Combined lingual and maxillomandibular debridement

Tongue and neck combined surgery for the treatment of oral and maxillofacial malignancies. Treatment of diseases: oral and maxillofacial tumors Indication 1. Tongue or mouth cancer has affected the periosteum of the mandible or destroyed the mandible, or the cancer originating in the lower jaw invades the mouth and tongue. 2. Patients with or without suspected submandibular or cervical lymph node metastasis. 3. Although the cervical lymph nodes are not swollen, the primary cancer cells have a low degree of differentiation, or the primary cancer has a wide range of invasion, and the possibility of metastasis to the cervical lymph nodes is large. 4. Primary and metastatic cancers are estimated to be completely resectable. 5. No distant metastasis, the general condition is still good. Contraindications 1. There have been distant metastasis or cachexia. 2. The scope of the primary cancer is too large, such as the tongue and the bottom of the mouth are widely fixed, the cancer is difficult to cut. 3. Regional lymph node metastasis is too broad, such as multiple tumor nodules in the lower lip, tendon, submandibular skin and soft tissue on the way to the cervical lymph node metastasis, or extensive metastasis of the cervical metastatic carcinoma and deep tissue, the carcinoma is difficult to cut. By. Preoperative preparation 1. Systemic examination includes blood, urine, fecal routine examination, cardiopulmonary condition, liver and kidney function. If there is hypertension, anemia or heart, lung, liver, kidney dysfunction, etc., the necessary treatment should be done before surgery, try to correct and improve to reduce intraoperative and postoperative complications. 2. Face, neck, chest skin preparation. 3. Preoperative medication is given according to general anesthesia before administration of anesthesia, and blood transfusion and infusion preparation are prepared. 4. Clean your teeth. 5. Prefabricated intermaxillary fixation devices or prefabricated bevel guides on the upper and lower jaw teeth for postoperative application to prevent mandibular dislocation. Surgical procedure Cervical lymphadenectomy A full neck dissection was performed, and the submandibular and infraorbital triangles were removed to the lower edge of the mandible. 2. Lower lip, median incision The lower lip and the soft tissue of the ankle are cut from the full thickness of the midline of the lip, reaching the bone surface so as to be continuous with the upper incision of the neck. 3. Flip up the soft tissue flap of the cheek side From the midline to the affected side, the cheek and gingival gingiva were opened and the posterior molar region was bypassed. From the anterior to the posterior, the lip and cheek tissue flap was sharply separated on the periosteum of the mandible, revealing the lateral aspect of the mandibular surface and above the mandibular angle. 4. Saw the mandible First remove the affected incisor or remove a mandibular tooth 2 cm away from the anterior border of the tongue. Use the periosteal stripper on the lower edge of the mandible at the extraction site, close to the bone surface, up to the lingual side Edge, separate a tunnel. A single end of the wire (wire) saw is passed through the tunnel to cut the mandible at the extraction. The lower alveolar blood vessel is filled with bone wax to stop bleeding. 5. Cut the tongue and bottom tissue from the midline Use a thick thread to sew 1 stitch on each side of the tip of the tongue to pull the tongue out. Cut the tongue from the midline (the tumor is close to the midline and can go beyond the midline and cut 1 cm outside the tumor boundary). Cut the open bottom muscles longitudinally at the midline to the plane of the hyoid bone. Cut the muscle attached to the hyoid bone and sew the broken end. 6. Cut the back boundary of the tongue Pull the affected jaw outward and try to pull the tongue out to reveal the back of the tongue. The root of the tongue was transversely 1.5 cm from the posterior border of the tumor. It passes outward through the root of the tongue and is connected to the gingival incision in the posterior region of the molar. Ligation of the tongue, veins and bleeding points of the section, and filling the gauze to stop bleeding. 7. Free mandibular ascending branch and surgical resection specimen The lower end of the chewing muscle was cut, and the pericardium was peeled off from the outer side of the mandibular branch to reveal the mandibular ascending bone surface. The mandible is pulled downward and rotated outward to reveal the diaphragmatic tendon attached to the front of the condyle and ascending branch, and the diaphragm is cut in the mandible. The mandible was turned outward, and the pterygoid muscle was cut inside the mandibular angle, and the pterygoid muscle was separated by a periosteal stripper. Cut and ligature the inferior alveolar nerve vascular bundle. The pterygoid muscle was cut off from the condylar process. At this point, the specimen of the combined surgery of the tongue and neck can be completely removed. 8. Examine the removed specimen and surgical wound Check that the tumor tissue has been cut and the safety margin is insufficient. For suspicious parts, the tissue should be taken for pathological examination of frozen sections to see if there is any residual cancer tissue. Additional resection should be performed if necessary. 9. Suture mouth wound The front part of the tongue can directly suture the wound edge of the tongue and the belly of the tongue with the 4th line. The wound edge of the tongue and the base of the tongue is sutured relative to the wound edge of the buccal mucosal flap. 10. Rinse the wound Wash the wound thoroughly with warm saline. And clean gloves, equipment, and replace sterile towels. 11. Close the suture wound A suture along the oral mucosa is further submucosally sutured. At the equivalent of the mandibular branch, the residual pterygoid muscle and the chewing muscle or other soft tissue are sutured to eliminate the invalid cavity. The osteotomy of the jaw was trimmed and smoothed with a rongeur, and the soft tissue of the buccal and lingual side was used to suture it. Then the lip, ankle, submandibular and cervical incision were layered and placed in the lower jaw and the lower neck. One tube of latex tube for pressure drainage. 12. The dressing covers the neck wound. The cheeks can be properly pressure bandaged. 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. 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 is damaged; When the external maxillary artery and the anterior vein were ligated, the mandibular branch was not examined again. The ligature was not located 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. 6. Intracranial hemorrhage and respiratory obstruction Generally, it is not easy to produce respiratory obstruction after one side mandibular resection, but if there is intracranial hemorrhage, the face is pressurized and bandaged, resulting in difficulty in breathing due to hematoma at the bottom of the mouth and the pharyngeal side. 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. 7. Relationship disorder After the mandibular resection of 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. 8. The salivary glands flow into the wound cavity The main reason was that the parotid gland was accidentally injured during the operation and was not treated, but the internal hemorrhoids were 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.

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