Operative videos

2 min 24 s · patient consent taken · patient identity not shown · for surgical education

Advanced hypopharyngeal cancer: laryngopharyngectomy with a tubed pectoralis major flap

Squamous cell carcinoma of the hypopharynx (pyriform sinus, posterior pharyngeal wall and postcricoid region, extending to the glottis) in a man in his sixties, first tracheostomised for stridor. CT showed bilateral nodal disease, with the right nodal mass invading the external carotid artery; PET-CT showed disease confined to the neck. Upfront surgery was followed by chemoradiotherapy.

Staging (AJCC 8th)

• T: several subsites and the glottis, airway closed: at least T3; T4a if cartilage, thyroid gland or central soft tissue is invaded
• N: right nodal mass invading the external carotid artery = clinical extranodal extension, N3b
• M: PET-CT negative, M0
• cT3–4a cN3b cM0 = stage IVB; histopathology gives the final pT, pN, ENE and margins

Why upfront surgery

• Organ preservation suits a larynx worth keeping; this one had already closed the airway
• Salvage surgery after failed chemoradiotherapy carries more fistula and wound breakdown
• External carotid involvement is resectable; common or internal carotid encasement would not be

Operative steps

1. Incisions marked around the tracheostome
2. Right radical neck dissection; invaded external carotid artery ligated, common and internal carotid preserved
3. Left modified radical neck dissection
4. Total laryngectomy, total pharyngectomy and total thyroidectomy in one piece
5. Circumferential defect from oropharynx to cervical oesophagus
6. Pectoralis major myocutaneous flap raised, tunnelled and tubed
7. Neck closed; permanent tracheostoma

References

• Lydiatt WM et al. CA Cancer J Clin 2017;67:122-37
• Lefebvre JL et al. J Natl Cancer Inst 1996;88:890-9
• Weber RS et al. Arch Otolaryngol Head Neck Surg 2003;129:44-9
• Bernier J et al. / Cooper JS et al. N Engl J Med 2004;350:1945-52 / 1937-44

3 min 35 s · patient consent taken · patient identity not shown · for surgical education

Tongue cancer: transoral partial glossectomy with selective neck dissection, levels I–IV

Squamous cell carcinoma of the lateral tongue in an adult man with a long history of tobacco chewing and smoking; chronic non-healing ulcer, biopsy-proven. Treated with transoral partial glossectomy and primary closure, with selective neck dissection of levels I to IV through a single cervical incision.

Operative steps

1. Single skin-crease incision; subplatysmal flaps
2. Levels Ia and Ib: marginal mandibular nerve protected, facial vessels controlled
3. Levels II to IV cleared along the internal jugular vein
4. Cautery dissection over the carotid sheath; great vessels and sternocleidomastoid preserved
5. Margins marked about 1 cm around the palpable tumour
6. Traction suture; deep margin cut under palpation
7. Specimen delivered en bloc; primary closure

Why levels I–IV

• Oral tongue cancer can skip to levels III–IV (Byers 1997)
• Elective neck dissection improved overall survival in node-negative early oral cancer (D'Cruz 2015)

References

• D'Cruz AK et al. N Engl J Med 2015;373:521-9
• Byers RM et al. Head Neck 1997;19:14-9
• Shah JP. Am J Surg 1990;160:405-9
• Robbins KT et al. Arch Otolaryngol Head Neck Surg 2008;134:536-8

4 min 15 s · patient consent taken · patient identity not shown · for surgical education

Selective neck dissection: anatomical, level by level

An anatomical, level-by-level walkthrough of selective neck dissection through a single cervical incision.

Operative steps

1. Skin-crease incision; subplatysmal flaps to the lower border of the mandible
2. Level Ia: submental fat cleared between the anterior bellies of digastric
3. Level Ib: fascia over the submandibular gland raised low to protect the marginal mandibular nerve
4. Facial vessels clamped and ligated; submandibular contents mobilised
5. Fascia over sternocleidomastoid incised; muscle retracted
6. Posterior belly of digastric as the upper landmark of level II
7. Running cautery dissection peeling nodal tissue off the internal jugular vein and carotid sheath

Principles

• Work level by level, keeping the specimen in one fascial envelope
• Preserve the internal jugular vein, sternocleidomastoid and spinal accessory nerve

References

• Robbins KT et al. Arch Otolaryngol Head Neck Surg 2008;134:536-8
• Medina JE. Otolaryngol Head Neck Surg 1989;100:169-76
• Shah JP. Am J Surg 1990;160:405-9

4 min 12 s · patient consent taken · patient identity not shown · for surgical education

Bloodless total laryngectomy, step by step

A stepwise, bloodless total laryngectomy for ulcerative carcinoma involving the supraglottis, glottis, subglottis, anterior commissure and thyroid cartilage.

Operative steps

1. Exposure and strap muscles: investing fascia, anterior jugular veins, omohyoid, sternohyoid, sternothyroid
2. Superior laryngeal artery ligated; superior thyroid pedicle preserved; isthmus divided
3. Suprahyoid release; inferior constrictor and perichondrium divided; pyriform fossa stripped subperichondrially
4. Greater cornu freed on its medial aspect, protecting the hypoglossal nerve
5. Same sequence on the opposite side
6. Vallecular entry; trachea transected with the posterior wall longer; mucosa divided under vision; specimen delivered

Principles

• Control vessels before dividing them
• Subperichondrial stripping preserves pharyngeal mucosa for closure

References

• Wolf GT et al. (VA Laryngeal Cancer Study Group). N Engl J Med 1991;324:1685-90
• Forastiere AA et al. N Engl J Med 2003;349:2091-8
• Hoffman HT et al. Laryngoscope 2006;116(Suppl 111):1-13

4 min 20 s · patient consent taken · patient identity not shown · for surgical education

Total laryngectomy with neck dissection: live demonstration, HAOICON 2022

Key steps from the live operative demonstration of total laryngectomy with neck dissection at HAOICON 2022, Rohtak.

Operative steps

1. Apron flap around the tracheostomy
2. Neck dissection along the sternocleidomastoid and carotid sheath; specimen reflected medially
3. Strap muscles divided; thyroid lobe mobilised
4. Superior thyroid pedicle and superior laryngeal vessels controlled; suprahyoid release
5. Pharynx entered away from the tumour; mucosal cuts tailored
6. Larynx delivered; defect inspected before closure

References

• Wolf GT et al. N Engl J Med 1991;324:1685-90
• Forastiere AA et al. J Clin Oncol 2013;31:845-52
• Robbins KT et al. Arch Otolaryngol Head Neck Surg 2008;134:536-8

3 min 4 s · patient consent taken · patient identity not shown · for surgical education

High-grade mucoepidermoid carcinoma of the parotid: radical parotidectomy, radical neck dissection and PMMC flap

A middle-aged man with a right parotid mass infiltrating the skin, a discharging sinus and complete facial palsy. Fine-needle aspiration showed high-grade mucoepidermoid carcinoma; MRI showed deep-lobe extension and cervical nodes (T4a). The parotid was resected en bloc with the overlying skin and the involved facial nerve, with radical neck dissection and single-stage pectoralis major flap reconstruction, followed by adjuvant radiotherapy.

Operative steps

1. Elliptical skin margin marked, including the lower ear lobule
2. Radical parotidectomy en bloc with the overlying skin and the infiltrated facial nerve
3. Radical neck dissection, levels I–V, with the sternocleidomastoid, internal jugular vein and spinal accessory nerve
4. Common carotid artery, vagus and phrenic nerves and brachial plexus preserved
5. Pectoralis major myocutaneous flap raised on the thoracoacromial vessels and tunnelled to the neck
6. Composite defect covered; great vessels protected

Learning points

• A parotid mass with facial palsy is malignant until proven otherwise
• Resect en bloc with skin and the involved nerve; reconstruct in the same sitting
• Eye protection after facial nerve sacrifice; reanimation considered later

References

• Lydiatt WM et al. CA Cancer J Clin 2017;67:122-37
• Ariyan S. Plast Reconstr Surg 1979;63:73-81

2 min 10 s · patient consent taken · patient identity not shown · for surgical education

Giant goitre: three cases, three approaches

Three patients with giant multinodular goitre, each treated by total thyroidectomy through a collar incision without sternotomy: cervical delivery of a retrosternal extension below the aortic arch, a lateral strap-sparing approach, and a midline strap-dividing approach.

Operative steps

1. Case 1: retrosternal extension delivered into the neck by blunt finger dissection along the capsule
2. Case 2: plane between the strap muscles and sternocleidomastoid developed; lobe delivered from beneath intact straps
3. Case 3: strap muscles divided in the midline for access and re-approximated at closure
4. In all three: recurrent laryngeal nerves and parathyroid glands identified and preserved

After surgery

• Airway observation and early voice assessment
• Serum calcium monitoring
• Thyroxine replacement after total thyroidectomy

References

• Testini M et al. Ann Surg Oncol 2011;18:2251-9
• Patel KN et al. Ann Surg 2020;271:e21-e93