I never needed a tracheotomy because I breathed well on my own through the entire procedure.
When they wheeled me into the OR room I yelled out Hi People! to all the nurses and others in the room. I got a response back too! They hooked me up and then I was out.
I remember being woke up and wheeled down a hallway. As we passed another person on a gurney I asked them if they wanted to race. The male nurse pushing me laughed. I was just so glad to be alive and wanted to be funny, like usual. LOL
That started the trend that I was their star patient through the whole 7 days I was there. Everyone was so astounded how well I was doing, and how fast I healed. I think just being a happy person in general helped me a lot. Laughing is the best medicine. After animals, of course.
After informed consent was reviewed, the patient was brought back
to the main operating room and placed in asupine position.
General anesthesia was induced, and the patient was
nasotracheally intubated. The tube was secured to the nasal
septum with a 2-0 silk suture. The bed was turned 180 degrees
away from Anesthesia. An arterial line and Foley were placed.
The intraoral cavity lesion was inspected and injected with 1%
lidocaine with 1:100,000 epinephrine for a total 7 mL. The
planned right neck incision was marked approximately 2
fingerbreadths below the mandible in a natural skin crease and
injected with 10 mL 1% lidocaine with 1:100,000 epinephrine. The
patient was then prepped and draped in sterile fashion for the
procedure. A time out was performed.
A bite block was placed, and the oral cavity was inspected. The
patient had an approximately 6 x 4 cm right buccal mucosa cancer
that appeared to extend into the gingival buccal sulci
bilaterally and encompass the parotid duct. The tumor extended
anteriorly towards the oral commissure and posteriorly toward the
RMT. The planned incisions were marked with monopolar cautery,
with approximately 1 cm margins. The resection extended to the
oral commissure, to include the red lip, with the white lip left
intact. The mucosa was incised with monopolar cautery. The
buccinator was taken as the deep portion of the specimen. The
specimen was released off the buccal fat pad. The dissection was
carried more superficially, as we worked anteriorly toward the
oral commissure, releasing the specimen off the orbicularis
muscle. The specimen was released without coming through the
cheek skin. The specimen was oriented and handed off to nursing
for permanent pathology. Frozen section margins were taken
circumferentially from around the specimen for frozen section. A
deep margin was taken from the buccal fat pad posteriorly as well
as along the deep muscle anteriorly. The anterior mandibular
gingival margin came back positive for focal CIS. A second
margin was taken from this area which also returned positive for
focal CIS. Ultimately, a permanent section was sent from around
tooth #29, which was the only remaining mucosa in this region.
Hemostasis was achieved with bipolar cautery.
We then turned our attention to the right neck. A 15 blade was
used to make an incision down through the skin and through the
platysma. A subplatysmal flap was raised superiorly up to the
mandible. The external jugular vein was preserved for use in
reconstruction. The greater auricular nerve was also preserved.
The inferior subplatysmal flap was also raised. The nerve
stimulator was used to identify the level of the marginal
mandibular nerve. The fascia was divided using blunt dissection
inferior to the marginal mandibular nerve working superiorly
towards the mastoid tip. The fascia was raised off the
submandibular gland, which was then carefully retracted
inferiorly. The facial vein was identified and divided for use
in reconstruction. The submandibular gland was dissected
bluntly. The digastric muscle was identified and traced
posteriorly back towards the mastoid tip. The facial artery was
identified and suture ligated. There was a large nodal
conglomeration in level IB which was taken in conjunction with
the submandibular gland. As this nodal mass was retracted
inferiorly with the submandibular gland, the mylohyoid muscle was
identified. The mylohyoid was retracted superiorly. The
submandibular duct was clipped. The level 1B specimen was
released and handed off to nursing for permanent pathology. An
additional perifacial node was dissected and handed off to
nursing for permanent pathology.
Monopolar cautery was used to release the fibrofatty contents
along the anterior belly of the digastric. This was released
towards the contralateral anterior belly of the digastric. The
specimen was released down to the level of the hyoid. The level
of 1A was handed off to nursing for permanent pathology. We then
turned our attention to dissection of an external jugular vein
node. This was released and handed off to nursing for permanent
pathology. The fascia was then released off the anterior border
of the SCM and unrolled medially. The spinal accessory nerve was
identified and traced superiorly toward the IJV. The fascia was
released off the SCM down to the level of the omohyoid. The
floor of the neck was identified inferior to the spinal accessory
nerve. The fascia was released along the floor, and the
fibrofatty contents were rolled from lateral to medial, working
toward the internal jugular vein. The fibrofatty contents were
sharply dissected off the internal jugular vein. The specimen
was then released off the omohyoid inferiorly. The specimen was
divided into levels II-III and handed off to nursing for
permanent pathology. Hemostasis was achieved in the neck.
A Dobbhoff was placed in the right side of the nose and secured
with 3-0 nylon. The patient was then handed over to Dr.
Pagedar's team for reconstruction.
Following the ablative portion of the procedure, the
reconstructive portion of the procedure commenced. The defect
was inspected, and found to require reconstruction with tissue
taken from the radial forearm based on the radial artery. The
left arm was prepared for harvest. Preoperative testing had
demonstrated intact collateral perfusion from the ulnar artery.
The radial artery and cephalic vein were marked. A skin paddle
measuring approximately 8 x 6 cm was drawn out centered over
these vessels. The arm was exsanguinated, and a tourniquet was
applied and inflated to 250 mm/mercury. Total tourniquet time
was 70 minutes. An incision was made outlining the cutaneous
paddle and carried into the subcutaneous tissue of the arm. The
ulnar side of the flap was elevated off the flexor carpi radialis
muscle and tendon. The cephalic vein was identified proximal to
the skin paddle. Once the direction of the vein was confirmed,
the incision was extended superiorly towards the antecubital
fossa in a lazy "s" configuration, down to the level of the
cephalic. The cephalic vein was then elevated with a vessel loop
and dissected in a circumferential fashion up to the antecubital
fossa. It was then followed distally to the wrist, carefully
dissecting from the radial nerve and keeping it attached to the
skin paddle. The cephalic vein was ligated distally. The lateral
paddle of the flap was raised off the brachioradialis muscle
towards the radial artery. Sensory branches of the radial nerve
were spared. Proximal to the skin paddle, the pedicle containing
the radial artery and venae commitantes was identified between
the bellies of the brachioradialis and FCR, the fascia between
the muscles was released and the pedicle traced proximally, with
ligation of perforation branches to the muscles. The pedicle was
then isolated and ligated distally and dissected proximally in a
suprafascial manner between the muscle bellies of the
brachioradialis and flexor carpi radialis muscles, with attention
to hemostasis and control of perforating vessels. Dissection
proceeded until the communicating vessels at the elbow were
identified, and these were spared. Once the flap was pedicled on
its nutrient vessels, the tourniquet was released.Hemostasis was
achieved in the arm and on the flap itself. The hand demonstrated
adequate perfusion. Subsequently, the radial artery, venae, and
cephalic vein were suture ligated and the free flap was passed
off the table to be prepared for inset.
The forearm wound was repaired in the following manner: A JP
drain was placed and the proximal incision, measuring 12 cm, was
closed primarily in two layers with deep 3-0 vicryl and a running
4-0 nylon. A split thickness skin graft measuring 8 x 8 cm was
harvested from the left thigh with a dermatome and sutured to the
forearm donor site defect with 5-0 fast gut in interrupted and
running fashion. The thigh donor site was dressed with Allevyn
foam, secured with staples. The skin graft was bolstered with
vaseline gauze and moist gauze. The arm was wrapped with ABD
pads and webrill. A volar splint was made with plaster sheets
and wrapped with an ace bandage. Attention was paid to padding
the arm and hand at the pressure points.
Attention was turned to the oral cavitydefect. The flap pedicle
was passed into the neck through a soft tissue tunnel created on
the lateral surface of the right mandible. Flap inset was then
performed; the free flap skin was sutured to the mucosal edges
of the buccal defect using 3-0 Biosyn sutures in horizontal
mattress fashion. Circumdental sutures were placed where the
resection margins included the gingival mucosa. Portions of the
skin of the flap at the right oral commissure were brought out
and sutured to the skin of the white lip, where the resection
extended to this area. The complete mucosal and skin defect was
closed, creating a water-tight seal separating the neck from the
oral cavity.
Anastomoses were then performed using the operating microscope.
The flap vessels and recipient vessels in the neck were dilated
and cleaned with microsurgical instruments and irrigated with
heparinzed saline. 2% lidocaine solution was applied directly to
the vasculature to counteract vasospasm. An end-to-end arterial
anastomosis was performed from the radial artery to the right
facial artery using 8-0 nylon in an interrupted fashion.
End-to-end venous anastomosis was performed from the larger of
the two radial venae to a branch of the lingo-facial trunk on the
right; a 2.0 mm coupler was used (this vein was positioned deep
to the arterial anastomosis to maintain good geometry of the
pedicle). An additional end-to-end venous anastomosis was
performed from the cephalic vein to the external jugular vein
using a 3-0mm coupler. Upon removal of the vascular clamps,
excellent flow-through was noted in the vein, strong doppler
pulse in the perforating branch, and the skin of the flap was
noted to be well-perfused.
Hemostasis was confirmed. Two round JP drains were placed; one
deep to the right SCM, and the other in the submental region.
The 15cm neck incision was closed in 2 layers: the platysma was
closed in interrupted fashion with 3-0 vicryl. The skin was
closed in running fashion with 4-0 nylon. There were no
complications.
I was taken to ICU. They put a bite block in my mouth.
What a hopeless feeling with one arm in a cast, the other hooked up to IVs and a blood pressure monitor, and tubes coming from all over. I was also catheterized. I had two tubes coming from my neck, one from my left top arm and one from my crotch. Couldn't feel the crotch one though, not that it would have mattered.
I also had a feeding tube down my right nostril and a clear long thing with a hole inserted into my other nostril. They gave me Percocet every 4 hours so the pain was manageable. The worst was that the things down my nose created THICK snot that traveled down behind my nose and mouth and then made me feel like I couldn't breathe because it would get over my airway. They had to suction out the snot, A LOT. Most times they couldn't see it but I could feel it between my nose and mouth behind my uvula and it was literally scaring me to death. The ICU nurse was amazing. She'd listen to me and by the end of the night I had her trained to go down my nose only about 2 -3 inches and suck out the snot there. I also snorted it into my mouth a few times and she sucked it out from there. They really didn't want me doing that because of the sutures inside my mouth. Once me and her had that down we were a team. But it took about 8 hours to get there and in the meantime I was panicky because of the mucus. I truly though I was going to smother to death for those 8 hours. That feeling never really went away until day 6. Because of that feeding tube the mucus was crazy, plus I wasn't taking any liquids by mouth and that added to the viscosity of the mucus. It was horrible. HORRIBLE. That first night was the worst though. I also got no sleep for about 5 days. They had to come in every hour for 48 hours and put this Dopple thing between my fingers and also inside my mouth to make sure that my hand was still getting blood flow and also that the new blood vein they had put in my cheek was still working. After the 48 hours, then it was every 4 hours, then every 8 etc. Just when I started falling asleep someone was coming in to dopple me or take my vitals, or push drugs down my feeding tube. etc. I got so exhausted that I couldn't sleep. Plus it hurt to sleep. I had to be in a 30 degree or more position so my head would loll to the side and since they removed nerves, tissue etc from my neck, it would make me feel like I didn't have any blood going to my brain and it HURT. Once I woke up after being asleep less than 2 minutes and the room was yellow. I'm serious. It was like someone strangled me then released right before I passed out, Then I was afraid to sleep.
The next morning one of the doctors removed the clear plastic thing from my left nostril and that so eased the mucus and I could breathe better. He was my hero that day.
I will post more later under a different heading. The notes above from the doctors is available to me online. I thought it was interesting so assumed you would too.
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