Marginal mandibulectomy, help..
1. Marginal mandibulectomy.
2. Bilateral supraomohyoid neck dissections.
4. Full-thickness skin graft.
5. Split-thickness skin graft.
The patient was noted to have an exophytic lesion of the floor of the mouth
positive for squamous cell carcinoma which was extending into the
symphyseal region of the mandible on the oral cavity side. There was no
breakthrough of the mandible to the mucosal surface of the lip exteriorly
as well as any skin penetration. Marginal mandibulectomy was performed.
Frozen sections returned back negative margins including mucosal specimens
from the tongue as well as the floor of the mouth as well as the marrow
from mandible. There was a positive margin on the left anterior tongue.
Frozen sections x2 were sent revealing a final section with minimal
dysplasia and no invasive carcinoma. Our defect was reconstructed
utilizing a full-thickness skin graft from the patient's left upper thigh.
PROCEDURE IN DETAIL:
After the patient was successfully intubated and prepped and draped in
usual fashion tracheostomy was then performed. On the individual a
tracheostomy, the endotracheal tube and a coiledtube was then inserted into the patient's tracheal stoma. At this point , apron flaps were raised allowing us to have adequate visualization of the
patient's bilateral neck. At this point, the right neck dissection was
begun. Supra-omohyoid neck dissection in standard fashion was performed.
Dissection (__________) submental lymph nodes in zone IA was sent of
separately. At this point, attention was turned to delineating the
anterior and posterior (__________) muscles. After fully exposing these
muscles, exposing reflection of the lipo-tissue in zone IB was carried
allowing us to resect the submax gland all the way identifying the lingual
nerve and hypoglossal nerve in the process. Following this, retractor was
utilized to retract under posterior belly of digastric muscle allowing us
to appreciate the hypoglossal nerve. Following this, elevation of the
fibrofatty tissue of the SCM was carried out in the lateral to medial
direction allowing us to unwrap it (__________) the deep neck floor
allowing us to then identify the surface of rootlets marking the deep
(__________) specimen allowing us to retract this in a lateral to medial
fashion. Identification of the internal jugular vein and carotid artery
and the vagus had been all appreciated allowing us then to wrap this
fibrotic tissue from the region of the skull base down to the omohyoid
muscle to delineate any injury over the extent of zone III and it was
finally resected off the internal jugular vein in a (__________) fashion.
The left supra-omohyoid neck dissection was performed in the same fashion.
Following this, mucosal cuts were then made along the inner aspect of the
lower lip mucosal surfaces just adjacent to the mandible and around our
tumor in question from canine to canine. Tooth extractions were then
performed bilaterally to provide adequate cuts for osteotomies. At this
point, internal cuts were made on the floor of mouth from mucosal surface.
Following adequate exposure of the periosteum of the mandible, a sagittal
saw was then utilized to make our marginal mandibulectomy cuts, followed by
mallet osteotome application to free up this cortical aspect from the inner
surface. At this point, (__________) was utilized for traction on the soft
tissue allowing us to rock the mandible forward at which point mucosal
attachments were then severed utilizing electrocautery Bovie. This allowed
us to free up the entire (__________) specimen, which was then passed off
to the back table. Frozen sections were taken from the marrow cortex as
well as the anterior tongue, the left tongue, the right anterior tongue.
The central portion of the floor of mouth as well as the left floor of
mouth and right floor of mouth all of which returned back negative except
for the left anterior tongue which upon 2 more frozen section attempts
returned back minimal dysplasia and no invasive carcinoma. At this point,
reconstruction was planned. A full-thickness graft 7 x 7 cm was harvested
from the left upper thigh and applied to the floor of mouth and was sutured
in place utilizing a running Vicryl stitch followed by bolster application
with Xeroform gauze sutured in with 5 silk sutures. At this point, the
left upper thigh incision was closed and a defect was appreciated at which
point a split-thickness skin graft was utilized for coverage on this region
marking the completion of closure of the left upper thigh. At this point,
our tracheostomy tube, a #8 Portex was then inserted into our tracheostomy
site after removal of the endotracheal tube from anesthesia. This marked
completion of procedure.
I came up with 21045, 38700-50 and 15100? but im not really sure about the 15100. Can anyone help me?
Carl Hurst, CPC, CCVTC