combined tongue and neck debridement

Tongue-neck combined radical surgery for the surgical treatment of oral and maxillofacial malignancies. Treatment of diseases: oral and maxillofacial tumors Indication Tongue neck combined radical surgery is applicable to: 1. Tongue cancer has not affected the bottom of the mouth. 2. Although the tongue cancer has invaded the mouth, but there is still a certain distance from the periosteum of the mandible. 3. Bottom cancer affects the tongue and abdomen, but has not invaded the periosteum of the mandible. 4. There are or suspected lymph node metastases in the neck. Or although there is no cervical lymphadenopathy, due to the high rate of tongue cancer metastasis, it can also be used for selective neck dissection or combined radical surgery. Contraindications 1. Tongue cancer, oral cancer has invaded the periosteum or affected the mandibular bone. 2. Primary cancer and metastatic cancer are too extensive, and it has been difficult to surgically cut. 3. The general condition is poor, and can not tolerate general anesthesia and surgery. 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. Surgical procedure Cervical lymphadenectomy First full neck dissection. The specimen for neck dissection is still connected to the submandibular tissue. 2. Lower lip, median incision The lower lip and the soft tissue of the ankle are cut in the entire layer of the midline of the lip, reaching the bone surface and connecting it to the incision of the lower jaw. 3. Open the lip and cheek tissue flap The longitudinal incision was made from the gingival nipple of the incisor between the incisors, and the lip and cheek tissue flaps were turned from the anterior and posterior iliac crests to expose the lateral side of the mandible. 4. Mandibular alveolar bone resection This step can be omitted when the simple tongue and neck combined with radical surgery. A tooth can be drawn at each of the expected osteotomy, and then the alveolar bone of the adjacent tumor is marginally removed with an electric drill. 5. Excision of the tongue and the primary cancer at the base of the mouth The tumor was excised 1 cm away from the lesion with an electric knife, and with the alveolar bone mass, pushed out through the bottom of the mouth to the lower part of the jaw, and then the specimen of the neck dissection was removed. 6. Close the intraoral incision The mucosal incision and submucosal tissue were sutured with a 3-0 gut or a 1st silk thread. The osteotomy is trimmed with a rongeur, and the bone wound can be stopped by bone wax. Make the mucosal flap complete the bone wound edge and tightly suture. 7. Close the skin incision After adequately rinsing the wound, the lips, tendon and neck incision are layered. Place a vacuum drainage tube under the jaw and neck. 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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