Combined radical mastectomy

Combined neck and radical surgery for the treatment of malignant tumors of the parotid gland. Treatment of diseases: parotid gland mixed tumors Indication Radial neck combined radical surgery is applicable to: 1. Patients with low or moderate malignant tumors suspected of having or having cervical lymph node metastasis. 2. High-grade malignant tumors of the parotid gland, such as adenocarcinoma, undifferentiated carcinoma and squamous cell carcinoma, although the cervical lymph nodes have not been enlarged, it is still suitable for combined radical surgery. Contraindications 1. Benign tumor of the parotid gland. 2. The malignant tumor of the parotid gland has affected the mandible. 3. There has been distant metastasis or cachexia, and can not tolerate joint radical surgery. 4. The primary focus and neck metastases are too extensive and difficult to surgically cut. 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. Surgical procedure 1. Cervical lymphadenectomy first complete the whole neck lymphadenectomy, from the bottom up to the upper neck. 2. S-shaped incision in front of the tragus, the lower end of which is connected to the submandibular incision. 3. Parotid gland resection for low-grade malignant tumors of the parotid gland. If the facial nerve is not involved, it can be used as a parotidectomy to preserve the facial nerve or part of its branches. If the facial nerve has been involved, facial paralysis, or a high malignant tumor of the parotid gland, the facial nerve should be removed along with the tumor. Specific surgical procedures and methods are referred to as "parotidectomy". complication Skin flap necrosis It is often 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. Vagus nerve injury Often, the internal jugular vein is severed 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 vessel injury Most of the internal jugular vein injury occurs when the lower end of the supraclavicular region is treated with its lower end, 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. Parotid gland complications The main complication is facial nerve injury, which leads to temporary or permanent facial paralysis, followed by postoperative tumor recurrence and postoperative hernia formation. The reasons and preventive measures of the former two are as described above. As for the cause of the formation of sputum, the main reason is that when the parotid gland tissue is cut off, the stump (stump) is not sutured and the dressing is small, and the corresponding measures are taken. Prevent the formation of cockroaches.