After informed consent was obtained, the patient was brought back to the operating room and placed on the operating room table in supine position. General anesthesia was administered and the patient was orotracheally intubated. A foley catheter was placed. All pressure points were padded and the table was rotated 180 degrees. The head, neck, and leg were all prepped and draped in the usual sterile fashion.
A left neck incision approximately two finger-breadths below the mandible along an existing skin fold was delineated to expose both the left neck. Local anesthetic (1 % lidocaine with epinephrine 1 was infiltrated subcutaneously. Using a No. 15 scalpel, an incision was made through skin and subcutaneous tissue along the delineated path. The superficial cervical fascia and platysma muscle were identified and divided sharply. Skin hooks were placed subplatysmal flaps were elevated. The inferior skin flap was elevated in a subplatysmal plane. Dissection proceeded bluntly at the superior flap to protect the marginal mandibular nerve. Before division of tissue, the tissue was clamped and the lip was monitored for twitching. As dissection proceeded superiorly, the marginal mandibular nerve was identified bilaterally and preserved. The flaps were raised up to the mandible.
Next, level la dissection proceeded by removing lymph node tissue between the anterior belly of the right and left digastric muscles. Next, the superior border of the dissection proceeded along the mandible and the left level 1b lymph nodes posterior to the anterior belly of the digastric were dissected free.
The left submandibular gland was dissected free and removed with care to avoid injury to the hypoglossal and lingual nerves.
Next, the left sternocleidomastoid muscle was identified and the superficial layer of the deep cervical fascia over the sternocleidomastoid was divided along its length and traced posteriorly. At this point the spinal accessory nerve was identified at the anterior aspect of the sternocleidomastoid muscle and skeletonized. The dissection was advanced superomedially. The posterior belly of the digastric was identified. The anterior border of the sternocleidomastoid muscle was traced down to the level of the omohyoid which was the inferior limit of the dissection. The sternocleidomastoid muscle was elevated away from the carotid sheath contents until the internal jugular vein was identified. The left internal jugular vein was followed up superiorly to level ll. The left level Il lymph node basin was then dissected free and followed inferiorly into the level Ill nodal station. The ansa cervicalis was identified and preserved. The nodal stations Il and Ill were then reflected medially and dissection proceeded towards the previously elevated specimen. The carotid sheath contents including the internal and external carotid arteries and vagus nerve were identified and preserved. The left neck dissection specimen was then released from its final attachments, marked and labelled and sent for permanent histopathologic assessment. The pterygomassetric sling was then divided and the inferior aspect of the mandible was exposed through the neck. We then turned our attention to the oral cavity. A side biting mouth gag was placed on the left side. A mucosal incision was outlined using a needle tip bovie extending from the left mandibular body to the right mandibular parasymphysis with a 1 cm margin around the tumor. The incision extended minimally posteriorly along the floor of mouth. The incision was then made using the bovie beginning anteriorly in the vestibule. It was then extended over the lingual surface of the mandible laterally at the body of the left mandible, then connected at the labial mucosal surface/ floor of mouth around the tumor to the other side. The incision was then deepened and the mandible was exposed with a #9 elevator. Further inferior and posterior muscle attachments were dissected off the mandible using a combination of blunt dissection and electrocautery. The tumor posteriorly was dissected free and the genioglossus and geniohyoid muscles were released from their attachments to the mandible. Once all surrounding tissue was released, we proceeded to our osteotomies. Using the oscillating saw, the osteotomies were made. The specimen was then sent to pathology for permanent histopathologic analysis. Hemostasis was achieved with bipolar cautery at 20 watts. The wound was copiously irrigated with saline. Multiple margins were taken circumferentially for frozen section analysis. All margins were negative for carcinoma.
We then proceeded with the tracheostomy. Laryngotracheal and anterior neck landmarks were identified, including the thyroid notch, cricoid cartilage and sternal notch. A horizontal incision between the cricoid cartilage and sternal notch was delineated. Local anesthetic (1% lidocaine with epinephrine was infiltrated subcutaneously. Using a No. 15 scalpel, an incision was made through skin and subcutaneous tissue along the marked path. The superficial cervical fascia and platysma muscle were identified and divided sharply. The superficial layer of the deep cervical fascia was then identified and divided in a vertical fashion along its midline raphe using monopolar electrocautery. The sternohyoid and sternothyroid muscles were identified bilaterally. Dissection continued until the thyroid isthmus was identified. The isthmus was then partially divided with Ligasure. The pretracheal fascia was then encountered and separated from the underlying trachea using a combination of blunt dissection and electrocautery. The cricoid cartilage and upper tracheal rings were identified. A decision was made to enter the airway between the 2nd and 3rd tracheal cartilages. The ETT cuff was deflated by the anesthesiologist. Using a No. 15 scalpel, the membranous space between these rings was scored; a Metz scissors were used to complete the incision bilaterally. The ETT was gradually withdrawn until the distal end was just above the tracheotomy. The tracheotomy was dilated using a dilator instrument. The tracheostomy tube (a #6 Shiley cuffed tube) was inserted into the trachea. Correct placement was confirmed by the effortless passage of a flexible suction catheter, suctioning of tracheal secretions, and the presence of end-tidal C02. The tracheostomy tube was secured by suturing the neck plate at four points using 2-0 silk suture. Xeroform packing was placed.