Superficial Parotidectomy

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Preoperative Considerations

Consent:

  • Facial nerve weakness/paralysis
  • Frey's Syndrome
  • Sialocele
  • Need for additional surgery/ recurrence

Anesthesia/Positioning:

  • Supine
  • Hold paralysis
  • Shoulder roll

Other:

  • None

Armamentarium:

  • Local anesthesia
  • #15 blade
  • Monopolar/bipolar electrocautery
  • Intraoperative EMG monitor
  • Skin hooks
  • Metzenbaum or tenotomy scissor
  • Army/Navy Retractor
  • Debakey Forcep
  • Gerald Forcep
  • Lone Star/ Self Retaining Retractor
  • Tonsil
  • Small/Medium Vascular Clip
  • 2-0 Silk Traction Suture
  • 3-0 VIcryl Suture
  • Skin Suture

Technique

Postoperative Considerations

Immediate:

  • Q4 drain output
  • Facial nerve exam, consider early steroids if weakness

Follow Up:

  • None

Operative Note

Surgeon(s): ***

Assistant Surgeon(s):  ***

Preoperative Diagnosis: ***

Postoperative Diagnosis: Same

Procedure(s): ***

Anesthesia: General

Implants: None

Specimen:***

Drains: None

Fluids: See anesthesia record

EBL: Minimal

Complications: None

Counts:  Correct x2

Indications: ​***

Findings: As expected

Procedure in Detail:

The patient was seen in the preoperative holding area where consents were reviewed including risks, benefits and alternatives to the proposed treatment, the H&P was updated, and all questions were invited and answered. The patient was then transferred to the OR and onto the OR table in supine position without any issues. All appropriate monitors were placed and confirmed to be working properly. IV induction of general anesthesia was then performed, followed by oral endotracheal intubation. The tube was secured by the surgical team after confirming end tidal CO2 and bilateral breath sounds. Lacrilube was placed in the eyes and tegaderms were placed bilterally. Pre-operative antibiotics were given.  The patient was then prepped with betadine and draped in standard sterile fashion. Time out was then performed with two patient identifiers and team agreed on procedure, laterality, and correct patient.

A modified Blair incision was marked starting at a left pre-auricular crease and coursing behind the left ear lobule into a skin crease two fingerbreadths behind the angle of mandible. 10ml of epinephrine 1:100,000 was infiltrated along the planned incision line. Bovie electrocautery was used to make the modified Blair incision, which was carried down to the level of the sternocleidomastoid muscle in the neck and the tragal cartilage anterior to the auricle. The great auricular nerve was identified with the posterior branches preserved and the nerve mobilized posteriorly out of the region of dissection. The posterior belly of digastric muscle was identified. The tragal cartilage pointer was identified. The intervening tissue spanning the two landmarks were carefully dissected until the facial nerve was identified in its usual location. Next, the skin flap was dissected off the parotid fascia until the leading edge was anterior to the parotid mass. The facial nerve was was then dissected out to the pes anserinus where the inferior and superior divisions were identified. NIMS facial nerve monitoring was used throughout the entire dissection to ensure facial nerve integrity. The mass was identified between the inferior and superior divisions. The facial nerve branches around the tumor were dissected out past the mass so that the tumor could be peeled away from the facial nerve. In this fashion the mass was completely removed along with a cuff of normal-appearing parotid tissue on all sides with grossly negative margins. The mass was then oriented and sent to pathology. The main trunk of the facial nerve was stimulated and caused contraction of all facial muscles supplied by the nerve. Bleeding was stopped with bipolar cautery and the wound was irrigated with sterile saline. It was noted at this point that the mass resection left significant dead space with a noticeable facial defect. Decision was made to harvest abdominal fat to fill the defect.

Abdomen was prepped and draped. An approximately 1cm incision was created just below the umbilicus and carried through skin and subcutaneous layers to expose abdominal fat. Approximately 0.5 x 0.5 x 0.5cm fat graft was harvested and taken to the neck where it was inset into the defect site. Abdominal wound was then copiously irrigated with normal saline and closed in layers with deep 3-0 vicryl sutures and 3-0 monocryl in the skin layer. Dermabond and steri strips were then also applied.

A flat Jackson Pratt drain was then placed in the left neck and the wound was closed in layers using 3-0 Vicryl sutures to reapproximate subcutaneous tissue and and running 4-0 Prolene stitches to reapproximate the skin.

The patient's face was then cleaned and the posterior pharynx was suctioned. BSS was used to irrigate the patient's eyes. An OG tube was used to suction out the contents of the stomach. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

Coding

  • 42410 - Parotidectomy, superficial, partial, or total (separate procedure)
  • 42415 - Parotidectomy, superficial, partial, with dissection and preservation of facial nerve
  • 42420 - Parotidectomy, superficial, total with dissection and preservation of facial nerve In addition to the above, the following codes might apply for specific aspects of the procedure:
  • 38500 - Biopsy or excision of lymph node(s); open, superficial
  • 38525 - Biopsy or excision of lymph node(s); open, deep axillary or other, except sentinel lymph node (separate procedure) For intraoperative biopsy:
  • 88331 - Pathology consultation during surgery; intraoperative consultation For nerve monitoring during the procedure:
  • 95940 - Continuous intraoperative neurophysiology monitoring, from outside the operating room (e.g., in a special unit, in the office), per hour (List separately in addition to code for primary procedure)

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