Incision in Total Laryngectomy

Incision Design Options

1. Long Apron Flap (Long-Flap Approach)

• A single, broad curvilinear horizontal incision running from mastoid tip to mastoid tip, intersecting the midline at approximately the level of the cricoid cartilage — usually about 2 cm above the sternal notch in the midline.
• The tracheostomy stoma is incorporated in the line of the incision itself (the tracheal end exits through the center of the lower flap).
• The superior flap is elevated to expose the entire laryngeal framework.

• More reliable stoma creation
• Avoids a bipedicled skin bridge between two separate incisions, which can cause stoma stenosis
• Preferred when concurrent bilateral neck dissections are performed (incision can be extended toward the mastoid tips)

• A technically demanding three-point closure is required at the stoma site (lower stoma edge is created within the flap)
• If pharyngocutaneous fistula occurs and requires diversion, the stoma may be involved in the resulting wound

2. Short Apron Flap with Separate Tracheostome Incision

• The main flap incision is placed higher in the neck.
• The tracheostomy skin incision is made 2–3 cm inferior to the flap incision as a separate elliptical incision, creating a skin bridge between the two.
• The stoma is fashioned by excising a shield-shaped skin island from the lower neck in the midline, just above the sternal notch.

• If pharyngocutaneous fistula develops requiring wound diversion, the stoma is less likely to be involved — particularly important in previously irradiated patients
• Avoids the technically complex bilateral three-point closures at the stoma necessitated by the long-flap approach
• Simpler stoma construction

• The bipedicled skin bridge between flap and tracheostomy incision can lead to stomal stenosis

3. U-Shaped Incision

• Rarely used
• Feasible when neck dissection is not performed
• Not routinely recommended

Positioning and Planning Principles

• Patient is placed on a table with a head holder that allows the head to be cantilevered (extended), facilitating bilateral neck dissection.
• The operating table is turned 180° from the anesthesiologist to maximize surgeon access.
• Airway planning is coordinated with anesthesia preoperatively:
  • Unobstructed airway → orotracheal intubation at induction; tube is removed at tracheotomy or left in until tracheal transection
  • Obstructed airway / risk of tumour displacement → preliminary tracheotomy under local anesthesia, with the skin incision at the intended final stoma site
• The tracheotomy skin incision is made at the intended final stoma site — this is the same incision used for the permanent stoma.

Summary Table