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HOW I DO IT / HOW I DID IT SURGICAL PROCEDURES |
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PAROTIDECTOMY:
§ 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
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