DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Deep lobe parotid tumor.
POSTOPERATIVE DIAGNOSIS: Deep lobe parotid tumor.
OPERATION PERFORMED: Total parotidectomy and facial nerve dissection.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe
1. A 3 cm deep lobe tumor.
2. Facial nerve identified and preserved in all branches.
SPECIMENS: Superior and deep parotid lobes sent to pathology.
ESTIMATED BLOOD LOSS: 30 mL.
INDICATION FOR OPERATION: The patient is a (XX)-year-old male with slowly-growing right parotid tumor, concerning for possible mucoepidermoid carcinoma on fine needle aspiration. Informed consent explaining the risks, benefits, and alternatives of the procedure was obtained from the patient for total parotidectomy and facial nerve dissection.
DESCRIPTION OF OPERATION: The patient was brought to the operating room. Under general endotracheal tube anesthesia, in the supine position, after appropriate surgical time-outs were called x2, the patient was connected to the nerve integrity monitor for continuous facial nerve monitoring throughout the case. A preauricular sulcus skin incision was marked with a marking pen and extended down below the right ear lobule and into the right neck in a curvilinear fashion. This was injected with dilute epinephrine solution. The neck and face were prepped with Betadine solution and scrubbed and draped sterilely.
A skin incision was made sharply and carried down through subcutaneous tissues with Bovie electrocautery. Skin flaps were elevated anteriorly with Bovie electrocautery and then bluntly at the anterior-most aspect, just past the tumor. The anterior border of the sternocleidomastoid muscle was skeletonized with Bovie electrocautery and blunt dissection until the posterior belly of the digastric muscle was identified. This was dissected superiorly. The tragal pointer was then skeletonized. Using the tragal pointer and posterior belly of the digastric muscle as landmarks, all tissue overlying the main trunk of the facial nerve was carefully dissected under loupe magnification in a blunt fashion and made hemostatic with bipolar cautery until the main trunk of the facial nerve was identified. This was identified quite deep.
Then, using a right angle hemostat and meticulous dissection technique using loupe magnification, each branch including the temporozygomatic branch and the marginal mandibular branch of the facial nerve were dissected and parotid tissue overlying this was divided with the Harmonic scalpel. The buccal branches were similarly dissected out. The tumor was found to be deep to the facial nerve and approximately 3 x 3 cm in size. After each of the branches of the facial nerve was dissected, as mentioned above, the superficial lobe of the parotid gland was sent off the table to pathology as a specimen.
Of note, during the dissection, the marginal mandibular branch of the facial nerve was carefully identified and dissected in its entirety as was the temporozygomatic branch and the buccal branches. Also noted during the dissection, the great auricular nerve was identified and dissected free and preserved.
Next, the branches of the facial nerve overlying the deep lobe were carefully dissected away bluntly with tenotomy scissors and retracted carefully with vessel loops. The deep lobe of the parotid gland was then dissected away from the masseter muscle with the Harmonic scalpel. Stensen’s duct was divided between clamps and tied distally with 3-0 silk suture. The deep lobe of the parotid gland was dissected circumferentially away from any nerve branch and then excised completely and sent off the table to pathology with the tumor intact.
The parotid bed was copiously irrigated and made meticulously hemostatic with bipolar cautery. Any residual parotid tissue edges were cauterized with bipolar to prevent seroma formation. The superficial myoaponeurotic system was then dissected free from the skin flaps and sutured to the anterior border of the sternocleidomastoid muscle to close any parotid defect.
A 7-French closed suction drain was brought through a separate stab incision and secured to the skin with 2-0 nylon. The skin was then closed with interrupted 3 and 4-0 Vicryl and 5-0 nylon. A pressure Barton’s dressing was then placed. The patient was then awoken from anesthesia and extubated and taken to the recovery room in stable and awake condition.