DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Jaw cancer.
POSTOPERATIVE DIAGNOSIS: Jaw cancer.
OPERATIONS PERFORMED: Partial glossectomy; mandibulectomy; bilateral neck dissection, levels I, II, III, and IV; tracheotomy; direct laryngoscopy and esophagoscopy; fibula osteocutaneous free flap reconstruction of jaw; excisional preparation of surgical site; repair of complex wound; adjacent tissue transfer, 10 cm; split-thickness skin graft to left leg, 6.5 x 6.5 cm; excision of left cheek lesion, approximately 1.2 cm; and use of operating microscope.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was administered. All pressure points were carefully padded. A laryngoscope was used to inspect the oral cavity, oropharynx, hypopharynx and larynx. Only the anterior jaw lesion was noted. The esophagoscope was used to inspect the esophagus, and no mass or lesion was noted. This was done atraumatically.
Next, the neck and leg were prepped and draped in the usual sterile fashion. An incision was made low below the cricoid. The strap muscles were divided. A tracheostomy tube was inserted after excising tracheal rings 2 and 3. Next, an apron flap was elevated from mastoid tip to mastoid tip to the jaw and inferiorly to the clavicles. Following this, neck dissection on the left was initiated first. Fibrofatty tissue in level I was grasped and brought inferiorly. The facial artery was ligated. The submandibular duct was ligated. The mylohyoid muscle was retracted, and all fibrofatty tissue in level I was dissected to the digastric, with care taken to preserve the hypoglossal nerve and lingual nerves.
A similar procedure was performed on the opposite side. On the right side, fibrofatty tissue in level I was grasped and dissected as well. All fibrofatty tissue in level I was left attached to the jaw. Having done this, the fibrofatty tissue in levels II, III, and IV was dissected. This was done by unwrapping the sternocleidomastoid muscle of its fascia. Cranial nerve XI was found in its normal anatomic position. Fibrofatty tissue was dissected posterior to the cervical rootlet. Dissection was carried deep into the deep cervical fascia and carried anteriorly to the carotid artery, jugular vein, hypoglossal nerve and vagus nerve, which were all protected. The phrenic and branchial plexus were protected. This was done on both sides, completing a neck dissection of levels II, III, and IV.
Next, the jaw was carefully dissected over its anterior surface. The tumor was in close proximity to both mental nerves, which were sacrificed. Osteotomies were carried out through both mental foramen and the floor of the mouth was dissected, with care taken to preserve the hypoglossal nerves and the lingual nerves and their most distal branches were transected anteriorly. The tongue mucosa was incised, and a portion of the tongue was also excised in this process to complete the partial glossectomy. This was brought into continuity with deep tongue musculature, which was dissected with the cautery. This excised the jaw, the floor of the mouth, and a portion of the tongue to complete the mandibulectomy, glossectomy, and the excision of the tumor, which was also involving the floor of the mouth. The wound was irrigated and hemostased. Margins from the edges of the wound were sent for frozen section and returned as negative.
Next, the leg, which had been prepped in the usual sterile fashion, was exsanguinated of blood. An incision was made over the fibula with care taken to preserve a skin paddle around dopplered perforators. The peroneus longus and brevis muscles were retracted superiorly to reveal the fibula bone, which was osteotomized with care taken to preserve bone proximally and distally in the ankle joint and knee joint. The interosseous membrane was sectioned. The tibialis posterior muscle was sectioned. The peroneal artery and vein were ligated and dissection was carried to the popliteal fossa to identify an appropriate-sized vascular pedicle. Skin paddle was carefully excised, taking the flexor hallucis muscle. The cuff was released and excellent blood flow to the leg, the toes, and the free flap was noted.
Next, the edges of bone were carefully trimmed. The edges of mucosa were carefully trimmed. The deep tongue musculature was carefully cauterized with care taken to preserve the hypoglossal nerves. This completed the excisional preparation of the surgical site. The fibula was brought to the jaw where the left facial artery, a branch off the internal jugular vein and the external jugular vein were lysed for maxillary anastomosis. A Synthes type recon plate was wrapped around the jaw to reconstruct the normal occlusion. The fibula bone was dissected subperiosteally. Two osteotomies were made. It was placed deep to bone and locked in place using locking recon screws, and the reconstruction plate was also locked to the jaw.
Following this, the facial artery was anastomosed to the peroneal artery and approximated using 9-0 nylon under the operating microscope. Following this, two 3 mm microvascular anastomotic coupling rings were used to anastomose internal and external jugular vein to the peroneal veins. Following this, a split-thickness skin graft was harvested from the left thigh under sterile conditions. A sterile gauze dressing was placed over this. It was brought to the leg, which had been hemostased in the usual fashion. A drain was placed in the leg. The superior portion of the incision was closed primarily using 3-0 Vicryl and staples. The skin graft was affixed to the left leg and stapled into place. A foam bolster was placed over this, over which an Ace wrap was placed. This completed the split-thickness skin graft of the wound, which was over 6.5 x 6.5 cm, as well as closure of the left leg.
Following this, the tongue was closed upon itself to approximately 1 cm below where the floor was at one time. The fibula skin paddle was placed in the mouth deep to the bone of the jaw and secured to the floor of the mouth using 3-0 Vicryl. It was de-epithelialized, and the lip was placed onto the skin paddle and then the skin paddle was wrapped onto the chin, where it was attached to the skin of the flap using 3-0 Vicryl. The skin of the flap was rotated superiorly using advancement suture. Approximately 10 cm2 of neck skin was advanced superiorly to help provide support to the new lip.
Following this, the wound was thoroughly irrigated and hemostased. The pedicle was allowed to drape in a relaxed fashion. Penrose and suction drains were placed in the neck. The neck was closed using 3-0 Vicryl as well as staples. A Doppler station was placed up over the skin paddle. The patient tolerated the procedure well. The tracheostomy tube was placed in the stoma. The patient was taken to the intensive care unit in stable condition.
