Submandibular gland excision

1.Incision is made parallel and 2 finger breadths below the body of mandible.
2.Sharp dissection is carried out up to and including the investing cervical fascia overlying the inferior margin of the gland. The marginal mandibular nerve is thus protected within the creation of the upper flap as it is superficial to the investing layer. Raise a submandibular flap to the level of the mandible above and the hyoid bone below. The posterior portion of the gland wraps behind mylohyoid. Retract forward to reveal deeper lobe of gland.
3.The common facial vein is ligated below the gland and incorporated in the creation of the upper flap, if it is in the way of dissection and can assist in retraction of the upper flap.
4.The facial artery is occasionally densely adherent to the gland. In this situation ligate it twice above and below gland; and remove en bloc.
5.The lower border of the gland is then grasped and retracted upwards to reveal the digastric and hyoglossus muscles along with the hypoglossal nerve. Sharp dissection is used here to free the gland from its muscular bed.
6.The gland is retracted downwards and fascial attachments to the mandible divided to visualise the lingual nerve and the submandibular ganglion. The branches from the ganglion to the gland are divided to prevent avulsion injury to the main nerve trunk as the nerve can be seen to bowstring with traction on the gland. There will be small vessels that run with the parasympathetic branches.
7.The gland is then retracted posteriorly and a blunt retractor inserted deep to the mylohyoid to visualise the deep part of the gland and dissection is then carried anteriorly to the duct.
8.The duct does not need to be ligated as far anteriorly as possible (1cm will suffice).
9.A drain tube is not usually required.
10.Close in layers.