Presentation Bile vomiting in the neonatal period indicates intestinal obstruction and, of all possible causes, volvulus requires urgent intervention as the bowel is at risk of becom ing ischaemic. In peritonitis, frank haematemesis, or PR bleeding, laparotomy should not be delayed by other investigations. Plain X-ray can be abnormal, ultrasound may show abnormal relative position of superior mesenteric vessels but upper GI contrast study is diagnostic (DJ junction on right, corkscrewing of small bowel). Preoperative Warn parents of possibility of catastrophic bowel ischaemia if you suspect. Cr oss-match blood and correct any coagulopathy. Incision Supra-umbilical transverse. Procedure (cid:142)(cid:3) Deliver intestine completely and determine if volvulus present. If pre- sent, it is usually clockwise. If intestine is compromised, untwist and cover with warm saline packs to encourage reperfusion. (cid:142)(cid:3) Determine nature of malrotation. Ladd \200\231s bands may run across duode - num to attach to mobile, high lying caecum. Divide these bands follow- ing diathermy coag ulation. Mobilize duodenum so that it lies relatively straight on the right side of the spi ne. Attempt to broaden mesentery by opening one leaf of the mesentery. (cid:142)(cid:3) Return intestine to the peritoneum in the non-rotated position \200\224lar ge bowel on the left and small bowel right. The appendix does not need to be excised but, i f left in situ, the fact and position should be accurately documented and parents informed. (cid:142)(cid:3) If intestine found to be ischaemic with little recovery with warm packs, consider closing and performing a \200\230second-look \200\231 laparotomy after 48 hours. (cid:142)(cid:3) Layered closure with continuous 2/0 or 3/0 absorbable. Subcutaneous 4/0 absorbable. Subcuticular 4/0 or 5/0 absorbable. MALROTATION AND VOLVULUS1 621 Postoperative management NG tube on free drainage until signs of ileus resolve. Consider pa renteral nutrition may be required if this is prolonged. Complications Short gut syndrome if a large amount of small bowel resected. Early diagnosis and intervention essential to avoid this. Stomach Duodenum Ladd s bands Colon Small bowel Clockwise volvulus Fig. 14.13 Volvulus of small bowel CHAPTER 14 Pediatric surgery 622 Epigastric hernia This is herniation of extraperitoneal fat through a small defect in linea alba of upper midline abdominal wall. Commonly midway between xiphisternum and umbilicus b ut can be at any point. It presents either as a visible lump or due to discomfort caused by traction of tethered hernia on underlying peritoneum. Confusion at referral with the much larger, diffuse, midline swelling due to divarication of the rectus abdominis mus- cles, wh ich is not a true hernia and improves and eventually disappears with spontaneous approximat ion of the muscles. Preoperative Mark hernia site carefully as it may be impossible to palpate in the anaes- th etised relaxed patient. Position Supine. Incision Short transverse centered on hernia in midline of abdomen. Procedure (cid:142)(cid:3) Divide subcutaneous fat and fascia transversely to reveal slight ly differ- ent texture of extra peritoneal fat protruding through linea alba fascia. (cid:1 42)(cid:3) The defect often very small (2 \200\2233mm) \200\224enlarged by lateral incision s to permit reduction of fatty hernia. If the fat amputated, supplying vessels must be liga ted/cauterized. Defect closed with 3/0 interrupted non- absorbable sutures. (cid:142)(cid:3) Use interrupted 3/0 absorbable to fascia subcutaneous fat: continuous 4/0 absorbable subcuticular to skin. Complications (cid:142)(cid:3) Bruising or bleeding if haemostasis not secured at operation (cid:142)(cid:3) Residual discomfort if peritoneum tethered to closure of defect. This page intentionally left blank CHAPTER 14 Pediatric surgery 624 Umbilical hernia This is due to a residual small defect in fascial closure at the umbilical ring following cord separation in newborn. It is noted as bulge into umbilicus when infant cries or strains. It is very rarely symptomatic and often remains small. There is potentia l for spontaneous closure up to about 4 years of age especially if defect <1cm at 1 year of age. It is diagnosed by tip of examining finger palpating defect in umbilical ring. Preoperative Standard preparation for day case surgery. Position Supine. Local anesthetic peri-umbilical infiltration or rectus sheath block improv es post-op recovery \200\224rectus sheath block preserves operative field for the surgeon. Incision Subumbilical curved (semilunar) incision in skin fold. Symmetry best achieved by s mall central stab incision and lateral split by opening forceps. Procedure (cid:142)(cid:3) Carry out subcutaneous dissection cephalad on each side around umbilical ring and hernia to isolate. (cid:142)(cid:3) Divide the ring completely to open defect with tissue forceps and retract each lateral extremity of sac. Inspect it to ensure no vitello- intestinal, intraperitoneal connection at umbilicus. (cid:142)(cid:3) Close the defect with closely-spaced, interrupted 2/0 absorbable suture. T ack down the umbilicus to site of hernia repair with one 4/0 absorbable suture. Closure Use subcutaneous interrupted 4/0 absorbable to obliterate dead space and subcuticul ar continuous/interrupted 4/0 absorbable or adhe- sive strip skin closure. Pressure dressin g for 24 \200\22348 hours reduces risk of haematoma. Complications (cid:142)(cid:3) Bruising or haematoma related to residual wound dead space ( cid:142)(cid:3) Infection (umbilicus harbors bacteria) (cid:142)(cid:3) Postoperative abdom inal pain due to intraperitoneal air/blood irritation. This page intentionally left blank CHAPTER 14 Pediatric surgery 626 Inguinal herniotomy Incidence, anatomy, and presentation Commoner in boys (8:1) and on righ t side (3:1). Almost invariably indi- rect (through both rings of inguinal canal), through a patent processus vaginalis. Emerges above and lateral to pubic tubercle (cf. femoral hern ia). Fundus varies from external ring to lower scrotum. Distinguish from hydrocoele by inab ility to get above swelling and no transillumination, but in neonates latter is less useful . Often presents as an intermittent swelling with a cough impulse at inguinal canal. Sperma tic cord feels thickened. Indications In first months of life, chance of irreducibility leading to bowel strangula- t ion and ischaemia is highest \200\224surgery should not be delayed. After 6 months of age, herniotomy is elective unless irreducibility occurs. Par- ents should be warned to present urgently if hernia is red, tender or hard. Incision Skin crease incision (about 2cm) over inguinal canal. Procedure (cid:142)(cid:3) Divide subcutaneous tissue and Scarpa \200\231s fascia in line o f incision (super- ficial epigastric vessels retracted or divided). Expose external oblique fascia and rolled edge of inguinal ligament. Perform herniotomy either at external ring or by opening inguinal canal by splitting external oblique fibers (avoiding the ilioinguinal nerve beneath). (cid:142)(cid:3) Expose hernial sac by dividing external spermatic fascia (if outside inguinal canal), cremaster fibers and internal fascia in line of cord. Lift sac with the co rd into the wound and posterior aspect freed after reducing contents. Separate vas (postero medial) and vessels (poster- olateral) from hernial sac \200\224great care needed to avoid damage to these fine structures. Separate fragile, friable sac from vas and vessels with mi xture of sharp and blunt dissection. (cid:142)(cid:3) Clear sac to the internal ring and transfixion-ligate with 3/0 absorbable (herniotomy) sutures. No muscle repair or narrowing of hernial ori- fices (herniorraphy) re quired. If testis has retracted, replace it in the scrotum. If it lies within hernial sac, it should be separated carefully and mobilized with lengthening of vessels to allow a scrot al orchidopexy. In girls, identification of sac external to superficial ring. Divide the sa c and round ligament and open to reveal contents. Inspect the ovary, if easily identified ( remember rare possibility of androgen insensitivity syndrome with testis in sac). Transfix sac and close external oblique to the pubic tubercle. INGUINAL HERNIOTOMY1 627 Closure Use absorbable 3/0 to close external oblique and Scarpa \200\231s fascia and subcut icular 4/0 or 5/0 sutures to skin. Complications/consent issues (cid:142)(cid:3) Recurrence rare but may follow difficult hern iotomy with oedematous sac (cid:142)(cid:3) Damage to the vas (cid:142)(cid:3) Testicular atrophy follo wing irreducible/strangulated hernia (cid:142)(cid:3) About 10% chance of inguinal hernia o n contralateral side (cid:142)(cid:3) In girls, abnormal \200\230ovary \200\231 should be biopsied to exclude testicular feminisation (androgen insensitivity syndrome). CHAPTER 14 Pediatric surgery 628 Hydrocele Presentation Usually congenital due to persistence of a patent processus vaginali s. Very occasionally secondary to infection, inflammation, trauma, or tumor of testis/epidi dymis. Clinically distinguished from hernia by soft fluid consis- tency, bluish color, posi tion of testis within swelling, non-reducibility and ability to palpate normal cord above i t. Equal incidence left and right. If communicating, it may vary in size diurnally (larger at end of day) and may resolve completely (usually before age 4 years.). Encysted hydrocoel e presents as firm, discrete swelling in remnant of processus above testis \200\224 also in girls as swelling in canal of Nuck (round ligament). Preoperative Mark appropriate side clearly by \200\230X \200\231 with indelible pen. Incision Short (about 2cm) groin crease incision over external inguinal ring/ inguinal cana l. Procedure (cid:142)(cid:3) Divide subcutaneous tissue and superficial fascia in line of wou nd. Expose external oblique aponeurosis and divide in line of fibers to open inguinal canal or continue dissection at the external ring. Identify and preserve ilioinguinal nerve. (cid:142)(cid:3) Divide layers of spermatic cord (cremaster fibers and spermatic fascia) in the line of cord. Separate processus from vas and testicular vessels which lie posterior t o it (medially and laterally respectively). Clamp processus and divide and clear proximally to deep inguinal ring then transfixion ligate with 3/0 absorbable. Express fluid from hydr ocele/distal processus. It is not necessary to excise hydrocele sac. Return testis to fundu s of scrotum by traction on scrotal skin. Closure Use 3/0 absorbable to external oblique fibers if divided and to superficial fascia \200\2244/0 subcuticular absorbable sutures to skin. Complications (cid:142)(cid:3) Scrotal haematoma \200\224bleeding from cremasteric vessels (cid:142)(cid:3) Recurrent hydrocoele \200\224may be transient (cid:142)(cid:3) Testicular atrophy \200\224damage to testicular vessels (cid:142)(cid:3) Inguinal pain or dysaesthesia due to ilioinguinal nerve damage. HYDROCELE1 629 Inguinal incision exposing processus, vas and vessels Processus Encysted hydrocele Testis and epididymis Vaginal hydrocele Fig. 14.14 Approach for hydrocele CHAPTER 14 Pediatric surgery 630 Orchidopexy Incidence Undescended testis found in 2 \200\2234% of infant boys: percentage h igher if premature. By six months of age this falls to around 1.5%. Incidence slightly high er on right side. Examination With the patient in supine position and relaxed. Palpate for cord struc- tures at the superficial ring, then for the testis along line of descent. If testis palpated, att empt to manipulate into scrotum. A retractile testis can be brought to the base of the scro tum without any tension, and does not require surgical intervention. Rationale and timing Lower temperature conditions of the scrotum enhance spermatogenesis. A 5 \200\22310 fold increase in neoplasia may not be reduced by orchidopexy, but a scrotal t estis is essential for self-examination later in life. Orchi- dopexy should not be planned until after the first birthday. Preoperative If testis impalpable, warn parents that rudimentary testis may be discov- ered and excised. Laparoscopic approach may be of benefit in impalpable testis, and can be comb ined with the Fowler-Stevens technique (initial in situ ligation/division of testicular ves sels and delayed orchidopexy relying on hypertrophied blood supply via vas. Position Supine. Procedure (cid:142)(cid:3) Make a skin crease groin incision. Open Scarpa \200\231s fascia in line of incision. The testis will be found in superficial inguinal pouch or, occa- sionally, ectopi c in a penile, perineal or crural site. (cid:142)(cid:3) Grasp testis with toothed forceps and deliver into wound. With blunt disse ction peel away superficial coverings and expose deep surface of cord. Once around the cord , thin out gubernacular connections with forceps watching for \200\230looping vas \200\231 distal to testis. Divide gubernaculum. Separate external spermatic fascia and cremaster fr om underlying cord structures and clear to superficial ring. (cid:142)(cid:3) Open inguinal canal by dividing external oblique in line of fibers. Separate vas and vessels from (patent) processus vaginalis, divide this and clear it to dee p ring. Divide any lateral bands associated with vessels to give extra length. Occasionally retroperitoneal dissection is required to mobilize testis further. Identify testis by open ing the tunica vaginalis over it and remove any testicular or epididymal appendages. ORCHIDOPEXY1 631 (cid:142)(cid:3) Develop the route to scrotum by finger or mosquito forceps, and create extra Dartos pouch created through transverse scrotal incision with blunt dissection . Pass mosquito forceps cranially from scrotum to groin and grasp the testis and draw into scrotum. If cord under mild tension, suture from testis to midline raphe may limit retracti on. Closure Use interrupted 5/0 absorbable to scrotum. External oblique and Scarpa \200\231s fa scia closed with 3/0 or 4/0 absorbable. Subcuticular 4/0 absorbable to skin. Morbidity (cid:142)(cid:3) Retraction and recurrence of undescent (cid:142)(cid:3) Testicul ar atrophy due to trauma to the vessels. CHAPTER 14 Pediatric surgery 632 Circumcision Natural history of the foreskin At birth, the prepuce is adherent to the glans . Over the first few years of life the potential space develops and small retained pearls o f smegma may be noted. The foreskin becomes retractable at a variable stage over the first five years of life as the adhesions lyse. Allowing this process to occur naturally, without advising regular retractions, prevents parental and patient anxiety. Balanitis and posthit is may cause scarring of the foreskin which may, in turn, stenose (phimosis). A non-retract ile foreskin may respond to short term topical application of steroid ointment. Indications (cid:142)(cid:3) True phimosis: note a history of ballooning on micturition and previous balanoposthitis. Balanitis xerotica obliterans (BXO) can also be associ- ated wit h scarring of the glans. (cid:142)(cid:3) Paraphimosis: strangulation of the distal penis and glans due to retrac- t ion of a very tight foreskin over the glans. Consider dorsal slit and delayed circumcision if oedema marked. (cid:142)(cid:3) Recurrent UTI (controversial). (cid:142)(cid:3) Religious circumcision for boys of Jewish or Muslim faiths \200\224both parents should give informed consent. Contraindications (cid:142)(cid:3) Hypospadias: the foreskin may be needed for repair. (cid :142)(cid:3) Buried penis: circumcision may lead to inflammation of unprotected glans. Procedure (cid:142)(cid:3) Local penile or caudal block is used as an adjunct to general anesthesia. (cid:142)(cid:3) Retract foreskin completely and separate all adhesions. Foreskin is held i n artery forceps (usually in dorsal/ventral midline) so that it can be symmetrically drawn distally \200\224good assistance essential for this. Care- fully judge amount of skin to be excised \200\224excision either by amputa- tion with foreskin cross-clamped distal to glan s tip or by scissor dissec- tion around glans. Trim mucosa to leave a 2 \200\2233mm cuff ar ound corona of glans. Identify all vessels (dorsal, lateral and ventral) by retracting skin to expose denuded penile shaft and control them by bipolar dia- thermy or fine (5/0 absorb able) ties. Carry out accurate skin to mucosa repair around corona using 5/0 or 6/0 absorba ble interrupted. Insert an \200\2308 \200\231 suture at the frenulum to secure the frenula r artery. CIRCUMCISION1 633 Postoperative Child best left without dressing to avoid trauma of removal. Apply ligno- cai ne gel (1%). Give regular baths after 24 hours which aids micturition and healing. Complications (cid:142)(cid:3) Bleeding \200\224reactionary and secondary can be profuse an d require transfusion/exploration (cid:142)(cid:3) Infection around suture line \200\224apply local antibiotic ointment (cid: 142)(cid:3) Urethral meatal stenosis \200\224especially if BXO present (1% hydrocorti- sone ointment) or baby still in nappies (ammoniacal dermatitis) (cid:142)(cid:3) Pain related to excessive skin removal (cid:142)(cid:3) Disturbance of sen sitivity of glans. CHAPTER 14 Pediatric surgery 634 Retraction of foreskin (adhesionolysis) Absence of true phimosis demonstrated by lifting fo reskin away from glans to demonstrate laxity of skin. Occasionally a foreskin may by par- t ially retractable but some adhesions may limit full retraction (usually dorsally). Procedure General and local or topical (EMLA cream) anesthesia. Develop subpreputial space by: (cid:142)(cid:3) Sweeping blunt probe around glans beneath foreskin. (cid:142)(cid:3) Separ ating foreskin from glans using dry swabs for traction on tissues until foreskin gradually fully retracted. (cid:142)(cid:3) Clean residual smegma with saline or chlorhexidine soaked swab to expose corona fully. Any persisting difficulty in retraction due to tight- ness of foreskin raises possibility of need for prepuceplasty. Apply Vaseline, 1% hydrocortisone ointment o r lignocaine gel (1%). Postoperative Frequent bathing and gentle retraction of foreskin to maintain retractibility . Complications (cid:142)(cid:3) Recurrent fusion (adhesion) of foreskin to glans (cid:142)(c id:3) Secondary phimosis due to scarring of stretched and traumatized foreskin (cid:142)(cid:3) Paraphimosis. This page intentionally left blank CHAPTER 14 Pediatric surgery 636 Prepuceplasty Commonly performed in place of circumcision. Allows widening and consequent r etractabilty of previously tight, phimotic foreskin. Not advis- able if significant banalit is or BXO present. Procedure (cid:142)(cid:3) Carry out dorsal penile or caudal block. Procedure performed und er general anesthesia. (cid:142)(cid:3) Retract foreskin if possible with separation of all adhesions. Identify th e site of tight constricting ring around penile shaft. Option 1 Perform a dorsal slit longitudinally through area of constricting band (about 1cm) . Achieve haemostasis with bipolar diathermy. Close transversely with 5/0 or 6/0 absorbable . Option 2 Draw foreskin distally over glans and two forceps applied to either side of dors al midline of foreskin. Apply straight forceps forcibly to crush dorsal midline foreskin lo ngitudinally to desired distance (about 1cm). Perform dorsal longitudinal incision of both layers of foreskin. If bleeding from dorsal vein, use bipolar diathermy or 5/0 ligature. Cl ose incision transversely (circumferentially) with 5/0 or 6/0 absorbable. (cid:142)(cid:3) Ensure foreskin retracts easily over glans at end of procedure. Postoperative As for circumcision. Complications (cid:142)(cid:3) Bleeding \200\224reactionary and secondary (cid:142)(cid:3) Recurrent preputial stenosis (phimosis) due to inadequate dorsal incision (cid:142)(cid:3) Unsatisfactory appearance of foreskin with small lateral dog-ears of excess skin. PREPUCEPLASTY1 637 Phimotic prepuce Dorsal midline prepuce incision Stay sutures to hold prepuce Skin to mucosa repair Fig. 14.15 Prepuceplasty CHAPTER 14 Pediatric surgery 638 Torsion of testis or appendix Presentation and anatomy Torsion of testis or testicular appe ndage (hydatid of Morgagni) are equally common \200\224occasionally the epididymis (or its appendage) torts. Peak ages for testis torsion are perinatally or in later childhood. Extra vaginal torsion (perinatal) involves the cord whereas intravaginal torsion (later childhoo d) involves the testis on long mesorchium (bell and clap- per anatomy). Onset characterized by abrupt and severe pain with testis in high position and excruciatingly tender. Torsion of hydatid may pro- duce precisely localized tenderness and hard pea-sized swelling at uppe r pole of testis \200\224blue tinge sometimes seen through skin. Prompt explora- tion is ne eded unless torsion can be excluded by positive evidence of epididymo-orchitis \200\224pyur ia or obvious primary infection (e.g. mumps). Torted hydatid may be treated non-operatively as infarction rapidly resolves although relief of pain may be quicker following excision. Preoperative Informed consent includes possibility of orchidectomy and fixation of contrala teral side. Incision Approach tunica vaginalis either by oblique incision in hemiscrotal skin crease or through midline scrotal raphe. Procedure (cid:142)(cid:3) Open tunica vaginalis to release haemorrhagic fluid and expose t estis. The anatomy of torsion defined by inspection of testis, hydatid and spermatic cord. (cid:142)(cid:3) Detort by twisting testis in appropriate direction \200\224usually towards midline septum. If perfusion recovers, color of testis will improve. If testis remains dark purple/black, incise tunica albuginea to further release constriction and tension. If ther e is significant recovery, fix testis at 3 or 4 points to tunica vaginalis using 3/0 absorb able. (cid:142)(cid:3) If no recovery of color, incise testis to assess perfusion \200\224if no u seful perfusion, excise testis with ligation of cord. (cid:142)(cid:3) Fixation of contralateral testis is mandatory if viability of index testis is in doubt or if anatomy is bell and clapper variety \200\224most surgeons rou- tinely fi x contralateral testis at same operation if torsion encountered. There is no indication for contralateral exploration in a torted hydatid. Closure Use 3/0 interrupted absorbable to scrotal skin. Complications (cid:142)(cid:3) Scrotal haematoma/abscess (cid:142)(cid:3) Atrophy of testis if established ischaemia (cid:142)(cid:3) Relative infertility (cid:142)(cid:3) Cosmetic i ssue about scrotal asymmetry \200\224Silastic prosthesis can be placed subsequently. Chapter 15 639 f15 Head and neck surgery A. J. Dickenson and B. S. Avery Tracheostomy 640 Thyroglossal cyst excision 644 Thyroidecto my 646 Parathyroidectomy 650 Submandibular gland excision 652 Sublingual gland excision 656 Parotidectomy 658 Neck lump biopsy 664 Neck dissection 666 External carotid artery ligatio n 670 Excision of branchial cyst, sinus, or fistula 672 Pharyngeal pouch excision 676 Tonsi llectomy 678 Adenoidectomy 682 Caldwell-Luc procedure 684 Access incisions to the facial sk eleton 686 CHAPTER 15 Head and neck surgery 640 Tracheostomy A tracheostomy is usually performed as an elective procedure under a general a nesthetic with an endotracheal tube in place. In patients with advanced cancers of the mout h, pharynx, or larynx, or severe infection such as Ludwig \200\231s angina, it may be neces sary to do the operation under local anesthetic. These are potentially very dangerous opera tions and should be performed by an experienced surgeon. In a life and death situation wher e the airway has been lost, no attempt should be made to perform a tracheostomy, but instea d a cricothyroidotomy should be performed. This account deals with the procedure of electiv e tracheostomy. Indications There are many reasons for performing an elective tracheostomy. (cid:142)(cid:3 ) Prior to major head and neck surgery, e.g. cancers of the mouth, pharynx or larynx, maxillofacial trauma. (cid:142)(cid:3) The management of acute respiratory problems, e.g. acute respiratory distress syndrome (ARDS). (cid:142)(cid:3) Patients with severe neurological problems, e.g. head or spinal injuries/bulbar palsy etc. (cid:142)(cid:3) Congenital disease in children, e.g. cardiac, lung or facial deformity problems. Equipment required Like any operation a tracheostomy can vary from being very easy to extre mely difficult and dangerous. (cid:142)(cid:3) Number 11 and 15 surgical blades. (cid:142)( cid:3) Bone cutters, monopolar and bipolar diathermy. (cid:142)(cid:3) Portex and/or Shiley disposable PVC tracheostomy tubes should be used. They should be cuffed and for a normal a dult size 8 \200\2239mm are appropriate. The cuff should be inflated and tested together wi th all the anesthetic tube connections. Position Supine with a sandbag under the shoulders and the head extended as far as possible . Mark the sternal notch and cricoid cartilage and use dispos- able sticky edged drapes to create a square around the operative area. Incision Make a 4cm transverse incision just below the level of the cricoid carti- lage (Fi g. 15.1). A longer incision may be advisable in a bull-necked indi- vidual and a vertical i ncision starting just below the cricoid cartilage may be useful to avoid entanglement with other procedures, such as a radical neck dissection. The area should be infiltrated with lo cal anesthetic and adrenaline, if safe to use, for the purpose of haemostasis. The incision will vary according to the circumstances. TRACHEOSTOMY1 641 Thyroid Sternomastoid Clavicle Incision Fig. 15.1 Tracheostomy incision CHAPTER 15 Head and neck surgery 642 Procedure (cid:142)(cid:3) Incise the skin and subcutaneous fat with a number 15 blade. Whi lst palpating the trachea, dissect vertically in the midline down to the thyroid isthmus. (cid:142)(cid:3) Retract the anterior jugular veins, which lie either side of the midline, sometimes they have to be divided. (cid:142)(cid:3) On reaching the thyroid isthmus diathermy it in the midline with uni- pola r diathermy and divide with a knife. Clean the trachea and keep the wound open with suitabl e Langenbeck retractors. (cid:142)(cid:3) Use a cricoid hook to pull the trachea upwards if there is not much space. Open it at the level of the 2nd and 3rd tracheal rings using a number 11 blade. In the eld erly the tracheal rings may be calcified and bone cutters are some times required. (cid:142)(cid:3) Either a hole can be cut in the trachea or make a flap attached inferiorly (Fig. 15.2). Ask the anesthetist to withdraw the endotracheal tube just beyond t he top of the hole in the trachea, and insert the tracheostomy tube. Inflate the cuff and a ttach the anesthetic tubes. (cid:142)(cid:3) Initially suture the tracheostomy tube flanges to the skin, and attach the tapes if appropriate. Postoperative care of the tracheostomy (cid:142)(cid:3) Apply suction under sterile conditi ons. This varies according to the amount of secretions produced. (cid:142)(cid:3) Ensure that inspired gasses are humidified. (cid:142)(cid:3) When room air is inspired, attach a humidifier to the tracheostomy tube. (cid:142)(cid:3) Change the tracheostomy tube if it becomes crusted and obstructed. Normall y by 4 \200\2235 days the tracheostome is well-established and it is then easy to remove an d replace the tube. Removal of the tracheostomy tube Deflation of the cuff may allow the patient to breathe pas t the tube. Alternatively the tracheostomy tube can be plugged and a fenestrated Shiley tub e can be used. At the time of tube removal the secretions should be sucked out first and th e tube removed. The neck wound should be covered with a hand held pack to make sure that th e patient is breathing comfortably in the normal way. An adhesive dressing is used to cover the tracheostome and the wound will close spontaneously over the next 1 \200\2232 weeks. Complications Intraoperative (cid:142)(cid:3) Intratracheal fire caused by ignition of oxyg en with diathermy. This is rare but well documented. The anesthetist should be asked to ins ert the endotracheal tube a long way into the trachea so that the cuff is below the larynx. Inflate the cuff with saline and not air. This will avoid puncture at the time of opening the trachea, and the cuff may protect the lungs from fire. A bowl of saline should be avail able to douse the flames. Ask the anesthetist to reduce the oxygen concentration when openi ng the trachea and avoid using diathermy at this stage if possible. TRACHEOSTOMY1 643 Postoperative (cid:142)(cid:3) Tube displacement or blockage. If this occurs the tube shoul d be replaced. Normally after 4 \200\2235 days replacement is straightforward. Before this time replacement may be more difficult and good lighting is needed. (cid:142)(cid:3) Bleeding from the soft tissues may occur postoperatively. Usually it stops but it may require a return to the operating theater for haemostasis. (cid:142)(cid:3) Chest infection. Where tracheostomy has been performed electively for surgery the risk of postoperative chest infection is increased. (cid:142)(cid:3) Infection around the tracheostomy tube. This sometimes occurs and is more likely when there has been extensive neck surgery, e.g. radical neck dissection. Appropriat e treatment of the infection whilst keeping the cuff inflated will resolve the problem. Late complications Sometimes the tracheostome does not fully heal and air and secretions ma y bubble onto the neck through a small fistula. Under a general anaes- thetic a fistula can be repaired by excising it down to the trachea and closing the soft tissues in layers. Cricoid cartilage (retracted) First tracheal ring Retracted strap muscles Platysma Cut edge of thyroid isthmus Tracheal window Fig. 15.2 Window created into the trachea for a tracheostomy tube CHAPTER 15 Head and neck surgery 644 Thyroglossal cyst excision Anatomy Embryologically, the thyroid gland arises at the foramen caecum at the base of the tongue and descends through the anterior neck into a normal pret racheal position. Remnants of the embryological duct can persist at any point along this pa th of descent, forming a smooth, round swelling. It is unusual for this to be functioning e ndocrine tissue. On the whole, the majority (>95%) are midline, 70% below the hyoid bone. C haracteristi- cally the lesion moves on swallowing or protruding the tongue. Indications (c id:142)(cid:3) Infection (5% of cases; the majority are symptomless) (cid:142)(cid:3) Fistu la formation (cid:142)(cid:3) Suspected malignant change. Equipment required (cid:142)(cid: 3) Number 10 and number 15 surgical blades (cid:142)(cid:3) Monopolar and bipolar diathermy (cid:142)(cid:3) Bone nibblers. Position Supine with a sandbag between the shoulders and h ead supported by a head ring. Procedure (Sistrunk \200\231s operation) (cid:142)(cid:3) Mak e a 35 \200\22345mm transverse skin crease incision over the cyst. The platysma is divided and deep cervical fascia incised vertically in the midline to exposing the cyst. (cid:142)(cid:3) Mobilize the sac and using gentle traction identify the pedicle passing up to the hyoid bone. During its embryological migration the thyroid tissue passes behind the posterior aspect of the hyoid bone. Resect the central portion of the hyoid to gain adequa te access to the remaining tract. This can be achieved with bone nibblers. (cid:142)(cid:3) If there is any remaining tract dissect it bluntly up to the base of the tongue. This can be assisted by a finger placed in the mouth to displace the tongue base in feriorly and anteriorly into the neck. Closure Close the wound in layers over a suction drain. Postoperative care The drain is retained until there is no further drainage. Complications Intraoperative (cid:142)(cid:3) Hemorrhage. Postoperative (cid:142)(cid:3) Ha ematoma (cid:142)(cid:3) Seroma (cid:142)(cid:3) Scar. This page intentionally left blank CHAPTER 15 Head and neck surgery 646 Thyroidectomy Indications Absolute (cid:142)(cid:3) Suspicion of malignant change (cid:142) (cid:3) Compression of the trachea by a benign lesion Relative (cid:142)(cid:3) Treatment o f thyrotoxicosis (cid:142)(cid:3) Unsightly goiter Choice of operation (cid:142)(cid:3) Thyroid nodule: thyroid lobectomy (cid:142)(cid:3) Thy roid cancer: total thyroidectomy (cid:142)(cid:3) Nodular colloid goiter (with hyperthyroid ism): subtotal thyroidectomy Preoperative preparation Investigations may include indirect l aryngoscopy, thyroid function tests, serum calcium, ECG, thyroid antibodies, fine-needle as piration, and ultra- sound to exclude malignancy. Patients with thyrotoxicosis need preop- erative preparation with carbimazole, iodine, or possibly beta blockade. Informed consent m ust be obtained beforehand, and in particular it should include advice on possible change i n voice and possible hyperthy- roidism or damage to the recurrent nerve. Position of patien t Supine with neck extended at 20 \200\22325 and the table foot down. Place the head o n a padded ring with a pillow or pad beneath the shoulders. Place packs on either side of t he neck. Use a double towel as a head set. Stand on the side opposite the lobe to be remove d. Incision (Fig. 15.3A) Look for skin creases. Mark the incision beforehand with ink or a 2/0 thread pressed on the skin. Make a transverse incision near to midway between the thyro id cartilage and manubrial notch, in a crease if possible. The incision should reach the st ernomastoid on each side. Procedure (cid:142)(cid:3) Use a no. 15 blade. Deepen the incisio n through fat, platysma, and cervical fascia to expose the strap muscles. Reflect skin flaps proximally and distally. Be gin with the knife and then use gauze dissection. Stop bleeding. Insert a Joll retractor. (cid:142)(cid:3) Divide the strap muscles in the midline (Fig. 15.3B). Apply gentle tractio n to rotate the inferior pole to the opposite side. Wipe away the fascia on its undersurfac e to identify the superior para- thyroid. Now pay attention to the recurrent laryngeal nerve and the inferior thyroid artery. Move th e assistant \200\231s retractor to exert a pull laterally. Apply a small swab to the gland and exert a medial pull with the left hand to expose the fascia overlying the inferior thyr oid artery, the recurrent THYROIDECTOMY1 647 (A) Position of patient Skin creases Thyroid gland (B) Strap muscles retracted or divided Fig. 15.3 Incision for thyroidectomy and division of strap muscles CHAPTER 15 Head and neck surgery 648 laryngeal nerve, and the inferior parathyroid (Fig. 15.4). Gently divide the fascia longitu dinally to identify the nerve close to the ligament of Berry. Do not disturb the inferior p arathyroid. Simply locate it. Ligate the artery in continuity and then the inferior thyroid veins. The lobe is now free and can be removed by dividing the isthmus, dissecting the gla nd off the trachea, and oversewing the isthmus with Vicryl. In a subtotal lobectomy the gland is not dissected off the trachea. Instead, several small haemostats are applied along the lateral aspect of the gland anterior to the recurrent nerv e and the tissue anterior to the forceps is excised. The remnant is oversewn with Vicryl if possible. Total thyroidectomy Total lobectomies are performed on each side with or without radical ne ck dissection. Further operative details are given in the chapter on endocrine surgery (Cha pter 5) Closure Close in layers. Bring suction drains (one on each side) through separate stab woun ds. Close the platysma with Vicryl and the skin with clips. Postoperative care 1. Check the vocal cords postoperatively. The anesthetist usually does this (but the appearance of the cords may be misleading). 2. Ensure an adequate airway. If haematoma develops open all the layers of the wound. 3. Remove drains on day 2. Check serum calcium daily. 4. Home on day 3 \200\2235. Surgical out-patients department and thyroid function tests after 6 weeks. Complications These can be early, intermediate, or late. Early (cid:142)(cid:3) Thyrotoxic storm is rare after thyroidectomy for thyrotoxicosis but needs treatment with antithyroid drugs and beta blockade. (cid:142)(cid:3) Bleeding may be reactionary within hours of the operation and requires urgent decompression. (cid:142)(cid:3) Tracheal collapse is usually recognized by the anesthetist and requires re-intubation. (cid:142)(cid:3) Paralysis of the recurrent nerves or superior laryngeal nerve damage usually presents as a voice change if not recognized early. Intermediate (cid:142)(cid:3) Wound infection and hypocalcaemic tetany which usually occurs within a week of surgery. Always check the serum calcium preoperatively before the patient goes home. Tetany is treated by intravenous infusion of calcium and then oral administrati on of vitamin D. Late (cid:142)(cid:3) Hypothyroidism \200\224confirmed by measuring thyroxine levels. (cid: 142)(cid:3) Hypertrophy of the scar. (cid:142)(cid:3) Keloid is rare except in the dark-ski nned races. THYROIDECTOMY1 649 Inferior thyroid vein ligated Ligament of Berry Recurrent laryngeal nerve Superior parathyroid Inferior parathyroid Inferior tyroid artery Fig. 15.4 Exposure of recurrent laryngeal nerve CHAPTER 15 Head and neck surgery 650 Parathyroidectomy Indications Parathyroid adenomas, carcinoma, secondary- or tertiary-hyper parathyroidism (all four glands). Preoperative preparations Frozen section facilities should be available. The laboratory sho uld be informed. Position of patient Supine with the head on a neck ring, the neck extended, and a 20 \200\22325 downward tilt. Incision and access The same approach as for subtotal thyroidectomy is used (p646). Procedure (cid:142)(cid:3) Mobilize the thyroid gland and retract its upper and lower lobes forward. Also asssess its areolar bed. The normal parathyroid glands are difficult to ident ify but lie posterior to each of the four poles of the thyroid. Each gland is yellowish and is flattened with a small vascular pedicle. (cid:142)(cid:3) If there is an adenoma carefully remove it. If the patient has secondary- or tertiary-hyperparathyroidism, remove all four glands. (cid:142)(cid:3) Apply tissue or dissecting forceps to the gland and dissect it free by a c ombination of sharp and blunt dissection. Diathermise bleeding vessels. If you are in doubt about the nature of the tissue send biopsies for frozen section. Sometimes an adenoma can be found in the mediastinal region or in relation to the superior or inferior thyroid arter ies. Closure Layers. Clips to skin. Suction drainage. Postoperative care (cid:142)(cid:3) Observe for signs of hypocalcaemia and haematoma. (cid: 142)(cid:3) Remove the drain at 2 \200\2233 days. (cid:142)(cid:3) Repeat serum calcium dai ly to observe the trend. (cid:142)(cid:3) Most patients can have their sutures removed on d ay 4 or 5 and go home. (cid:142)(cid:3) Arrange surgical out-patients department appointment in 6 \200\2238 weeks. Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Nerve injury (cid:142)(cid:3) Unilateral recurrent laryngeal nerve injury: hoarseness (cid:142)(cid:3) B ilateral recurrent laryngeal nerve injury: stridor (cid:142)(cid:3) Superior laryngeal nerv e: change in \200\230timbre \200\231 of voice (cid:142)(cid:3) Cervical sympathetic chain: Horner \200\231s syndrome This page intentionally left blank CHAPTER 15 Head and neck surgery 652