Bocca's Technique Hemipharyngo‐Total‐Laryngectomy for Right Pyriform Sinus Squamous Cell Carcinoma

Abstract

This report describes the step‐by‐step surgical technique of Bocca's hemipharyngo‐total laryngectomy for right pyriform sinus squamous cell carcinoma in an elderly patient with significant comorbidities. The procedure allowed oncologically radical resection with immediate neohypopharyngeal reconstruction using the preserved hemilaryngeal mucosa, avoiding flap reconstruction. Bocca's technique represents a valuable option in carefully selected cases, providing adequate functional outcomes while reducing operative complexity.

1. Introduction

Hypopharyngeal squamous cell carcinoma (SCC) is a relatively rare malignancy that most commonly arises from the pyriform sinus, followed by the posterior pharyngeal wall and the postcricoid region. In many cases, it is diagnosed at an advanced stage due to its tendency for submucosal spread and the late onset of symptoms. The optimal therapeutic approach for this tumor remains a matter of debate, as there is still a significant lack of prospective, randomized trials directly comparing surgical and non‐surgical treatment modalities [1]. Although no clear superiority of one treatment modality over another has been established, several studies have demonstrated that, in advanced hypopharyngeal carcinoma (T3/T4, N0/N+), surgery provides better overall survival (OS) outcomes compared to chemoradiotherapy (CRT) [2]. Moreover, in elderly patients with comorbidities, the use of chemotherapy—both induction and concurrent—may be significantly limited.

In most cases, advanced hypopharyngeal carcinoma requires a multimodal approach consisting of surgery followed, when feasible, by adjuvant CRT or, alternatively, radiotherapy (RT) alone. Traditionally, advanced hypopharyngeal SCC (T3/T4) amenable to surgery has been managed with total laryngectomy extending to the pharynx, often requiring reconstruction with a pedicled flap such as the pectoralis major or supraclavicular flap, combined with neck dissection and, in most cases, postoperative RT [3]. Extensive surgical resection of pharyngeal tissues often requires flap reconstruction to ensure an adequate mucosal surface for neohypopharyngeal formation and to achieve satisfactory functional outcomes, particularly in swallowing. For optimal reconstruction of the pharyngeal wall, pedicled or free flaps are usually required. However, since patients with advanced hypopharyngeal SCC are often elderly and burdened with multiple comorbidities, they may not be suitable candidates for major surgery involving flap reconstruction. To address this issue, Bocca in 1979 proposed the hemipharyngo–total laryngectomy (HTL) with immediate neopharyngeal reconstruction using the healthy tissue of the preserved hemilarynx [3].

The present case concerns an 82‐year‐old man with progressive dysphagia and dysphonia. Flexible fiberoptic endoscopy revealed an exophytic mass arising from the hypopharynx and involving the right pyriform sinus, without extension to the midline or interarytenoid area, but with initial involvement of the thyroid cartilage. Preoperative CT imaging demonstrated a solid lesion originating from the right pyriform sinus with ipsilateral cervical lymph node metastases. According to the 9th edition of the AJCC TNM classification, the disease was staged as cT4a cN2b cM0. Given the patient's advanced age, comorbidities, and the specific characteristics of the disease, we decided to perform Bocca's hemipharyngo–total laryngectomy [3, 4].

2. Methods

The surgical technique is demonstrated in Video 1 (Bocca's hemipharyngo–total laryngectomy for right pyriform sinus squamous cell carcinoma) and described below.

VIDEO 1.

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Bocca's technique hemipharyngo–total laryngectomy for right pyriform sinus SCC. Video content can be viewed at https://onlinelibrary.wiley.com/doi/10.1002/lary.70487.

The patient provided written informed consent prior to participation.

All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki.

The procedure was performed under general anesthesia with orotracheal intubation. The patient was placed in a supine position with a small shoulder roll to achieve slight neck extension. The video omits the bilateral neck dissection.

The prelaryngeal fascia was dissected and submitted for histologic examination. A thyroid isthmectomy was performed to facilitate tracheal access. On the right side, the strap muscles—including the sternohyoid and sternothyroid—were divided, and the right lobe of the thyroid gland was removed after ligation of the superior and inferior vascular pedicles using Ultracision. The hyoid bone was skeletonized and resected to provide complete access to the supraglottic space. The right constrictor muscles were dissected free from the thyroid cartilage, and the right superior laryngeal pedicle was identified and ligated, ensuring wide exposure of the upper laryngeal framework and pyriform sinus region. Care must be taken to preserve the contralateral superior laryngeal pedicle in order to ensure adequate vascularization of the tissue used for reconstruction of the remaining hemilarynx. The right recurrent laryngeal nerve was then identified and divided. At this stage, the larynx was fully mobilized. The pre‐epiglottic fibro‐fatty tissue was subsequently dissected and reflected downward toward the larynx.

The trachea was opened between the second and third rings, after which the inferior portion of the tracheostoma was fashioned, and a Montandon's tube was inserted to secure the airway. Dissection then continued along the tracheoesophageal membrane up to the retrocricoid area.

The larynx was opened anteriorly along the midline with cold instruments, following a pre‐marked cautery line, creating an anterior laryngofissure that enabled bilateral mobilization of the thyroid laminae and full exposure of the hemilaryngeal structures. The neoplastic mass was clearly visible, occupying the right pyriform sinus and extending posteriorly toward, but not beyond, the midline (Figure 1).

FIGURE 1.

Book‐like exposure of the larynx following a median section of the thyroid cartilage. The neoplastic mass was clearly visible (green circle), occupying the right pyriform sinus and extending posteriorly toward, but not beyond, the midline.

A superior pharyngectomy was performed to ensure full exposure of the tumor margins. Under direct vision, a right hemipharyngo–total laryngectomy was carried out. The resection included the right hemilarynx containing the tumor, the ipsilateral half of the cricoid cartilage, and the right pharyngeal wall. Care was taken to preserve the contralateral mucosa, maintaining the external perichondrium and internal mucosa intact on the left side (Figure 2).

FIGURE 2.

Subperichondrial and submucosal dissection to remove the cartilaginous framework of the remaining left hemilarynx (green circle on the thyroid cartilage).

The resection margins were meticulously evaluated intraoperatively, with frozen sections obtained from both the specimen and the surgical field to confirm negative margins. A subperichondrial and submucosal dissection was then performed to remove the cartilaginous framework of the remaining left hemilarynx, including the left hemithyroid cartilage and arytenoid, providing a wide and well‐vascularized tissue base for subsequent reconstruction.

The epiglottis was included in the specimen to achieve complete tumor removal and ensure wide oncologic safety margins. This also helps prevent postoperative foreign body sensation [3]. A phonation prosthesis was inserted, and both a 12 French salivary stent and a nasogastric tube were positioned. The stent was secured with a single transcutaneous U‐shaped silk suture placed at the submental region. The decision to place the stent in this case was based on the extensive mucosal resection extending superolaterally to the base of the tongue.

Reconstruction of the neohypopharynx was achieved using the mucosa and external perichondrium of the preserved left hemilarynx. These tissues were sutured with interrupted extramucosal stitches to recreate the missing wall of the neohypopharynx. The procedure concluded with the creation of the definitive tracheostoma.

3. Results

The mucosa of the contralateral healthy hemilarynx was sufficient to reconstruct the neohypopharynx without the need for a flap. The reconstructed neohypopharynx had an adequate diameter to allow functional rehabilitation of both swallowing and phonation. The stent remained in place for a couple of weeks, and the patient resumed regular oral feeding without limitations.

4. Discussion

Hypopharyngeal SCC requires meticulous surgical management to achieve oncological radicality. The hypopharynx represents a critical anatomical region involved in several vital functions, including swallowing and phonation. Neoplasms arising in this area pose considerable challenges for surgical treatment, particularly concerning reconstruction aimed at functional preservation. Evidence from the literature indicates that, to ensure satisfactory neohypopharyngeal function, a residual mucosal segment of at least 2.5 cm should be maintained [4]. In most cases of advanced tumors, primary closure is not feasible; therefore, pedicled or free flaps are required to reconstruct the defect resulting from oncological resection. However, flap surgery is associated with a higher risk of complications and generally results in longer operative times, particularly in the case of free flap reconstruction [5].

Bocca's HTL is a surgical technique that, in selected cases, allows surgeons to avoid the use of pedicled or free flaps by using the mucosa of the patient's healthy hemilarynx. This approach enables oncologically safe resection of pyriform sinus carcinoma while preserving the contralateral laryngeal framework and providing functional reconstruction of the neohypopharynx.

The present case involves an elderly man with multiple comorbidities; thus, the use of this technique spared him the risks associated with prolonged operative time and the potential complications of pedicled or, even more so, free flap reconstruction. Bocca's HTL is indicated exclusively for lesions involving the lateral wall of the pyriform sinus, such as in this case. Conversely, it is unsuitable for very large hypopharyngeal tumors, as achieving adequate oncological margins would result in an insufficient amount of residual tissue for reconstruction [3]. This approach ensures preservation of the residual laryngeal structures and facilitates postoperative rehabilitation of swallowing and phonation while avoiding the need for pedicled or free flap reconstruction. According to data presented by Lucioni et al. [3], Bocca's HTL provides outcomes in terms of overall survival (OS) and disease‐free survival (DFS) comparable to other surgical approaches, confirming its reliability as a treatment option for selected cases of hypopharyngeal SCC. Specifically, the indications for Bocca's HTL include small tumors (cT2–T3) of the lateral wall of the pyriform sinus not eligible for conservative protocols; tumors with limited invasion of the hemilarynx or hemithyroid cartilage; tumors not involving the cervical esophagus and tumors not crossing the midline [3]. The present case was staged as cT4a but met all the other criteria and, due to the patient's comorbidities, was deemed suitable for Bocca's HTL.

5. Conclusion

To conclude, Bocca's HTL may represent a valuable surgical option in carefully selected patients, offering oncological radicality comparable to other available reconstructive approaches—including those requiring flap use—while reducing operative time and theoretically minimizing flap‐related complications.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.