Zenkers diverticulum

Repair of pharyngo-oesophageal diverticulum
1.Position the patient supine on a head ring facing the right side with a sandbag between the shoulder blades.
2.Make an incision along the anterior border of the SCM for a variable distance depending on the size of the diverticulum, through skin and platysma.
3.Free the anterior border of SCM, retracting it laterally and divide the omohyoid muscle.
4.Continue dissection in the plane between the SCM and the thyroid medially and ligate the middle thyroid veins as they are usually in the way.
5.Identify the ITA and RLN, and then ligate the ITA (usually necessary).
6.Grasp the fundus of the diverticulum and dissect down to its neck using sharp dissection.
7.There may be some fibrous tissue at the neck of the diverticulum, divide these to visualize the fibres of crico-pharyngeus.
8.Insert a right angled clamp between the mucosa and the crico-pharyngeus to perform a cricomyotomy using diathermy for a distance of 5-6cm.
9.With the mucosa bulging, apply and fire a TA30 stapler across the neck of the diverticulum, amputate the diverticulum.
10.Ensure haemostasis and close in layers.

PS For endoscopic stapling use Collard 93 stapling device.

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.

Cricothyroidotomy

1. Position patient on head ring and sandbag between shoulder blades.
2. Prep and drape.
3. Grasp the thyroid cartilage between the thumb and middle finger of left hand and palpate the cricothyroid membrane with the index finger.
4. Make a transverse incision at this level about 2cm in length after infiltrating with LA through skin, fascia and cricothyroid membrane.
5. Insert curved Mayo scissors into the opening and spread to enlarge.
6. Insert a cuffed Tracheostomy tube Size 8 (8mm internal diameter) into the lumen and secure as above. No need to close the wound.

Superficial parotidectomy

Gland size esp inferior extent is variable, but main trunk as it enters the parotid is relatively constant.

Separation between deep and superficial lobe is arbitrary

80% of parotid gland parenchyma is lateral to the nerve

Turn head away. Head ring.
Prep to expose ear, lateral corner of eye, corner of mouth and entire ipsilateral neck
45 deg reverse Trendelenburg
Swab in auditory canal
Modified Blair (sigmoid) incision to 2 finger breadths below mandible
Raise flaps with scalpel and rake retractors. Raise flaps to edge of gland but no further anteriorly as facial nerve branches emanate from anterior border. Use tenotomy scissors with spreading action
Masseter muscle fascia is identified
Do not look for Stensens duct at edge of gland as this can injure buccal branches that travel with it
Identify SCM and dissect from posterior margin
EJV and greater auricular nerve should be seen
In most cases will need to divide nerve but don't do it until after it branches as it may be needed as a nerve graft
Separate inferior aspect of gland from SCM and dissect using Kochers on the gland to the level of the lobule of the ear
Assistant puts rake on tragus and dissect parotid from cartilage. Again Kocher on gland for retraction and identify cartilagenous pointer
There will be a small bridge of tissue that will need division between mosquito
After this division, only bipolar should be used
Look for posterior belly of digastric (palpate mastoid for landmarks)
Free parotid, then identify main trunk of facial nerve:

Nerve exits stylomastoid foramen just posterior to styloid process. Nerve enters parotid just anterior to border of mastoid and digastric muscle. Assistant watches for twitching of face. Use a curved mosquito anterior to cartilagenous pointer to divide tissues layer by layer. Nerve is 2-3mm wide. Posterior auricular artery travels posteriorly along digastric muscle. Generally inferior to main trunk of nerve. Do not divide artery until facial nerve identified. Always ligate artery.

Spread along nerve with artery until pes is seen. Work on broad front. Alternatively use tenotomy scissors and right angle for dissection. In general, work from sup to mid portion and inf to mid portion but tailor to tumour.

Venous anatomy is variable.

Nerve is usually superficial to posterior facial vein.

Gland will then be pedicled on duct.

Traction up not anteriorly by assistant an counter traction with sponge by surgeon is important. Avoid making tunnels along nerve

Complications
1.Facial N palsy after superficial parotidectomy
a.Permanent 1%
b.Transient 30-43%
2.Frey’s syndrome
a.Up to 60% but only 20% complain
b.Resolves or improves
c.Persistence can be treated by tympanic neurectomy (Jacobsen’s nerve) which divides the parasympathetic pathway
d.Topical agents can be used
e.Placing a PTFE implant can reduce the incidence to 3% (? Trial)
3.Salivary fistula
4.Hypoaesthesia of ear lobe
a.Due to division of great auricular nerve
5.Neuroma
a.May be due to cut end of above

Radical Neck Dissection

Rolled sheet beneath shoulder
Neck rolled toward opposite side
Reverse Trendelenburg
Hockey stick incision (encompass prev biopsy) Start @ mastoid process and curve along posterior border of SCM and curve at base of neck into horizontal limb
Divide platysma down to enveloping layer of deep cervical fascia and elevate skin flaps in subplatysmal plane
Laterally platysma is absent, stay in correct plane be staying superficial to greater auricular nerve
STEP 1: LATERAL (LEVEL V OR POSTERIOR TRIANGLE) DISSECTION
Accessory nerve is an important landmark
Divide greater auricular nerve and mastoid head of SCM, which facilitates medial rotation of specimen, dissect from lat to med in floor of posterior triangle
Identify inferior belly of omohyoid @ corner of clavicle and trapezius. Nothing of significance lies superficial to this plane
Divide muscle and dissect of brachial plexus
Dissect inferior border medially, divide EJV and identify phrenic nerve on scalenus anterior
After phrenic nerve, don't dissect further as this risks damaging sympathetic chain which lies deep to carotid artery
STEP II: LEVEL 1 DISSECTION
Skeletonise contralateral digastric
Clear submental triangle
Identify MM br of CN VII by identifying anterior facial vein (nerve lies immediately superficial to this) Dissect submandibular triangle
Exposing mylohyoid muscle to delineate its lateral border is crucial to identify vital structures (lingual nerve above, hypoglossal nerve below and the submandibular gland duct bewtween the two.
Posterir belly of digastric is important landmark in this region: superficial to it are no vital structures, IJV, carotid, vagus, accessory and hypoglossal below it.
STEP III: JUGULAR DISSECTION
Divide IJV after identifying carotid and vagus. Preserve thoracic duct at base of neck on the left side
STEP IV: MEDIAL DISSECTION
Plane of dissection is sternothyroid and sternohyoid muscles

Meticulous haemostasis
Interrupted sutures to platysma

Neck dissection

Described by Crile in 1906

Various incisions

Classification

Radical Neck dissection
Level I to V lymph nodes
IJV, CN IX, SCM

Modified radical
Level I to V
One of three above saved

Selective
3 structures always preserved
Preservation of one or more lymph node groups


Complications
Nerve injury:mandibular branch of facial (runs superficial to facial artery and vein, 1cm anteroinferior to angle of mandible), hypoglossal (deep to IJV, ICA, CN vagus and accessory, turns 90 deg and passes b/w IJV and ICA, most commonly injured in flor of submandibular triangle just deep to duct) and vagus
Chylous fistula (left side 85%)
Flap necrosis esp if irradiated neck

Tracheostomy

All patients will have ETT
Mild neck extension
Towel under shoulders, Head ring
LA infiltration
Prep and drape
Collar incision 1-2 finger breadths above sternal notch
Incise platysma
Separate strap muscles (sternohyoid and sternothyroid) in midline
Keep dissection exactly in midline to avoid bleeding
Divide isthmus with diathermy to expose second and third tracheal rings
Horizontal incision between rings with cricoid hook in place (Stomal size is directly related to tracheal stenosis, avoid 1st ring as risk of subglottic stenosis)
Withdraw ETT
Place suitably sized ETT (size 6-10: inner tube 6-10mm for adults) after cuff tested and lubricated
Suture cuff in place
Close skin with nylon
Tracheosotmy tape around neck

Complications
Haemorrhage (up to 40%) (3% pts have thyroidea ima artery)
Tracheoinnominate fistula if tube too low in trachea
Tracheal stenosis