Vertical Hemilaryngectomy
This procedure was designed to extirpate tumor of a vocal fold with limited extension, while still preserving reasonable voice, a safe swallow and an adequate airway without need for a tracheotomy—i.e., laryngeal function. In modern practice, where endoscopic techniques have become more commonplace and spare the patient an incision, a temporary tracheotomy and a more prolonged recovery, vertical hemilaryngectomy tends to be reserved for patients whose endoscopic exposure is poor, where laser equipment is not available or where post-radiation salvage is being pursued.
The extent of resection with open vertical partial procedures varies. Four open surgeries can be accomplished, through careful selection of cases, backed with preoperative radiology and intraoperative frozen section: (1) cordectomy—one vocal fold alone without removal of the thyroid cartilage superstructure or false vocal fold; (2) vertical hemilaryngectomy (as described in this chapter)—true cord with ventricle and false cord and extensions of this basic procedure; (3) frontolateral vertical hemilaryngectomy—true cord with ventricle and false cord, with part of the anterior contralateral vocal fold; (4) extended vertical hemilaryngectomy—true cord with ventricle and false cord and ipsilateral arytenoid.
Indications/Contraindications
Removal of a tumor limited to either a vocal fold or adjacent ventricle or false vocal fold (T1a or T2).
Involvement of the subglottis is a contraindication.
Deep extension into the thyroid cartilage, pre-epiglottic space or epiglottis is a contraindication.
Involvement past midline to the contralateral vocal fold is a contraindication.
Involvement of the ipsilateral arytenoid is a contraindication to this procedure although more aggressive procedures (e.g., extended vertical hemilaryngectomy, as noted above) can be performed to comprehensively extirpate more posteriorly extending tumors.
Poor preoperative swallowing function is a relative contraindication to performing this procedure, as swallowing will almost certainly decline, risking a situation of chronic aspiration.
In the Clinical Setting
Key Points
Careful endoscopy in the office and operating room along with CT findings are crucial in assessing if the tumor can be adequately extirpated with this operation.
Careful assessment of the patient′s swallowing and pulmonary function is crucial in assessing if the patient is an appropriate candidate for this operation.
Counseling the patient preoperatively that intraoperative conversion to more aggressive surgery, including total laryngectomy with or without neck dissections, may be required for tumor extirpation is wise.
Pitfalls
Inadequate assessment of tumor extent is the most common reason for an unsatisfactory result.
Failure to perform detailed laryngoscopy soon before and immediately before the procedure is begun will predispose to inappropriate procedural selection.
From a Technical Perspective
Key Points
Familiarity with the anatomy from the perspective of a laryngofissure is greatly improved by performing this operation on cadaveric specimens.
A common misconception is that the entire thyroid cartilage ipsilateral to the tumor is resected. This is not true. A posterior strut remains, which helps retain laryngeal superstructure and improved swallowing (as illustrated below).
Pitfall
Division of the thyroid cartilage off the midline can predispose to tumor violation when ipsilateral or transection of the vocal ligament when contralateral. Division of the vocal ligament will yield a foreshortened vocal fold and impaired voicing and swallowing.
Stepwise Procedure
Mount a larynx for open dissection.
OR Pearl: During surgery, always commence with a review of the CT scan, looking for evidence of cartilage erosion, and repeat an endoscopic evaluation, specifically looking for subglottic extension, anterior commissure involvement, etc.
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