DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: T4N0MX squamous carcinoma of the left buccal mucosa with mandible and maxillary involvement.
POSTOPERATIVE DIAGNOSIS: T4N0MX squamous carcinoma of the left buccal mucosa with mandible and maxillary involvement.
OPERATIONS PERFORMED:
1. Excision of malignant tumor of mandible.
2. Excision of malignant tumor of maxilla.
3. Excision of lesion of mucosa and submucosa of the buccal mucosa with skin.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 300 mL.
SPECIMENS:
1. Buccal lesion with maxilla.
2. Mandible.
3. Multiple frozen sections.
INDICATIONS FOR OPERATION: The patient is an (XX)-year-old gentleman with a history of a T4N0MX squamous cell carcinoma of the left buccal mucosa who underwent radiation therapy. Despite the radiation therapy, the tumor grew. This is now involving the inferior and superior alveolar ridges with bony erosion over the inferior maxillary sinus and erosion of the mandible. Decision was made to take the patient to the operating room for an excision of lesion with infrastructural maxillectomy and partial mandibulectomy. Risks and benefits of the procedure were explained to the patient, and the patient agreed to proceed.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in the supine position on the operating table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned. The patient’s face was prepped and draped in routine fashion. Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into a region from the right upper lip laterally underneath the inferior orbital rim and then inferiorly down to the left lower lip.
Surgery began with Harmonic scalpel for skin excision. This was carried through and through the upper lip on the lateral third of the left side. This was carried down to the maxillary bone and laterally into the deep tissues of the face. This was then carried inferiorly through the skin down to the lateral third of the lower lip. The incision was then carried down onto the lateral portion of the mandible.
Intraoral incisions were carried down over the alveolar ridge anteriorly down into the floor of mouth posteriorly to the retromolar trigone and then superiorly up under the soft palate and hard palate. Hemostasis was obtained with bipolar cautery and 3-0 silk sutures.
At that point, the bone cuts were made into the maxilla. An infrastructural maxillectomy was performed. The anterior cut was carried posteriorly back to the pterygoid plates. The superior cuts were carried through the maxillary sinus just inferior to the inferior orbital floor. This was carried laterally to the lateral wall of the antrum. Heavy Metzenbaum scissors were then used to resect the posterior infrastructural maxillectomy from the pterygoid plates. Hemostasis was obtained with Bovie cautery.
The mucosa overlying the mandible was then removed from the bony portion of the mandible back to the retromolar trigone. This allowed complete liberation of the tumor and tissues from the oral cavity. Frozen sections were then obtained from the upper lip, the lower lip, retromolar trigone, pterygopalatine fossa and the floor of mouth and the maxillary sinus. Maxillary sinus frozen pathology came back as atypia. The remaining lining of the left maxillary sinus was removed and sent for permanent pathology.
A new wide margin was obtained from the pterygopalatine space exposing the medial and lateral pterygoid muscle. This was sent for permanent pathology. A new margin on an erosion of the mandible was sent and was positive for squamous cell carcinoma. The decision was made at that point to perform a partial mandibulectomy. This was carried down to the body of the mandible posteriorly to the parasymphyseal region anteriorly. The hemimandibulectomy was then sent for permanent sections. A new floor of mouth margin was sent for frozen section. Hemostasis was the obtained with bipolar cautery. This completed the extirpation portion of the procedure. The wound was then packed with a wet lap gauze. Another doctor then scrubbed into the case and will complete the reconstruction and closure. There were no complications during the extirpation part of the procedure.
