation, so that the whole mass is removed, including, if necessary, the pharynx and upper part of the œsophagus. It is important not to drag upon the œsophagus; C. Jackson has shown experimentally that this causes severe shock by affecting the depressor fibres of the vagus, which may result in death. It follows, therefore, that this part of the operation, though easy in the dead body, requires the utmost care and detailed technique. The division of the constrictors should be as close to their attachment as possible, and the final division of the pharyngeal mucosa should be half an inch beyond the limit of the growth. The epiglottis should generally be removed.
Third stage. The toilet of the pharynx and œsophagus remains to be decided. In order to restore the cavity of the pharynx, the upper end of the œsophagus is brought upwards whenever possible and accurately united to the pharynx in the region of the hyoid bone, this being accomplished by a double layer of catgut sutures uniting the mucous membranes. The infrahyoid muscles are then brought together by a vertical row of stitches, so as to cover and support the line of union. The wound having been thoroughly packed with gauze, the skin is sutured, excepting the lower end, which remains open for drainage. In cases where the pharynx is thus completely closed, a tube must be passed previously through the nose into the œsophagus, and retained for purposes of feeding. This is preferable to sewing the tube into the wound itself, and is rarely troublesome if the tube is sufficiently stiff to prevent its displacement by retching. At the conclusion of the operation the tracheotomy tube is replaced by an ordinary silver canula, and the wounds are lightly dressed.
After-treatment. This is conducted upon similar lines to those adopted in the after-treatment of thyrotomy. During the first ten days, until the pharyngeal wound is firm, the patient must be fed through the tube and by rectal administration. Sterilized water may be sucked uphill, and, as swallowing improves, food may be administered by the mouth. In most cases a pharyngeal fistula results, which may require a later plastic operation. A second operation is necessary for the removal of lymphatic glands, probably on both sides of the neck.
The complications are similar to those following thyrotomy (see [p. 494]).
Modifications. The above operation, which in the main has been planned by surgeons in America (S. Cohen, Keen, &c.), is preferable to the numerous modifications, of which the following may be mentioned as examples:—
Gluck’s operation. In this there is no preliminary tracheotomy. A large rectangular flap is turned to one side to expose the front of the larynx and trachea, the latter being isolated laterally and the thyreoid isthmus divided. A transverse incision is made through the thyreo-hyoid membrane in order to expose the upper aperture of the larynx thoroughly. By plugging the pharynx and adopting a low position for the head, saliva and blood are prevented from running into the air-passages. The interior of the larynx having been cocainized, a tracheotomy tube is inserted between the vocal cords. This is sutured in position in such a manner that the cavity of the larynx is completely shut off from the pharynx. If a general anæsthetic be employed, it can be continued through the canula by a Hahn’s adjustment ([Fig. 266]). The larynx, and any part of the pharynx or œsophagus which is diseased, are separated from above downwards, the trachea being severed transversely as a final stage and sewn into a button-hole immediately above the sternum. A soft rubber tube having been introduced through the nose into the œsophagus, the walls of the latter are united over the tube by a double row of catgut sutures, completely isolating the gullet. The cavity is covered with gauze, and the skin flap is partially sutured into its original position. An ordinary canula is placed in the trachea and the wounds are dressed.
Fig. 263. Total Laryngectomy. Gluck’s Method. Tracheotomy canula with rubber tube for Hahn’s adjustment tied into the upper opening of the larynx. A, Epiglottis; B, Superior cornu of thyreoid cartilage; C, Posterior surface of cricoid with crico-arytenoid muscles; D, Trachea; E, Œsophagus.
In cases where the pharynx has been extensively removed a fistula remains, but Gluck has devised a plastic operation by means of which this can afterwards be closed. In some cases this fistula may be obliterated by the natural falling in of the parts, without further operation, and in the meantime the patient is provided with a funnelled tube for feeding, placed in the œsophagus with the upper end below the base of the tongue.
The advantages claimed by Gluck for this operation are the avoidance of preliminary tracheotomy, the prevention of blood from passing into the trachea, the complete separation of the trachea from the gullet, and the early feeding through the mouth. These, however, are chiefly met by the former operation.