Excision of submandibular gland

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

• weakness of the lower lip on that side (marginal mandibular nerve), usually temporary
• numbness of the side of the tongue (lingual nerve)
• weakness of the tongue (hypoglossal nerve)
• bleeding and haematoma, which can swell the airway and need return to theatre
• wound infection
• saliva collection (sialocele) or fistula
• visible or thick scar
• stone left in the duct in the floor of the mouth, needing a further procedure

Pre-operative details for this operation

1. SideRightLeftmarked
2. IndicationRecurrent sialadenitis not settling with conservative treatmentStone in the gland or hilumFailed sialendoscopySuspected tumourPart of level I neck dissection
3. Ultrasoundsize, stones (size and site), duct dilatation, mass
4. FNACresult, CT or MRI if malignancy suspected
5. Acute infection settledYesNo: antibiotics given first
6. Lower lip movement and tongue movement before surgeryNormalfor comparison after surgery

Anaesthesia and position

1. AnaesthesiaGeneralLocalanaesthetist asked to avoid further muscle relaxant if nerve monitoring is used
2. PositionSupine, neck extended, head turned to opposite side
3. Nerve monitoringUsedNot used: lower lip kept in view under the drapes
4. Local infiltrationadrenaline 1:200,000 in saline along the incision, volume

Operative findings

1. Glandsize, consistency (firm, fibrosed), adhesions from past infection
2. Stonenumber, size, site (gland, hilum, duct), all removed with the specimen or not
3. Marginal mandibular nerveIdentified and preservedNot seen, dissection kept on the gland capsule
4. Lingual and hypoglossal nervesBoth identified and preserved
5. Mass / lymph nodesif present: size, frozen section result

Procedure (steps)

1. Incisionskin crease about two fingerbreadths below the lower border of the mandible, length
2. Subplatysmal flapsupper flap to lower border of the mandible
3. Marginal mandibular nerve protectedNerve identified where it crosses the facial vesselsFascia opened low on the gland and dissection kept on the capsule
4. Facial vein and branches of the facial artery to the glandligated close to the gland, double ligature or suture ligation
5. Gland separated from anterior belly of digastric and mylohyoidfree border of mylohyoid retracted forwards
6. Lingual nerve identified, submandibular ganglion branch dividednerve allowed to go up out of the field
7. Wharton's duct ligated and dividedas far forward as possible, stone position checked
8. Hypoglossal nerve identifiedon hyoglossus, above digastric tendon, in the bed of the gland
9. Facial artery at posterior belly of digastricLigated and dividedPreserved
10. Gland freed from digastric and removed
11. Haemostasisbipolar near nerves, Valsalva if asked of anaesthetist

Closure, drains and dressing

1. DrainSuction drainsize and exit site
2. Platysma and subcutaneous tissuee.g. polyglactin 910 (Vicryl) 3-0
3. Skine.g. intracutaneous polyamide (nylon) 5-0
4. Lower lip and tongue movement after reversalas seen in recovery

Specimens and implants

1. Submandibular gland for HPEside, size, with duct end marked if needed
2. StoneWith specimenSent separatelyGiven to patient
3. Frozen sectionNot doneDone (result)

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 swelling and breathingcheck hourly, inform at once if the neck swells or breathing is difficult
2. Suction drainkeep at least 36 hours, remove when under 30 ml in 24 hours
3. Antibioticsonly if findings need them (drug, dose, days)
4. Analgesiadrug, dose, frequency
5. Dietliquids when awake, then soft diet
6. Lower lip and tonguerecord movement on POD 1
7. Suturesremove on POD 7
8. Follow-upwith HPE report

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