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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана

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Fig. 40 Elevation of the upper and lower skin aps with exposure of the anterior border of the sternocleidomastoid muscle
R. Mehta et al.
Fig. 43 Excised branchial cyst
Fig. 41 Delivery of the smooth-walled cystic swelling
Fig. 42 Surgical bed after excision of the lesion, which
shows the preserved underlying structures
Fig. 44 A smooth-walled cystic swelling along the ante­rior border of the right sternocleidomastoid muscle
Fig. 45 Surgical bed showing the underlying preserved IJV and carotid
Intraoperative steps of surgery and surgical specimen images are shown in Figs.44, 45, and
46.
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Fig. 46 Excised branchial cyst
7 Lymphangioma
Congenital lymphatic spongy multiloculated cys­tic lesions are known as lymphangiomas. When a signicant lesion exhibits a clear deformity or when a lesion compromises function due to encroachment into the airway or swallowing pas­sageways, excision of these lesions is suggested. Despite the fact that the cause is yet unclear, these lesions could be congenitally present and not show up clinically until much later in life, when they might start to enlarge.
For full excision of the lesion without leaving any loculi or parts of the cyst wall behind, radio­logical imaging using an MRI scan is essential in these lesions to determine the extent of numerous loculations interdigitating inside muscle planes.
Operative Procedure
• A transverse incision which is placed over the
upper part of the neck.
• Upper and lower skin aps are lifted, and the
skin incision is deepened till the level of the
platysma.
• It is essential to be careful and cautious while
lifting the skin aps to prevent rupturing the
thin walled cystic lesion.
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• The multiloculated cystic process is difcult to dissect when the lesion ruptures, and this frequently results in partial excision and recurrence.
• Therefore, great care should be used to maintain the cyst wall’s integrity in order to enable a full excision.
• The loculated lesion is seen as the dissection moves further. The cystic lesion is then metic­ulously dissected in tissue planes around it, progressively mobilizing each of its loculi and bringing them into the surgical area.
• The lesion is removed in one piece once all of its loculi have been removed.
• The skin incision is closed in stages, and suc­tion drains are installed.
• The surgical specimen reveals a multilocu­lated cystic tumour that was completely excised, resulting in its permanent management.
• For long-term management, it is crucial to pay close attention to every lymphangioma locula­tion that has to be removed. If the cyst lining is not removed completely, the lymphangioma may return locally.
7.1 Case 1
The patient in the image has a sizable cystic lesion that extends to the parapharyngeal borders and takes up much of the upper section of the neck. The anterior triangle of the top part of the right neck is affected by a well-dened multiloc­ulated cystic lesion in the T2-weighted MRI scan’s axial view. The cystic lesion’s bright white colour denotes the presence of uid.
Preoperative radiological imaging, intraopera-
tive steps of surgery and surgical specimen images are shown in Figs.47, 48, 49, 50, 51, 52,
53, and 54.
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Fig. 47 MRI scan: coronal cuts showing large hyperintense lesion in the right parapharyngeal space
R. Mehta et al.
Fig. 48 Planned modied Blair/Bailey incision in the right side of the neck for adequate exposure
Fig. 49 Elevation of the skin ap for exposure of the lesion
Fig. 50 Exposure of the part of lymphangioma which was present in the neck and plating done at the planned mandibulotomy site
Fig. 51 Complete exposure of the lesion in the neck and in the paramandibular region, medial to the mandible
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265
Fig. 52 Mandibulotomy cuts: horizontal over the ramus of the mandible and vertical cut over the body of the man­dible in the parasymphyseal region
Fig. 53 Surgical site after complete excision of the lesion
Fig. 54 Surgical specimen in toto after complete surgical
excision showing a multiloculate specimen
8 Neurobromatosis
Preoperative radiological imaging, intraoperative steps of excision of neurobromatosis and surgi­cal specimen images are shown in Figs.55, 56,
57, 58, 59, 60, 61, 62, 63, and 64.
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Fig. 55 MRI scan sagittal cuts showing lesion in the nape of the neck
R. Mehta et al.
Fig. 56 MRI scan coronal cuts
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Fig. 57 Multiple cutaneous neurobromatosis lesions present in the bilateral malar region
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Fig. 59 Soft tissue dissection and complete excision of the lesion from its bed
Fig. 58 Large neurobroma lesion present in the nape of the neck
Fig. 60 Surgical site after complete excision of the lesion
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Fig. 61 Surgical specimen after excision
R. Mehta et al.
Fig. 62 Upper surface of the surgical specimen
Fig. 63 Inferior surface of the surgical specimen
Fig. 64 Split-thickness skin graft over the surgical sit
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9 Nasal Dermoid
The most typical location for dermoid cysts, which are benign tumours of neuroectodermal origin, is the anterolateral frontozygomatic suture [93]. The anterolateral frontozygomatic suture is the most typical site for dermoid cysts, benign tumours of neuroectodermal origin [94, 95]. Gliomas, encephaloceles, epidermoid cysts and haemangiomas are among the possible differen­tial diagnosis for midline nasal tumours [96, 97]. The dura is in touch with the skin in the early embryo and separates when the frontal bone grows in between them, according to the most commonly accepted cranial hypothesis. Dermoid cyst development results from this process’ inability to achieve separation [98, 99]. Since intracranial extension may be present in certain nasal dermoid cysts; it has been highlighted how crucial a proper preoperative diagnosis is [100]. In this respect, preoperative computed tomogra­phy or magnetic resonance imaging studies may be necessary for dermoid cysts with intracranial extension [101].
Intraoperative transillumination, steps of sur­gery, surgical specimen and follow-up images are shown in Figs.65, 66, 67, 68, 69, and 70.
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Fig. 66 A brilliant transilluminating dermoid lesion
Fig. 65 Skin marking for mid-columellar inverted V
incision
Fig. 67 The soft tissue envelope is further reected supe­riorly in a relatively avascular supra-perichondrial plane to expose the dermoid till the upper lateral cartilage
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Fig. 68 Surgical bed after excision of the lesion
R. Mehta et al.
Fig. 70 Post-op follow-up after 2 months
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Fig. 69 Excised dermoid cyst
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