DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right parotid gland malignancy.
POSTOPERATIVE DIAGNOSIS: Right parotid gland malignancy.
OPERATION PERFORMED:
1. Right lateral parotidectomy with facial nerve dissection and preservation.
2. Intraoperative facial nerve monitoring x2 hours.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF OPERATION: After proper consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was administered. Once the patient was asleep, the bed was turned to 180 degrees and her neck was placed in general extension. The patient’s head was turned to the left, exposing the right parotid gland. Time-out was performed confirming the side of surgery, which had been previously marked.
An incision was drawn in the preauricular crease extending below the lobule and then curving forward in the neck two fingerbreadths below the mandible. This was injected with 1% lidocaine with epinephrine. Facial nerve monitoring electrodes were placed using four channels in the right face. The electrodes were personally placed by the operating surgeon. They were then connected to the nerve integrity monitor. Proper electrode impedances were confirmed. A tap test was performed to ensure appropriate functioning of the monitoring system.
The patient’s right face was then prepped and draped in the usual sterile manner. Using a 15 blade, the skin incision was made and carried down to the level of the parotid fascia and platysma muscle. Facial flap was elevated forward, superficial to the parotid fascia using tenotomy scissors. Dissection was then carried along the posterior edge of the incision identifying the greater auricular nerve. This nerve was dissected free and rotated posteriorly out of the field.
Next, the posterior edge of the parotid gland was identified, and this was dissected free from the cartilage of the ear. We then separated from the anterior edge of the sternocleidomastoid muscle. The digastric muscle was next identified. Dissection was then performed in the area of the tragus down to the level of the digastric muscle. The nerve stimulator was used at the setting of 2.5 to map out the general position of the nerve.
Gentle dissection of this area revealed the main trunk of the nerve. Dissection was first performed on the inferior branch, tracing it throughout its entire length until we had exited the parotid fascia. Working on each successively higher branch, the gland was gradually rotated forward and upwards. There was an obvious mass within the inferior lateral gland. Dissection was carried well around this, and it was rotated upwards with the specimen. The uppermost branches were identified and preserved. The lateral parotidectomy specimen was separated and set aside. It was sent to pathology as a frozen specimen. The frozen specimen diagnosis was carcinoma within the gland. There was no sign of obvious mucin suggesting a mucoepidermoid carcinoma. The sliced specimen appeared to have an approximately 1 cm lesion within it.
At this point, the decision was to not perform an additional total parotidectomy. The specimen was approximately 1 cm in size located within the lateral portion of the parotid, and adequate surgical margins were achieved around the lesion. The wound was copiously irrigated and complete hemostasis was achieved. A 7 flat JP drain was then placed within the wound but away from the branches of the facial nerve. The wound was then closed in three layers using interrupted 3-0 Vicryl and for the skin running Prolene suture. Antibiotic ointment was then applied.
Throughout the case, facial monitoring was performed. This was set up and monitored by the operating surgeon. The nerve stimulator was used on multiple occasions to assess the integrity of various branches of the facial nerve. Settings for stimulation ranged from 1.0 to 2.5 mA. There were intermittently small potentials from the facial nerve while dissecting around it, but no trained potential suggesting significant irritation or trauma to the nerve. At the end of the case, the facial monitoring electrodes were removed.
The patient was awakened and extubated without difficulty. The patient was transferred to the recovery room in stable condition. Estimated blood loss was minimal. Sponge and needle counts were correct.
