Excision of branchial cyst / sinus

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding and neck haematoma
• wound infection
• recurrence if part of the cyst wall or tract is left
• injury to the marginal mandibular branch of the facial nerve (lower lip weakness)
• injury to the hypoglossal nerve (tongue weakness)
• injury to the spinal accessory nerve or internal jugular vein
• a second incision higher in the neck for a long tract
• neck scar

Pre-operative details for this operation

1. Lesion type and sideCystSinusFistularight / left; for a sinus, site of external opening along anterior border of sternomastoid
2. Clinical featuressize, site in relation to sternomastoid, pulsatility, discharge
3. Infection historyNever infectedInfected, treated with antibiotics, now quietPrevious incision and drainage
4. ImagingUltrasoundCTMRIsize, relation to carotid and internal jugular vein; barium swallow if third or fourth arch anomaly suspected
5. FNAC / exclusion of malignancyresult; in older adults with a solid or cystic lateral mass, record whether upper aerodigestive tract was examined for a primary

Anaesthesia and position

1. AnaesthesiaGeneral, orotracheal tube led out of the corner of the mouth opposite the lesion
2. PositionSupine, shoulder sandbag, head ring, face turned to opposite side
3. Local infiltration with adrenalineNot usedUseddrug, adrenaline strength, volume

Operative findings

1. Cyst / tractsize, wall, contents (for example straw-coloured or turbid fluid), adhesions
2. Relation to great vesselslies on carotid sheath / adherent to internal jugular vein / extends between internal and external carotid
3. TractNo tractTract ending blindlyTract to pharynx (fistula)course and upper limit
4. Nerves seen and preservedhypoglossal, marginal mandibular, spinal accessory, greater auricular

Procedure (steps)

1. Skin preparation and draping
2. Skin incisionTransverse skin-crease incision over the cystTransverse ellipse around external opening of sinuslevel and length in cm
3. Platysma divided and flaps raisedupper flap kept limited to protect the marginal mandibular nerve
4. External jugular veinPreservedLigated and divided
5. Fascia opened at anterior border of sternomastoid, muscle retracted back
6. Cyst or tract dissected close to its wallfreed from facial vein, carotid sheath and internal jugular vein; posterior belly of digastric retracted; hypoglossal nerve identified
7. Second (stepladder) incisionNot neededMade at level of hyoid, skin bridge raised
8. Upper end of tractEnded blindly, ligated and dividedFollowed between carotids to pharynx, excised, pharyngeal mucosa closed in two layerssuture used
9. Specimen removed intactIntactRuptured during dissection
10. Haemostasispharyngeal veins ligated, bipolar

Closure, drains and dressing

1. DrainSuction drain through posterior stabNonesize
2. Platysma / subcutaneous layerabsorbable suture, size
3. SkinSubcuticularInterruptedStaplesmaterial and size
4. Dressing

Specimens and implants

1. Cyst / sinus tract with skin ellipse, sent for HPEmark upper end of tract with a stitch
2. Cyst fluidNot sentSent for cultureSent for cytology

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Neck and airway watchswelling under the wound, difficulty breathing; inform surgeon at once
2. Drainchart output; removal plan
3. Nerve check on the wardlower lip symmetry, tongue protrusion, shoulder shrug; record findings
4. Oral intakesips when awake; if pharynx was opened, write when feeds may start
5. Analgesiadrug, dose, frequency
6. Antibioticsonly if pharynx was opened or cyst was infected; drug and duration
7. Wound care and suture removalday
8. Follow-upHPE report; check for recurrence

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery