DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Cancer of the left retromolar trigone.
POSTOPERATIVE DIAGNOSIS: Cancer of the left retromolar trigone.
OPERATION PERFORMED:
1. Direct laryngoscopy and biopsy.
2. KTP/532 laser excision of left retromolar trigone cancer with frozen section control.
3. Left selective neck dissection, supraomohyoid dissection, levels I, II, and III.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General anesthesia.
FLUIDS: Crystalloid.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. He was intubated, intraorally given general anesthesia. First, the anterior commissure laryngoscope was passed, and all surfaces of the hypopharynx were examined. There was found to be a 1.5 cm mucosal cyst in the left epiglottic free edge. This was marsupialized and most of the cyst wall was removed and sent for permanent section analysis. All other surfaces of the hypopharynx were free of abnormalities.
Upon removal of the laryngoscope, attention was then addressed to the oral cavity. The mouth retractor was inserted and suspended off the Mayo stand. The face was prepped and draped in the usual fashion with wet towels around the face. All operating room personnel were protected with eyewear. KTP/532 laser with 0.6 Endostat was then used to circumscribe and excise the lesion of the left retromolar trigone. A 5 mm cuff of normal tissue was accomplished without difficulty and the excision carried out over the occlusal edge of the mandible and then down into the area of the soft palate and anterior tonsillar pillar. Inferior alveolar nerve was identified as it entered the left side of the mandible. The specimen was tagged at the superior or 12 o’clock position and sent for frozen section analysis. The frozen section returned negative for invasive neoplasm at the margins. However, there was an area of carcinoma in situ inferiorly, which would be at the level of the inferior pole of the tonsil and the retromolar area. Given that this patient has a diffuse condemned mucosa and margins difficult to achieve in this setting, it was elected to desist from further excisions and the plan for closed surveillance of this area postoperatively was made.
Attention was then addressed to the left neck. The left neck was prepped and draped in usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin of the neck. A curvilinear incision was made for the mastoid deep down into the mid neck level and brought up into the submandibular area. Skin flaps were elevated superiorly and inferiorly deep to the platysma layer. The supraomohyoid selective neck dissection was performed. The anterior border of sternocleidomastoid muscle and superior part of the omohyoid muscles were the limits of the resection. Actually, the SCM was retracted laterally and the fascia dissected off the underbelly of that muscle all over the carotid sheath structures with a special package being developed, including lymph nodes of the jugular chain. The fascial packet was dissected superiorly off the carotid sheath structures. The omohyoid nerve was dissected out. The specimen reflected superiorly to the level of the submandibular gland. The submandibular gland was then isolated and the facial vein and artery were ligated and divided.
The lateral aspect of the submandibular gland with fascia was elevated off the lateral aspect to the gland after ligating the facial vein. The submandibular gland was then retracted inferiorly into the neck. The omohyoid muscle was retracted to expose the lingual nerve attachments in the submandibular duct. These were ligated and divided sparing lingual nerve injury. The specimen was then delivered which included levels I, II, and III. There was a fairly large node in level II, but all other nodes appeared relatively normal. After saline irrigation with noted hemostasis, #10 flat fully perforated Jackson-Pratt drains were brought out in inferiorly stab wounds and sewn into place with silk ligature. Closure was accomplished with the deep layer in the platysma followed by a second layer in the dermis using interrupted 4-0 Vicryl stitches. Skin staples were applied to the skin and antibiotic ointment. The drain was taped into place. The patient was then allowed to awaken from anesthesia, extubated, and taken to recovery room in stable condition. Estimated blood loss was less than 100 mL.
