The patient should be positioned with a shoulder roll for full exposure of the neck and trachea and the neck prepped for bilateral neck dissections.  Total laryngectomy should begin with a tracheotomy placement.  This is placed low in the neck, approximately two finger breadths above the sternal notch.  Usually the tracheostomy incision will be incorporated into a low collar incision used for the laryngectomy.  Often bilateral neck dissections are performed in total laryngectomy.  In these cases, the approach is a bilateral apron incision, extending from one mastoid tip to the other.  Alternatively, the surgical incision can be placed 2 cm above the tracheotomy site as a separate incision.  The tyroid isthmus should be divided during tracheotomy placement and a wire spiral endotracheal tube used for ventilation.

At this point, one side of the neck dissection should be performed, which often includes levels II-IV depending on the underlying pathology.  Attention is then returned to the trachea.  The strap muscles are elevated off the larynx and divided low.  The thyroid lobe on the side involved with tumor will remain with the surgical specimen, but the contralateral thyroid should be elevated off the trachea.  Parathyroid glands will remain undisturbed on the uninvolved side, and should be attempted to be preserved on the contralateral side.  The inferior thyroid artery of the involved thyroid lobe is clamped and ligated and the recurrent laryngeal nerves are divided.   

Using palpation as a guide, cautery is used to divide the suprahyoid musculature from the superior border of the hyoid bone.  Dissection should be down onto, and then just above the bony rim along its entire course.  An Allis or Kocher clamp may be used to retract the lateral aspect of the bone into view.  The entire greater cornu should be skeletonized bilaterally and dissected completely free from its muscular attachments.   During this dissection, the superior laryngeal neurovascular bundle may be encountered entering the thyrohyoid membrane.   This should be identified, clamped, and ligated. 

The thyroid cartilage ala should be freed from its muscular attachments to the strap and inferior constrictor muscles.  The constrictor muscle wraps around the thyroid cartilage ala and should be dissected free.  Care should be taken with certain tumor locations to not violate the tumor margin.  Hooks may be used to fully rotate the thyroid cartilage and skeletonize the posterior border of the ala. 

The pharynx is then entered just above the hyoid bone using cautery.  The tip of the epiglottis should be palpated and the pharyngotomy placed just above this point.  Location of the tumor may dictate some alteration in the entry point to maintain an acceptable margin.  A Deaver retractor is then placed in the pharyngotomy to retract the tongue base and superior tissues.  An Allis clamp is placed on the epiglottis to give counter traction anteriorly.  Under direct visualization of the pharynx and glottis, the pharyngotomy is extended laterally and inferiorly using scissors along the larynx and into the pyriform sinuses.  As much mucosa as possible is spared, while still preserving a conservative margin around the tumor.  This is carried inferiorly to the level of the esophageal introitus. 

The back wall of the trachea is then separated from the esophagus using blunt dissection.  A finger placed in the esophagus will help define the plane.  The tracheotomy is extended circumferentially, fully dividing the airway.  The cuts should be beveled toward the cricoid when approaching the back wall of the trachea, spanning 2-3 tracheal rings, to allow the posterior wall of the trachea to sit higher than the anterior wall.  A clamp should be placed on the posterior tracheal wall to prevent it from retracting into the chest.  The larynx with the thyroid lobe of the involved side is then fully divided from the remaining hypopharynx, sparing as much native mucosa as possible.  If a cricopharyngeal myotomy is to be performed, a finger should be placed in the esophagus and the muscular belly clearly identified.  Using a #10 blade, the fibers are fully divided until nearly translucent mucosa is the only layer remaining.

A watertight closure is essential, and is achieved with a meticulous, multilayered closure.  A feeding tube should be placed, any remaining neck dissections performed, and hemostasis assured prior to any closing sutures.  The initial layer of closure is a running Connell stitch using 3-0 chromic or 3-0 undyed Vicryl.  One suture with needle attached should be anchored at the inferior portion of the pharyngotomy, just above the esophagus.  Another anchoring suture is placed at the near corner of the junction of the tongue base and pharynx, and a final anchor stitch, with needle attached, is placed just opposite, on the far juncture of tongue base with pharynx.  This effectively defines the pharyngeal opening as a “T” with the long limb extending down from the midline of the tongue base to the esophagus.  Closure begins with the inferior suture proceeding superiorly.  The stitch is through the outer layer of the mucosa, and should ideally not fully penetrate through to the inner mucosal surface.  The stitch then crosses the incision and another bite is taken on the contralateral side (see figure below).  Once the midline of the tongue base has been reached with this limb, the superior limb is closed in a similar fashion using the anchored suture and proceeding to the contralateral corner.  The stitches are tied to each other at their respective joining locations.

The second layer is achieved with interrupted, horizontal mattress sutures.  This is a closure of the fascia over the incision line again using 3-0 chromic or Vicryl.  The “T” pattern of the incision should be preserved.  Water may then be instilled into the mouth to ensure water tight closure.  Fibrin glue may then be liberally applied to the suture line.  In the third and final layer of closure, horizontal mattress sutures are used to close either constrictor muscle or strap musculature over the incision line.

The final portion of the laryngectomy is maturation of the tracheostoma.  The inferior border is addressed first, and sutures of 0 chromic are used.  The stitch is placed through the skin and then from outside to inside the tracheal lumen just below a tracheal ring.  The suture is then passed back through the skin from subcutaneous to external, just horizontal to the initial entry point.  In this manner a half mattress is formed for the tracheal portion of the stitch surrounding the tracheal ring and lending strength to the stoma.  As many stitches are placed to mature the inferior aspect.  The midline of the superior skin flap is then identified and a small ellipse of skin is excised to allow better closure over the superior aspect of the stoma.  Identical sutures are used to fully mature the superior stoma rim.  Care is taken at the corner of the upper and lower skin flaps to ensure secure closure and approximation of the skin edges to the tracheal wall.  The remainder of the skin incision is then closed and drains are placed in each dissected neck.  The endotracheal tube is then changed to a cuffed Shiley tracheostomy tube to prevent aspiration of blood or secretions and the patient is awakened.