The patient is placed on the operating table, under general endotracheal anesthesia through an orotracheal tube. If difficult intubation is anticipated due to airway compromise, a preoperative tracheotomy will need to perform with local anesthesia and vasoconstrictor preparation.

A standard total laryngectomy procedure encompasses the entire larynx with its attached prelaryngeal strap muscles and the lymph nodes in the jugular chain (levels II, III, and IV). The most common skin incision used for total laryngectomy is the Gluck - Sorenson U-shaped incision. The starting point of the incision is located at the apex of the mastoid, continued on the anterior border of the sternocleidomastoid muscle up to 1 to 2 cm above the upper edge of the sternal notch and it is continued in the same way on the opposite side. If a tracheotomy were performed before this procedure, the tracheal stoma would be included in the skin incision. Flap elevation should be in the subplatysmal plane, immediately above anterior and external jugular veins, thereby the vascularisation of the flap is guaranteed by the anterior and external jugular veins that should remain attached to the underlying tissues. The upper and lower skin flaps are elevated to get exposure from the hyoid to the suprasternal notch.

Mobilization of the larynx begins superiorly by detaching the muscles attached to the upper surface of the hyoid bone. Dissection proceeds to isolate the superior thyroid artery and its superior laryngeal branch, these are identified, dissected and ligated (identification and ligation of these vessels will minimize hemorrhage during mobilization of the larynx). The sternocleidomastoid muscle is retracted laterally to expose the carotid sheath, and deep jugular lymph nodes at levels II, III, and IV are dissected and mobilized toward the specimen.

As dissection proceeds, the sternohyoid and sternothyroid muscles are divided as low in the neck as possible. After having divided and ligated the inferior thyroid artery, the thyroid gland is separated from the trachea. Finally, the thyroid isthmus is divided using two clamps. Division of the isthmus exposes the cervical trachea. The inferior constrictor muscle is detached from the posterior edge of the thyroid cartilage bilaterally with the electrocautery.

An incision is made in the anterior tracheal wall at a level depending on the lower extent of the tumor. The trachea is divided obliquely, leaving a short anterior wall and a long posterior wall so to bevel lateral tracheal walls superiorly to enlarge the tracheostomy. The distal trachea is sutured to the skin edges of the permanent tracheostomy with interrupted nylon sutures. The proximal trachea and larynx are dissected from the cervical esophagus by sharp dissection.

Finally, entry is made in the pharynx either through the vallecula or the posterior cricoid region, depending on the tumor localization. After opening the mucosa to enter the pharynx, the mucosal incision is continued along the periphery of the larynx until the opening is large enough to permit the introduction of a retractor in the pharynx. Subsequent removal of the larynx by the division of its mucosal attachments is completed under direct vision. If planned, a tracheoesophageal puncture (TEP) is performed at this time. The pharyngeal defect is closed, preferably in a transverse fashion. A running Connell inverting suture (true or modified) with 3-0 Vicryl is used to close the pharyngeal defect beginning inferiorly with meticulous attention. After the closure of the pharynx, suction drains are placed lateral to the pharynx, the platysma is closed with interrupted Vicryl sutures, and the skin is closed with interrupted nylon sutures.[10][11][12]

Early complications after total laryngectomy are bleeding, postoperative edema, and airway compromise, these, especially in the immediate postoperative, should be carefully monitored. Administration of corticosteroids is recommended to minimize postoperative edema and airway compromise, hematoma or seroma, that should be prompt surgically evacuated, wound infection related to the perioperative exposure of the wound to bacteria, it could be minimized using a broad-spectrum antibiotic coverage and pharyngocutaneous fistula; total laryngectomy patients are at risk for pharyngeal suture line dehiscence with a resultant pharyngocutaneous fistula. The incidence of fistula formation is dependent on tension on the pharyngeal suture line, the configuration of the pharyngeal closure ("T" closure of horizontal closure), previous radiotherapy or chemoradiotherapy, nutritional status of the patient and presence of medical comorbidity (e.g., diabetes). Support of the pharyngeal suture line with a pectoralis muscle flap in a useful measure that may reduce the risk and the severity of pharyngocutaneous fistula.[13] Late complications include pharyngoesophageal stenosis, stoma stenosis, and hypothyroidism.[14]

Total laryngectomy represents a well codified ablative surgical procedure. Expertise and knowledge from an interprofessional team will likely require input from a head and neck surgeon, a pulmonologist, an oncologist, a radiologist, a radiotherapist, and a pathologist. The team will need to consider the biological behavior of laryngeal cancer and the anticipated responses to different therapies. Additional support from speech and swallowing therapists, nutritionists, psychiatrists, along with expert nursing care, are equally important in the treatment program. Interprofessional dialogue is critical in the management of laryngeal cancer.