key: cord-0946764-ckmieiuq authors: De Seta, Daniele; Marrosu, Valeria; Russo, Francesca Yoshie; Carta, Filippo; Puxeddu, Roberto title: Closed Total Laryngectomy During The Covid‐19 Pandemic Disease date: 2020-06-22 journal: Laryngoscope DOI: 10.1002/lary.28919 sha: 20404db06100ec71725bd0789ce18f9187c61707 doc_id: 946764 cord_uid: ckmieiuq nan Surgical activity during the coronavirus disease 2019 (COVID-19) pandemic diffusion has been reduced in several Centers to emergency and oncological procedures only, in accordance with the national scientific medical societies' guidelines and Governments' indications. Otolaryngology represents one of the most hazardous surgical specialty with regard to the SARS-CoV-2 exposure, due to the close contact with upper respiratory tract where viral load is particularly elevated. The exposure and manipulation of these areas during endoscopic evaluation and surgery can aerosolize the virus over the surgeon or in the operating room. 1 The Italian Society of Otolaryngology recently published the guidelines for the surgical management of ENT procedures (www.sioechcf.it). The elective procedures should not be performed, unless urgent or that can't be deferred, e.g. oncological diseases, risk of permanent organ damage or life-threatening conditions. The guidelines include the execution of two swabs (4 days and 48h before surgery) for the COVID-19 testing. If the test cannot be performed, the patient must be considered as positive and the procedure performed with full personal protection equipment (PPE). Moreover, it cannot be excluded that the quality of PCR testing for This article is protected by copyright. All rights reserved. detecting SARS-CoV-2 could be jeopardized by several factors (e.g. collection of inappropriate/inadequate material, virus-specific diagnostic window) 2 . Total laryngectomy represents one of the procedures that cannot be deferred, nevertheless it leads to a prolonged exposure of potentially infected or infected airway while performing the opening and suturing of the pharynx that cannot be underestimated during the current COVID-19 pandemic. Different suturing techniques of the pharynx have been described in the last years, and manual suturing is the most widely used, however the use of mechanical suturing devices is another well-established option 3 . In this report we present a modified surgical technique using the mechanical linear stapler for the closure of the pharynx that, beyond the already described advantages associated with the mechanical stapler suturing 3 , can be considered as an effective tool to reduce the risk of SARS-CoV-2 spread on the operating room during total laryngectomy. From the beginning of COVID-19 outbreak we modified our procedure for total laryngectomy. Together with the use of the linear mechanical stapler for the closure of the pharynx (ETHICON Linear Cutter NTLC75, J&J Medical N.V., Belgium) we made some modification to our tracheostomy technique and to the management of the specimen. This article is protected by copyright. All rights reserved. The surgical procedure is described below: During intubation and for the following 20 minutes only anesthesiologists and essential staff are allowed to be inside the operating room. 1. The nasogastric feeding tube (NGT) is inserted before surgery by the use of a video flexible naso-pharyngo-laryngoscope that increases the distance between the operator and the patient's airway. This article is protected by copyright. All rights reserved. 2. The skin incision, the raising of the flap, and the lateral neck dissection is performed following the standard technique. The use of cold scalpel and scissors is preferred to monopolar cautery, as well as suturing of vessels is preferred to bipolar coagulation, and a smoke evacuator is always used to reduce the spread of plume that can potentially contain viral particles. is placed into the distal tracheal stump in order to prevent exposure of the tracheal mucosa. 5. The stapler with its opened jaws is inserted obliquely below the larynx and the suture is performed allowing for a closed technique without any contamination of the surgical field and operating room (Figure 1 ). 6. The gauze in the trachea is removed only before the insertion of the tracheostomy tube which balloon cuff is inflated. 7. The specimen is opened in a dedicated area far from the operating room by the surgeon with full PPE to check the radicality of the resection, and the tracheal gauzes are considered and managed as hazardous waste. Between February 15 th and April 7 th, we performed 4 total laryngectomies (3 males, 1 female, mean age 66 years, range 41-87 years) using the described technique. All patients were treated for glottic squamous cell carcinoma (3 patients were never treated before, cT4N0M0, 1 patient was treated for recurrence of the disease after radiotherapy performed for cT2N1M0 glottic cancer). All patients underwent total laryngectomy and bilateral neck dissection. The evaluation of excision showed clear margins in all cases. After definitive histology, staging was T4N1M0 for the first two patients that were discharged at day 15, NGT was removed at day 13. The remaining two patients (currently still waiting for definitive histologic results) are still This article is protected by copyright. All rights reserved. There are some mandatory preoperative and postoperative procedures still at risk for viral exposure, such as diagnostic flexible naso-pharyngo-laryngoscopy that unfortunately is unavoidable. The preliminary direct laryngoscopy, that is usually performed for panendoscopy and biopsy under general anesthesia, can be avoided if the preoperative clinical staging is precise using NBI followed by radiologic imaging, since the histology can be obtained at the time of main operation as a frozen specimen. The positioning of the NGT can also be performed during the intubation in order to reduce the viral exposure. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. COVID-19 and the otolaryngologist -preliminary evidence-based review Efficacy of stapler pharyngeal closure after total laryngectomy: A systematic review Safe management of surgical smoke in the age of COVID-19 This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved.