Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана
.pdf
50
https://t.me/medicina_free
to identify the main trunk of the nerve when
the standard approach is not possible.
• Once the nerve has been identied, dissection
continues along the main trunk and branches
(Figs.3, 4, 5, 6, 7 and 8).
• To avoid injury to the nerve, the soft tissue
should be lifted, spread and then cut.
• The parotid lateral to the visible portion of the
nerve is divided.
Fig. 3 Identication of facial nerve main trunk
N. M. Nagarkar et al.
Fig. 4 Proceeding to the lower trunk dissection
Fig. 5 After dissecting the lower trunk, the tumour with
the gland is mobilized superiorly to expose and dissect the
upper trunk
Fig. 6 Upper trunk dissection
Fig. 7 The retromandibular vein can be clearly seen
medial to the facial nerve trunk
• Overstimulation of the nerve is to be avoided.
Overuse of the facial nerve stimulator can
cause praxis of the nerve, as can improper dissecting technique. The tissues over the nerve
should be spread apart in a plane parallel to
the nerve bres; any angulation away from
Salivary Glands
https://t.me/medicina_free
Fig. 8 Facial nerve
trunk following
completed supercial
parotidectomy
this plane may cause undue trauma to the
nerve.
• Extracapsular dissection descended from the
technique of intracapsular enucleation, which
was performed up to the 1960s. It was intended
to decrease injuries to the facial nerve but
resulted in recurrence rates of over 40% due to
incomplete resection of the capsule.
• Benign parotid neoplasms also require excision of a small cuff of the normal gland.
• However, the deep portion of the dissection of
the facial nerve often yields no margin of the
tissue other than the tumour capsule itself.
• Careful dissection of the tumour away from
the nerve is necessary to avoid injury to the
facial nerve and complete excision of the
capsule.
• Once the tumour has been dissected off the
facial nerve beyond the anterior limit of the
lesion, the parotid is divided, and the specimen is removed.
• In cases of malignancy, particularly low-grade
tumours, the extent of parotidectomy may be
similar to that involved in the resection of
benign tumours.
• Suture ligation of small vessels or bipolar cautery is used to avoid injury to the nerve.
• Dexamethasone instilled locally over the
facial nerve had been found to reduce the
facial nerve paresis postoperatively.
• Insertion of a suction drain is useful after the
wound is irrigated (Fig.9).
51
Fig. 9 The skin closed in layers with closed suction drain
• Defects resulting in obvious contour hollowing can be repaired by:
– Approximating the SMAS to the SCM or
creating a small rotation ap by dividing
some of the superior bres of the SCM and
suturing them anteriorly. Care must be
exercised to avoid injury to the spinal
accessory nerve.
– The use of allogenic dermal grafts. These
have been reported to be safe, but this avascular foreign body has also been found to
promote infection and salivary stula.
– Insertion of adipose tissue grafts, which are
limited by reabsorption and a separate
donor site.
• Subcutaneous layer approximated with an
interrupted suture (Fig.10).
• Steri-Strips are applied, followed by a sterile
parotid dressing.
52
https://t.me/medicina_free
Fig. 10 A postoperative 4-week, well-healed scar
N. M. Nagarkar et al.
Fig. 12 Arrow pointing towards the swelling
Fig. 11 A 2.2×3.1cm benign deep lobe of the parotid neoplasm
The fourth-week postoperative follow-up
shows a barely visible surgical scar (Fig.10).
1.4 Trans-parotid Deep Lobe
Tumour Excision
1.4.1 Case 2
A 55-year-old male presented with a 4-year history of left cheek swelling. The MRI showed a
2.2 × 3.1-cm-deep lobe of parotid neoplasm
(Fig. 11). FNAC—Milan IVa—Pleomorphic
adenoma.
1.4.2 Operative Technique
All operative steps are depicted in Figs.12, 13,
14, 15, 16, 17, 18, 19 and 20.
1.5 Radical Parotidectomy
withSND (II–V)
1.5.1 Case 3
A 64-year-old female presented with a 12-year
history of left cheek swelling, increase in its size
since 1year and facial asymmetry since 1month.
On examination a 6×8cm hard mass in the left
Salivary Glands
https://t.me/medicina_free
Fig. 13 Modied Blair incision
53
Fig. 15 Excision of the supercial parotid tissue to
expose the deep lobe of the parotid gland
Fig. 14 Skin ap elevation and identication of GAN
(yellow arrow) and EJV (green arrow)
parotid region, xed to the underlying masseter
muscle. Left VII N—HB grade III. FNAC—
Milan V—Suspicious of mucoepidermoid
carcinoma.
1.5.2 Operative Technique
All operative steps are depicted in Figs.21, 22,
23, 24, 25, 26, 27, 28, 29 and 30.
1.6 Extended Radical Parotidectomy
1.6.1 Case 5
A 57-year-old female presented with a 4-year
history of progressive right parotid swelling and
Fig. 16 Mobilization of the deep lobe tumour by blunt
dissection. Small yellow arrow, common facial trunk;
green arrow, upper division; black arrow, upper division
rapid increase in size (2 months). On examination a 6×8cm right parotid mass, skin involved,
masseter involved (Fig. 31). FNAC—(1) Milan
IVB—SUMP. (2) Milan IVA—Pleomorphic
Adenoma.
Intraop Frozen suggestive of High-grade
malignancy with skin invasion.
54
https://t.me/medicina_free
Fig. 17 Preserved facial nerve trunk and its branches following deep lobe tumour excision. Yellow arrow, common
facial trunk; green arrow, upper division; black arrow,
upper division
N. M. Nagarkar et al.
Fig. 19 Excised the supercial parotid lobe
Fig. 20 Excised well-capsulated deep lobe tumour
Fig. 21 Identication of the main trunk of the facial
nerve following skin ap elevation separating the parotid
gland from SCM identication of the posterior belly of
the digastric muscle
Fig. 18 Post resection
Salivary Glands
https://t.me/medicina_free
Fig. 22 Further dissection of the facial nerve trunk to
expose the upper and lower divisions of the facial nerve
55
Fig. 25 A cuff of the masseter muscle was taken as the
deep margin
Fig. 23 The nerve trunk is thickened and oedematous
suggesting nerve inltration
Fig. 24 Facial nerve sacrice due to involvement (for
oncological reasons)
Fig. 26 Post-resection bed
Fig. 27 Specimen of radical parotidectomy
56
https://t.me/medicina_free
Fig. 28 A posterolateral neck dissection (II–V) was done
N. M. Nagarkar et al.
Fig. 31 Incision planning done as per the extent of the
tumour. The involved skin was marked for excision along
with the lesion
Fig. 29 A cable nerve grafting was performed at the
same setting with GAN
Fig. 30 Wound closure and drain in situ
Fig. 32 The nerve trunk was identied
1.6.2 Operative Technique
All operative steps are depicted in Figs.32, 33,
34, 35, 36, 37, 38, 39 and 40.
Salivary Glands
https://t.me/medicina_free
Fig. 33 Complete encasement of the nerve trunk can be
seen
57
Fig. 36 Specimen with the involved skin
Fig. 34 The nerve is grossly encased by the tumour, and
a decision to sacrice the nerve was taken
Fig. 35 The tumour was dissected circumferentially
Fig. 37 Extended radical parotidectomy defect. The
mandible and parapharyngeal space are exposed
Fig. 38 Masseter muscle was released and used to close
the retromandibular hollow and parapharyngeal space
58
https://t.me/medicina_free
Fig. 39 A cervicofacial rotation ap was done to close
the skin defect
N. M. Nagarkar et al.
• Nerve ends should be examined and freshened
by excising a small amount of the nerve to create a blunt edge.
• Epineurium is reapproximated using an 8- or
9-0 monolament suture; a neural tube can be
placed to support the repaired nerve.
• If a nerve graft is required, the greater auricu-
lar is readily available.
• When the nerve is repaired in a second stage,
the sural nerve or medial branchial cutaneous
nerve is a good graft choice.
• If the nerve was normal preoperatively and a
microscopic repair is performed immediately,
the best result possible is a House-Brackmann
grade III.Recovery takes about 6–12months.
1.7.2 Facial Nerve Function
• If facial paresis is found but the nerve was
found to be intact intraoperatively, a full
recovery of function is expected.
• High-dose steroids are generally not indicated
as they do not improve the outcome.
• Reoperation is indicated only if the nerve was
not identied during the dissection. In this
case attempts to nd and repair the nerve
should be made.
Fig. 40 A larger defect can be closed with free aps/pectoralis major myocutaneous ap
1.7 Anticipated Complications:
Mitigation andManagement
1.7.1 Injury totheFacial Nerve
• Mild neuropraxia resolves in 4–6weeks.
• More severe traction injuries resulting in axo-
nal death will take much longer to recover
(6 months); imperfect recovery leads to permanent weakness and synkinesis.
• Transected nerve bres should be repaired if
possible.
1.7.3 Drains andDressing
• Drains are left to bulb suction to avoid inadvertent stress to the nerve.
• The drain is removed if total output is less
than 20mL in 24h. After that point, the drain
is removed if there is less than 5mL of drainage over the next 8h.
1.7.4 Hematoma
• Sudden facial swelling or rapid lling of the
drain should be treated by exploration of the
wound in the operating room.
• Evacuation of the hematoma is important in
order to avoid wound infection and necrosis of
the ap.
1.7.5 Frey Syndrome
• Occurs in up to 60% of parotidectomy patients,
but only about 10% has been considered to
have a negative impact on quality of life.
Salivary Glands
https://t.me/medicina_free
59
• Antiperspirant application or botulinum toxin
injections are temporary management options.
• Long-term control involves placement of the
vascularized tissue between the parotid bed
and the skin.
• Intraoperatively, a ap can be created by lifting the SMAS off the gland, leaving it pedicled anteriorly, and then placing in the defect
before closure.
• Revision surgery for Frey syndrome should be
carefully considered because of the increased
risk of facial nerve injury due to scarring.
1.7.6 Infection
• Occurs in less than 5% of cases.
1.7.7 Sialocele Formation
andSeroma
• It is a very uncommon (approximately 5%)
but persistent complication of supercial
parotidectomy.
• The use of allogenic dermal grafts or Surgicel
and anterior location of the tumour have been
implicated as risk factors.
• Ballotable swelling noted at the postoperative
check should be aspirated in the ofce. The
skin is prepped to avoid the introduction of
bacteria, and a large-bore (16–20 French) needle is used to aspirate the collection. Pressure
dressings at this point confer little advantage.
Repeat aspiration may be necessary, especially in cases of seroma formation.
• Expectant management is also reasonable, and
most of these conditions resolve without treatment in 4–6weeks.
1.7.8 Flap Necrosis andHypertrophic
Scars
• Flap necrosis is avoidable if the skin is elevated with the subcutaneous adipose tissue.
• Keloid formation may be seen early in the
postoperative period and is best treated when
rst noted. Injection of triamcinolone directly
into the scar is effective.
• Local anaesthesia with lidocaine prior to
injection or mixed with triamcinolone is
important, as hypertrophic scar injection is
often painful.
1.7.9 Recurrent Tumour or Infection
• Occurs in 2% of cases.
• Incomplete capsule removal and, less commonly, tumour spillage are causative.
• If capsule rupture occurs, the wound is irrigated with copious amounts of saline and
carefully inspected to remove all tumour
fragments.
• Imaging and FNAC are required.
• The goal of revision surgery is resection of all
tumour deposits, which may not be possible
without sacricing a portion of the facial
nerve.
• Radiation is used in cases of widespread
recurrence or multiple surgeries.
2 Submandibular Gland
Lesions
The submandibular gland is one of three paired
major salivary glands that drains into the oral
cavity. It is midway in size and location between
the largest, the parotid gland, and the smallest,
the sublingual gland. Histologically, it consists of
both serous and mucinous acini, which collectively drain into an excretory duct that carries the
secreted saliva into the oral cavity. A mass in the
submandibular gland or a minor salivary gland is
more likely to be malignant. In a review of more
than 2000 salivary gland tumour cases, 73% of
the tumours were found in the parotid with only
15% found to be malignant, while 11% were
found in the submandibular gland with 37%
found to be malignant. Tumours of the sublingual
gland are extremely rare and comprise 0.5–1% of
all salivary tumours, and 80–90% are malignant
[2, 14, 15].
It is imperative for the physician to distinguish
a chronic benign process, such as sialadenitis,
from a submandibular gland neoplasm, and then
further determine if a neoplasm is benign or
malignant. This is done through careful history
and physical exam, as well as utilization of preoperative imaging and ne-needle aspiration.
Management of submandibular gland malig-
nancy can be challenging due to the relative rarity
of the disease and the diversity of its behaviour
Соседние файлы в папке Библиотека им академика М.И. Перельмана