Combined radical mastectomy

Combined maxillofacial surgery for the treatment of malignant tumors of the parotid gland. Treatment of diseases: malignant tumors of the parotid gland Indication Combined gingivitis and neck surgery for: 1. The malignant tumor of the parotid gland has been involved in the muscles, periosteum or bone in the inner and outer branches of the mandibular ascending branch. The clinical manifestations of such patients often have a fixed mass and limited mouth opening. 2. A malignant tumor that develops from the deep lobe of the parotid gland, filled with the mandibular posterior fossa, has been extended to the back of the mandible. Contraindications 1. The salivary gland malignant tumor has distant metastasis, such as adenoid cystic carcinoma has occurred extensive lung metastasis. 2. The patient has severe lesions of important organs, or has cachexia, and the general condition cannot tolerate the operator. 3. The parotid gland is poorly differentiated or undifferentiated, highly malignant tumor, and the lesion range is too wide, such as destroying the skull base bone and invading the skull, it is estimated that the operation is difficult to remove. Preoperative preparation 1. Parotid gland tumors are generally not preoperative biopsy. Conditional units can be used for fine needle aspiration biopsy, cytological examination, to understand the type of tumor. 2. When it is estimated that there is a possibility of resection of the facial nerve, the patient or family member should be informed before surgery. 3. During the operation, it is possible to use liquid nitrogen to freeze the suspected residual cancer of the facial nerve and its surrounding tissues. The liquid nitrogen should be prepared before surgery. And tell the patient to have temporary facial paralysis after surgery. 4. Preoperative skin preparation In addition to the face and upper chest skin, the hair should be shaved 5cm on the hairline. 5. In order to prevent postoperative mandibular dislocation, preset intermaxillary fixation devices or prefabricated bevel guides on the intraoral teeth. Surgical procedure Cervical lymphadenectomy Complete a full neck dissection. From the bottom up to the upper neck, the surgically removed specimen is connected to the lower edge of the mandible and the upper end of the internal jugular vein. 2. Ear anterior incision Generally, the S-shaped incision is taken in front of the tragus, and the lower end is connected to the submandibular incision. If the tumor has invaded the skin, it should be removed at the normal skin around the tumor. 3. Parotidectomy According to the nature of the tumor and the degree of facial nerve invasion, it is decided whether to retain the facial nerve or its main branches. See "Mumpectomy" for specific surgical procedures. 4. Cut off the mandible According to the degree of tumor invasion, the location of the mandible in the mandibular body is determined. The mandibular ascending branch should generally be removed in whole or in part. 5. Remove the tumor and remove the specimen Continue to remove the tumor of the deep parotid gland. At this time, the surgical specimen can be turned up, the internal carotid artery and vein can be separated, the vagus nerve can be protected, the upper end of the internal jugular vein can be double-ligated and cut off, and the surgical specimen can be removed. 6. Close the incision After adequately rinsing the wound, carefully stop bleeding. When there is suspicious pterygopalatine hemorrhage, use hemostatic sponge to tamponade and suture to stop bleeding. The residual pterygoid or extrapteral muscle can be sewn together to help eliminate the dead space and stop bleeding. Negative pressure drainage should be placed on the upper and lower parts of the wound. The surgical incision is closed by stratification. complication 1. Skin flap necrosis is associated with improper design of the incision, wound infection and poor blood supply caused by preoperative radiotherapy. Once the infection has necrosis, if the treatment is not timely or improperly treated, the wound will often open and the tissue will fall off. In severe cases, there may be serious consequences such as carotid artery exposure or rupture and bleeding. So the key is early prevention and early treatment. Early prevention: design the incision to be reasonable, prevent blood supply, prevent infection, the same as before; early treatment: found skin infection, necrosis, that should be enhanced dressing, control infection, smooth drainage, and other necrotic tissue shedding, after wound cleaning, to Skin graft or flap repair methods to eliminate the wound. The carotid artery is exposed, it needs to be wet dressing, and the granulation tissue is grown and cleaned before being treated as described above. 2. The vagus nerve injury often causes the injury to the internal jugular vein due to insufficiently freeing the cervical vascular sheath. At this point, an immediate match should be made. 3. Thoracic catheter injury In the left neck dissection, when the inner and lower corners of the upper triangle of the clavicle are dissected, the thoracic duct is easily damaged, so care should be taken. If it is found that the chyle with fine lipids overflows, carefully look for the break and sew it exactly. If there is a chyle in the drainage fluid after surgery, the vacuum suction should be stopped immediately, fasted, intravenous infusion, local pressure bandaging, and the fistula can be healed. If it is invalid, it should be turned off, open the wound to find out, and find the mouth to carry out the purse-string suture. 4. Large vascular injury The internal jugular vein injury occurs when the lower end of the supraclavicular region is treated, and can also occur when the upper cervical segment is treated. The former is more dangerous, the vein is broken or the ligature is loose, and a negative pressure is generated in the proximal end of the blood vessel, and the air can be inhaled. If the amount of air entering is large, the output of the right heart can be suddenly reduced to form an air embolism. The patient developed pale, blood pressure, breathing, circulatory disturbances, and even death. The latter has a large amount of bleeding, and if it cannot be handled in time, it will also be dangerous. Therefore, when the vein is broken or the ligature is loose, immediately press the rupture of the rupture, carefully separate the lower (upper) end of the vein, and properly ligature after clamping. The key to preventing this serious situation is to strictly abide by the operating procedures. It is necessary to double the proximal (distal) heart end, then cut the vein, and then add 1 stitch through the suture. Regardless of the treatment of the lower or upper end of the internal jugular vein, the plane of the ligation and cutting is not too low (high), and it is easy to handle once it is broken. At the same time, the venous stump should not be free. Even if the venous ligature is loose, its stump will not be difficult to find due to retraction. The treatment of postoperative internal jugular vein bleeding is often very difficult. When the blood can not be clamped, the hemostatic can be filled with iodoform gauze. After 15-20 days, the vein can be closed and hemostasis. Carotid rupture is relatively rare, and more often occurs after postoperative wound infection. The skin flap is necrotic, the wound is opened, and the carotid artery is exposed. If the infection cannot be controlled and continues to develop, it will lead to carotid artery rupture and massive bleeding. Then there is hypotension, hemorrhagic shock, at this time ligature, the mortality rate is very high. Therefore, it is necessary to make a ligation in the case of supplementing the blood volume. Ligation of the common carotid artery or internal carotid artery can cause hypoxia, hemiplegia, aphasia, and even death of the brain tissue, which is a very serious complication. Small blood vessels in the wound after surgery, mostly due to incomplete hemostasis, showed excessive drainage after surgery, such as 24h drainage more than 500ml, should open the wound, stop bleeding. 5. If the mouth is repaired with free skin graft or pedicled tissue flap, the complications are described in the relevant sections. 6. Complications related to mandibular resection. (1) Facial nerve mandibular branch injury: The main reasons include: 1 the incision is not 1.5cm below the lower edge of the lower jaw, but is higher; 2 in the process of flapping, not in the deep surface of the shallow deep fascia The mandibular branch was damaged. 3 The mandibular branch was not examined again when the external maxillary artery and the anterior vein were ligated. The ligature was not below and inside the lower edge of the lower jaw, but it was easy to be damaged. If it is caused by intraoperative traction, it can be recovered. (2) Intracranial hemorrhage and respiratory obstruction: generally, it is not easy to produce airway obstruction after one side mandibular resection, but if there is intracranial hemorrhage, the facial surface is pressurized and bandaged, causing the bottom of the mouth and the pharynx to cause breathing due to hematoma. difficult. At this time, hemostasis and drainage should be performed, and if necessary, the hematoma should be removed or the tracheostomy should be performed. For difficult to control bleeding inside the mandibular ascending branch, the wound should be reopened to stop bleeding, or a hemostatic sponge should be filled in the hemorrhage, and then hemostatic should be filled with long iodoform gauze. The iodoform gauze was extracted in 10d and 14d after operation, and the effect was more reliable. (3) Disordered relationship: After the mandibular resection is performed on one side, the contralateral side is tilted inward due to muscle pulling. The next morning after the operation, the intermaxillary traction should be performed in time or the inclined guide plate should be worn. (4) The salivary gland sputum flows into the wound cavity: the main reason is that the parotid gland is accidentally injured during the operation, and no internal treatment is formed. First, the sputum should be drained from the mouth or the lower jaw; second, the pressure bandage can be cured. If it does not improve within a certain period of time, consider radiation exposure or surgical closure of the parotid gland.