OPERATION: EXCISION OF BRANCHIAL CLEFT CYST
Operative Technique
§ Patient supine, head turned to the contralateral side with neck hyperextended
§ A small transverse incision
done over the cyst
§ Creation & mobilization of superior & inferior Skin flaps
§ Mobilization of cyst from anterior border of sternocleidomastoid by gentle
retraction and elevation
§ Sharp dissection separates the fascial attachments and adhesions of the
cyst medially
§ The plane between the cyst and the posterior belly of the digastric and
stylohyoid muscles is developed by blunt dissection
§ Identification, isolation and separation of carotid sheath, hypoglossal
and glossopharyngeal nerves, and lingual vein from the cyst
§ Duct of the cyst is mobilized, dissected and followed cephalad up to its
pharyngeal origin, which is usually the tonsillar fossa; then it is suture-ligated with silk 2-0 and transected
§ A drain is inserted and the wound closed with approximation of the platysma
muscle and skin as separate layers
§ Hemostasis
§ Lavage or irrigation
§ Correct count
§ Wound closure
OPERATION: EXCISION OF CYSTIC HYGROMA
Operative Technique
§ Patient supine w/ neck hyperextended, tilted to the left
§ Curvilinear incision over the mass carried down to the platysma
§ Creation & mobilization of superior & inferior skin flaps
§ Fascia along the anterior border of the sternocleidomastoid muscle incised
§ Mobilization of cyst from anterior border of sternocleidomastoid by gentle traction and elevation
§ Using alternate blunt and sharp dissection, the inferior extension of the cyst is separated from the omohyoid muscle
§ Identification, isolation and separation of contents of carotid sheath, hypoglossal & spinal accessory nerves
from the cyst
§ Cyst is mobilized, dissected and followed cephalad up to the pharynx then it is suture-ligated with silk 2-0 and
transected
§ Attached lymph nodes are removed with the cyst
§ Operative field irrigated w/ saline
§ Hemostasis
§ Complete sponge & instrument count
§ Penrose drain is inserted & anchored to the skin
§ Platysma approximated with 4-0 chromic catgut
§ Skin is closed with 5-0 nylon
§ Patient tolerated procedure well
OPERATION: INCISION AND DRAINAGE
Operative Technique
Ø
Px supine under Gen mask
Ø
Asepsis antisepsis technique
Ø
Sterile drapes placed
Ø
Vertical incision made over the fluctuant portion
of the mass
Ø
Intraop findings noted
Ø
Wound debridement done
Ø
Purulent discharge suctioned
Ø
Wound flushing w/ NSS + betadine + Hydrogen
peroxide
Ø
Wet fluffy packing done
Ø
Elastic bandage applied.
OPERATION:
PAROTIDECTOMY
Operative Technique
§ Patient supine, head turned to the contralateral side with neck slightly extended, head elevated todecrease
venous return to the head and neck
§ asepsis/antisepsis done
§ sterile drapes placed
§ make an incision on the crease just in front of the ear, around the lobule and up to postauricular fold
the curves posteriorly over the mastoid process and swings down into the superior cervical crease
§ Elevate the flap in the plane just superficial to the dense superficial parotid fascia. Use skin hook
or rake retractors to exert upward traction on the skin flap as the plane developed between subcutaneous tissue and the superficial
parotid fascia by sharp dissection
§ Identify the main trunk of the great auricular nerve and preserve it.
§ Divide the posterior facial vein but not the retromandibular vein to prevent vein engorgement
§ Elevate the skin flaps as well as the ear lobe in a postero-cephalad direction to exposed the sternocleidomastoid
§ Locate the anterior border of the sternocleidomastoid muscle and
mobilize it from the capsule of the parotid gland, dissection is carried down in the area inferior and posterior to
the cartilaginous external auditory canal.
©
Be careful not to swing down the tail of the
parotid gland to define the inferior border, it might injure the mandibular branch of the facial nerve
§ Exposure of the main trunk of the facial nerve
©
Sternocalidomastoid muscle retracted posteriorly
©
Parotid gland retracted anteriorly
©
Identify the posterior belly of the digastric
muscle and gently push it up to its groove
©
LANDMARKS:
§
one fingerbreadth inferior to the membranous
portion of the external auditory canal
§
one fingerbreadth anterior to the mastoid process
§
medial to the branch of the postauricular artery
§ The superficial lobe of the parotid is dissected in the plane of the branches of the facial nerve
§ Elevate the superficial lobe by traction with gauze, or with grasping with forcep or by placing traction
sutures
§ Identify the two main branch of the facial nerve and trace each nerve by gently spreading in the plane
immediately superficial to the trunk of the nerve
©
Stimulate any structures that will be divided:
by gentle mechanical stimulation using a forcep. This will cause twitching of the innervated muscle
§ Further mobilization of the superior lobe of the parotid gland and identification of all the branches
of the facial nerve
§ Ligation and division of the Stensens duct
§ Removal of the superior lobe
§ To dissect the deep lobe of the parotid gland, gently elevate the branches of the facial nerve with
a nerve hook and gently separates the gland from around and beneath the nerves.
§ Hemostasis
§ Lavage or irrigation
§ Drain placed
§ Correct sponge and instrument count
§ Wound closure
©
Platysma muscle and dermis apposed
©
Skin closed subcuticularly using absorbable
sutures
§ DSD
§ Patient tolerated the procedure well
OPERATION: RADICAL NECK DISSECTION
Operative
Technique
§ Patient in dorsal recumbent position
§ Placed a sand bag under the shoulder to extend head and neck
§ Asepsis/antisepsis technique done
§ Sterile drapes placed
§ INCISION: Double Trifurcate Incision
¯
Upper arm : curve incision from the mastoid
process extending to the just below the midline of the mandible
¯
Lower Arm: from the trapezius in gentle curve
to the midline of the neck
¯
The upper and lower arm are connected by a straight
incision at their angle
§ The posterior flap turned back up to the anterior edge of the trapezius muscle at sub platysmal level
§ The anteriorateral flap extends up to the strap muscles
§ The superior flap created; the mandibular branch of the facial nerve identified and spared.
§ The inferior flap retracted down to exposed the superior aspect ot the clavicle
§ The sternocleidomastoid muscle transected just above its insertion at the clavicle and sternum
§ Dissection of the posterior cervical triangle done by sharp and blunt dissection; exposing the anterior
border of the trapezius muscle
§ The external jugular vein identified, clamped, cut and ligated at the posteroinferior corner
§ Spinal accessory nerve identified cut and ligated
§ Posterior triangle cleaned off its areolar and lymphatic tissues
§ Posterior belly of the omohyoid identified and cut
§ Transverse artery and vein identified and spared
§ Phrenic nerve identified lying upon the anterior scalene muscle between the brachial plexus and internal
jugular vein
§ Internal ugular vein, just medial to the phrenic nerve and is within the carotid sheath, is dissected
free, doubly ligated at its inferior ligation and cut
§ Dissection carried down to the prevertebral fascia overlying the deep muscle structures of the neck
§ The inferior compartment of the neck is the outlined mediallt
by division of the pretracheal fascia just lateral to the strap muscles covering the thyroid gland.
§ The common carotid artery identified and preserved
§ With the lateral limit of dissection defined and the common carotid artery identified, dissection inferiorly
is started and superiorly following the floor of the neck or the prevertebral fascia.
§ As the dissection is carried oout superiorly; the areolar and lymphoid tissues of the neck lying along
the course of the internal jugular vein are reflected upward.
§ All the loose areolar tissues surrounding the carotid artery are completely removed
§ The branches of the cervical plexus are identified and divided as they emerge through the prevertebral
fascia
§ Dissection anteriorly; the tributaries of the superior thyroid, superior laryngeal, and pharyngeal veins
are identified clamped cut and ligated
§ The bifurcation of the carotid artery can be identified by the appearance of the superior thyroid artery,
which can be preserved
§ Dissection carried superiorly to expose the hypoglossal nerve as it crosses both the internal and external
carotid artery just a centimeter above the bifurcation.
§ Attention is now directed to the submental area, where the fascia from the midline of the neck is divided
§ Anterior belly of the digastric muscle and the underlying mylohyoid muscle identified
§ By following the anterior digastric muscle posteriorly, the submaxillary
salivary gland is exposed
§ Mobilize the submaxillary gland from anterior to posterior, thus
exposing the submaxillary space
§ Ligual nerve identified and spared as it lies in the most superior aspect of the submaxillary space
and can be preserve
§ Hypoglossal nerve identified and preserved as it lies in the most inferior aspect of the area
§ To remove the submaxillary, gland,the submaxillary duct should be identified, clamped, cut and ligated
§ Anterior belly of the omohyoid muscle is divided from the sling of the digastric muscle
§ The posterior belly of the digastric muscle is exposed
§ Retract the posterior belly of the digastric muscle superiorly
§ Hypoglossal nerve exposed
§ Internal jugular vein exposed
§ The internal jugular vein is clamped high enough to include the tail of the parotid where it is ligated
and cut
§ Sternocleidomastoid reoved from the mastoid process
§ Hemostasis secured
§ Drain placed anteriorlly and posteriorly
§ Platysma closed using silk sutures
§ Betadine
§ DSD
§ Patient tolerated procedure well
§ Post-op condition-stable
OPERATION: TOTAL LOBECTOMY
Operative Technique
§ Patient lying supine with hyperexteded neck under GA
§ Asepsis antisepsis technique done
§ Sterile drapes placed
§ A low collar incision done carried down to the subcutaneous tissue
§ Platysma identified
§ Superior flap created by blunt and sharp dissection up to the level of the thyroid cartilage
§ Inferior flap created by blunt and sharp dissection and mobilized just up to suprasternal
notch
§ Incised the fascia in the midline up to the thyroid gland
§ Strap muscles identified, dissected and separated from the thyroid gland
§ Middle thyroid vein identified, ligated with silk 4-0 and cut
§ Mobilization of the superior pole of the thyroid done
§ Superior parathyroid gland identified
§ Superior thyroid artery and vein is identified, clamped , doubly legated and cut
§ Mobilization of the inferior pole of the thyroid
§ Inferior parathyroid gland identified
§ Recurrent laryngeal nerve identified
§ The inferior thyroid artery and vein identified, clamped. Cut and ligated
§ Gently do a blunt dissection of the isthmus from the trachea
§ Isthmus clamped, cut and suture ligated
§ Hemostasis
§ Drain placed
§ Layer by layer closure
§ Strap muscle approximated using chromic 3-0
§ Subcutaneous approximated using chromic 2-0 by inverted T suture
§ Skin closed by subcuticular using vicryl 4-0
§ Betadine
§ DSD
§ Patient tolerated procedure well
§ Post-op condition-stable
OPERATION: PARTIAL LOBECTOMY
Operative Technique
§ Patient lying supine with hyperexteded neck under GA
§ Asepsis antisepsis technique done
§ Sterile drapes placed
§ A low collar incision done carried down to the subcutaneous tissue
§ Platysma identified
§ Superior flap created by blunt and sharp dissection up to the level of the thyroid
cartilage
§ Inferior flap created by blunt and sharp dissection and mobilized just up to suprasternal
notch
§ Incised the fascia in the midline up to the thyroid gland
§ Strap muscles identified, dissected and separated from the thyroid gland
§ Pass a blunt-tipped hemostat between the isthmus and the trachea
§ Divide the isthmus at is narrowest area or at the far side
§ Divide the lobe by placing a Kelly clap in an angle that will preserve the posterior capsule
of the thyroid (leaving a remnant thyroid gland approximately 5 gms)
§ Suture ligate the thyroid by using silk 4-0
§ Tack the thyroid remnant to the trachea with running suture through the tough pretracheal
fascia
§ Hemostasis
§ Drain placed
§ Layer by layer closure
§ Strap muscle approximated using chromic 3-0
§ Subcutaneous approximated using chromic 2-0 by inverted T suture
§ Skin closed by subcuticular using vicryl 4-0
§ Betadine
§ DSD
§ Patient tolerated procedure well
§ Post-op condition-stable
OPERATION: TRACHEOSTOMY
Operative Technique
§ Patient supine
§ Slightly hyperextended the neck by placing a roll under the
patient’s shoulder
§ Asepsis antisepsis
§ Sterile drapes placed
§ Local anesthesia infiltrated
§ Palpate for the five midline landmarks
o Mental protruberance
o Body of hyoid bone
o Laryngeal prominence of the thyroid cartilage
o Cricoid cartilage
o Suprasternal notch
§ Vertical incision midway between the cricoid cartilage and
jugular notch provides better exposure
§ Skin, subcutaneous tissues and strap muscles are retracted
laterally to exposed the thyroid isthmus
§ The isthmus maybe divided and ligated or retracted upward
§ Dissect and cut the pre-tracheal fascia for better exposure
§ Identify the cricoid cartilage
§ Count the rings down the cricoid cartilage
§ With a tracheal hook, the trachea is pulled up
§ Incised and spread the tissue between the second and third
tracheal rings
§ Tracheostomy tube inserted
§ Skin closed Tracheostomy tube secured.
OPERATION: CRICOTHYROIDOTOMY
Operative Technique
§ Patient supine
§ Palpate for the landmarks : thyroid cartilage; cricoid cartilage, and the hyoid bone
§ Stabilized the larynx
§ Palpate for the cricoid cartilage
§ Stab through the cricothyroid membrane transversely with a scalpel
§ Spread the hole with Kelly clamp and insert the tracheostomy tube
§ Tracheostomy tube secure
OPERATION: HEMIMANDIBULECTOMY
Operative Technique
§ Patient supine,
head turned to the contralateral side with neck hyperextended
§ A curved incision is made in the submaxillary region carried
down to the outer surface of tumor or the mandible.
§ Create a superior and inferior flap by gentlely elevate skin
and fat using knife, scissors and blunt dissection upward, and downward
§ Mandible is sectioned at the site of election using a gigli
saw
§ If teeth are present the oral cavity must necessarily be entered.
The ramus is mobilized by splitting the pterygoid and temporal muscles from its attachments. The masseter muscle is sectioned
and stripped off the external surface.
§ The opening in the oral mucosa is closed with non-absorbable
sutures tied inside the mouth.
§ at least one layer of supporting buried sutures of chromic
catgut are placed within the wound itself, before closure of the skin and subcutaneous tissues
§ HEMOSTASIS
§ Lavage or irrigation
§ Drain (rational placement)
§ Correct count
§ Wound closure
§ Light dressing
OPERATION: MODIFIED RADICAL MASTECTOMY
Operative Technique
§
Patient supine with both arms at 900
and placed a folded sheet under the ipsilateral shoulder
§
Asepsis- Antisepsis
§
Sterile drapes placed
§
A Transverse elliptical incision done, that
includes the nipple-areolar complex and the biopsy scar with a 5 cm allowance on each side of the biopsy incision
§
Sharp and Blunt dissection done to liberate
the whole breast tissue up to the subclavicular-superiorly; subcostal-inferiorly; sternum-medially
and from the lateral border of the latissimus dorsi-laterally.
§
Dissection of fascis ovelying the major pectoral
muscle from the sternum to the lateral border by sharp and blunt dissection
§
Perforating branches of the intramammary artery
and vein identified and ligated
§
Lateral pectoral nerve identified and preserved
§
Dissection of fat and fascia from the ateroinferior
aspect of the coracobrachialis muscle
§
The underside of the pectoralis major muscle
was visualized and the fatty, areolar , node bearing tissue were removed exposing the underlying minor pectoral musclethe
axillary fat pad were bluntly dissected to exposed and unroof the anterior surface axillary vein
§
Branches of the axillary vein, except the subscapular
vein, were clamped, cut and ligated
§
All areolar and lymphatic tissues up to the
were the clavicle over crosses the axillary vein were all removed
§
Long thoracic nerve and thoracodorsal nerve
were identified and spared
§
Specimen removed and properly labeled
§
Operative site irrigated with sterile NSS
§
Hemostasis
§
Two multiperforated tubes were placed deep into
the axillary vein and another over the thoracic wall. Exited through two punctured
wounds below the axilla
§
Drain secured
§
Skin closed by subcuticular sutures using
§
Dry Sterile Dressing applied
§
Patient tolerated the procedure well
§
Post-op condition-
stable
OPERATION: PARTIAL MAXILLECTOMY
Operative Technique
¯ Patient supine
¯ Sutures of nylon are placed temporarily to
· fuse the eyelids for protection of the cornea.
· A weber-fergusson incision is made, keeping close to the
· ala, running up to the inner canthus and then laterally,
· close to the palpebral margin
¯ Creation of flaps require gentle elevation of skin and fat using knife, scissors and blunt dissection laterally
¯ Usually one or two teeth are extracted along the line of the incision
across the alveolus.
¯ With the chisel or vibratory saw, the anterior wall of the maxilla
and the palate is cut through.
¯ Care should be taken to slant the direction of the chisel or bone
saw downward along the infraorbital ridge to avoid entering the bony orbit.
¯ A bone cutting forceps may be used to sever the malar bone.
¯ The specimen includes the party wall between the antrum and the nasal
cavity.
¯ The mucous membrane lining the antrum is removed and the ethmoid
cells curetted.
¯ hemostasis
¯ lavage or irrigation
¯ A split thickness graft is placed so as to completely
cover all raw surfaces. Its edges are sutured to mucous membrane margins wherever possible.
¯ correct count
¯ wound closure
¯ Following placement of the graft, the operative defect is packed to hold the skin graft in accurate,
firm approximation to the raw surfaces
OPERATION: EXCISION OF THE THYROGLOSSAL DUCT CYST
Operative Technique
§ Patient supine with neck hyperextended and
the chin directly anterior
§ Asepsis antisepsis
§ Sterile drapes placed
§ Transverse incision above the external opening of the cyst carried down to the platysma
§ Creation & mobilization of upper & lower skin flaps
§ Vertical midline incision on the fascia overlying the tract
§ Strap muscles retracted laterally
§ Dissect carefully the cysts from its surrounding soft tissues
§ Transection of pyramidal lobe connection between clamps
§ Search, identify and mobilize the tract going to the hyoid bone
§ Detach the mylohyoid and the deeper geniohyoid muscles from the hyoid bone superiorly;
and the sternohyoid inferiorly
§ Transect the hyoid bone on both side
§
Put the index finger
of your non-dominant hand into the mouth and press down the foramen cecum
§
Continue dissection
of the cyst up to the foramen cecum, but do not remove the foramen cecum
§ Excision of the tract done
§ Suture ligate the sinus tract just below the foramen cecum
§ Closure by layer
·
Approximation of mylohyoid muscles to thyrohyoid
membrane
· fascia enveloping the strap muscles is closed in a vertical plane
|
Platysma à chromic 2-0 simple interrupted |
o
Skin à Vicryl 5-0 placed subcuticularly in vertical mattress fashion
OPERATION: TOTAL MASTECTOMY
Operative Technique
§ Patient supine under GA
§ Asepsis- Antisepsis technique done
§ Sterile drapes placed
§ A Transverse elliptical incision done on the skin carried
down to the subcutaneous tissue
§ Sharp and Blunt dissection done to liberate the whole
breast tissue from the skin flaps and from the pectoralis fascia
§ Ligation of bleeders done
§ Intra op findings noted
§ Closure done by simple interrupted sutures using Chromic
2-0
§ Skin closed by subcuticular sutures using Vicryl 5-0
§ Dry Sterile Dressing
applied
§ Patient tolerated the procedure well
§ Post-op condition- stable
OPERATION: WIDE EXCISION WITH AXILLARY DISSECTION
Operative Technique
§ Patient supine with both arms at 900 and placed a folded sheet under the ipsilateral
shoulder
§
Asepsis- Antisepsis
§
Sterile drapes placed
§
A curvilinear incision over the mass was done
§
Sharp and Blunt dissection done to remove the mass with adequate margin of normal mammary tissue
determine by gross appearance
§
Tissue sample brought to Pathology section for
frozen section
AXILLARY DISSECTION
§
Incision along the pectoralis major muscle done
§
Lateral border of the pectoralis major muscle
identified and clean the fatty tissue from the underside of the muscle
§
Retract the pectoralis major muscle medially,
exposing the pectoralis minor muscle
§
Incised the clavipectoral fascia on each side
of pectoralis minor muscle
§
Divide the pectoralis minor to gain access to
the axilary vein
§
Dissect medially in the anterior adventitial
plane of the vein to the surgical apex of the axilla
§
The highest axillary node are the subclavian
nodes, which lies in the medial apex of the field
§
Do sharp and blunt dissection and sweep the
node-bearing tissues down as the chest wall is exposed
§
Cleanly dissect the chest wall, progressing
from medial to lateral
§
Follow the axillary vein laterally, dividing
any small vessels that cross over it and any vein tributaries that pass inferiorly.
§
Long thoracic nerve identified and spared
§
Continue dissecting laterally in the anterior
adventitial plane of the axillary vein
§
Thoracodorsal vein identified, clamped, cut
and ligated
§
Thoracodorsal nerve identified and preserved
§
Sweep the axillary content downward
§
Remove the specimen by dividing the remaining
tissue laterally
§
Suction drain placed
§
Operative site irrigated with sterile NSS
§
Hemostasis
§
Skin closed by fine interrupted sutures
§
Dry Sterile Dressing applied
§
Patient tolerated the procedure well
§ Post-op condition- stable
