parotidectomy - rojoson's tpors

Parotidectomy

ROJoson’s TPORsApril 2014

ParotidectomyIncision:

Objectives: • Long enough to facilitate accurate intraoperative

evaluation and complete extirpation of the parotid tumor without complications.

• Place it at an area that will facilitate achievement of treatment goal.

• Place it at an area that will be cosmetically acceptable to the patient.

• Planning and execution of incision will be based on the above objectives.

Parotidectomy Exposure:

Objectives:• To facilitate accurate intraoperative evaluation.• To facilitate complete extirpation of the parotid

tumor without complication.

Parotidectomy Exposure:

Execution:• Create flaps to such an extent that will facilitate

accurate intraoperative evaluation and complete extirpation of parotid tumor without extirpation.

• Create flaps not beyond the anterior border of the parotid gland so as to avoid injury to the branches of the facial nerve.

• Create viable flaps.

Parotidectomy

Intraoperative Evaluation:Objectives:• To determine the exact diagnosis.• To determine the extent of the tumor.• To facilitate decision on specific operative

procedure and maneuvers.

Parotidectomy

Intraoperative Evaluation:Execution:• Inspect and palpate• To determine whether the mass is really parotid

in origin.• If parotid in origin, determine whether benign or

malignant, extent of tumor, superficial or deep, inferior pole, superior pole, whole gland, etc.

Parotidectomy

Intraoperative Evaluation:Execution:• Decide on extent of parotidectomy – total

parotidectomy; subtotal parotidectomy – total superficial parotidectomy; partial superficial parotidectomy; partial superficial and partial deep parotidectomy.

• Decide on operative maneuvers.

Parotidectomy Operative Procedure Proper:

Objectives:To completely extirpate all grossly evident tumor in such a way that there will be no local recurrence and no complications, particularly, facial nerve paralysis.

Parotidectomy Operative Procedure Proper:

Maneuvers:• Identify facial nerve• Main trunk to branches• Branches• Extirpate all gross parotid tumor with

a rim of normal parotid tissue (adequately)

Parotidectomy Operative Procedure Proper:

Maneuvers:• Avoid cutting or entering into the tumor

(cleanly)• Avoid injury to the facial nerve while

extirpating which can occur either by cutting, burning (with cautery) or traction

• Attack tumor initially through areas of lesser difficulty before entering through dense and difficult areas

Parotidectomy Operative Procedure Proper:

Be gentle.Be meticulous and precise.

Every move must have a reason!

Parotidectomy Hemostasis Check:

Objectives:• To avoid bleeding and hematoma.• To avoid injury to facial nerve during

hemostasis check.

Parotidectomy Hemostasis Check:

Execution:• Choice of suture-ligature and cauterization.• Avoid injury to the facial nerve during

clamping, tying, and cauterization by right choice of hemostatic method and by being meticulous and precise.

ParotidectomyDrain:

Objectives:• To prevent unwanted accumulation of fluid

(serum and saliva) in the wound space.• To drain continuous salivary secretion into

the wound site after a subtotal parotidectomy.

ParotidectomyDrain:

Execution:•Choice of tube drain or rubber drain.•Remove when drain is not needed anymore.

ParotidectomyCorrect Count:

Objective: • To avoid leaving sponges, surgical

instruments, and needles in the wound site.

ParotidectomyCorrect Count:

Execution:• Ensure correct sponge, instrument, and

needle count before wound closure.

ParotidectomyWound Closure:

Objectives:• To repair the skin incision used to remove

the parotid tumor.• To repair the skin incision in such a way that

- a cosmetically acceptable scar is effected- will promote patient comfort (e.g., pain

of skin suture removal)

ParotidectomyWound Closure:

Execution:• Use absorbable suture to avoid pain on

suture removal, if non-absorbable sutures are used.• Appose wound edges precisely to promote a

cosmetically acceptable scar.

ParotidectomyPostop Care

Objectives:• Supply basic needs of patient• Comfort• Analgesics• Fluids and Electrolytes• Nutrition

• Wound care• Monitoring for complications and treat as indicated• Advice on home care of wound• Advice on follow-up plan

ParotidectomyFollow-up Plan:

Objectives:• Evaluate results of treatment.• Provide psychosocial support. Monitoring guidelines

Physical examinationSymptom-directed investigation

ParotidectomyFrequency of Follow-up Guidelines:

Consider• Usual course of disease (recurrence probability

and incidence)• Personality of patient• Patient’s convenience

ParotidectomyOutcome of Treatment:

If at the end of the treatment, I have achieved all the following:

Resolution of the health problem – parotid tumor extirpated with no recurrence

Live patientNo facial paralysisSatisfied patient

No medico-legal suit

Then,I can consider myself to be successful in my problem-solving and

decision-making in the management of the patient.