see also: Buccal Mucosa Graft for Urethral Reconstruction and Buccal mucosa and Masticator space anatomy

Example dictation:

After informed consent was reviewed, the patient was brought back to the operating room by Anesthesia and placed in the supine position following intubation with the tube off to the right corner of the mouth. Urology was present for positioning. A throat pack was placed with care to ensure the end of it extended outside the mouth adjacent the endotracheal tube.

Retraction on the left buccal surface was performed using Army-Navy retractors and the entire buccal surface was injected with 1% lidocaine with 1:100,000 epinephrine in the quantity of 10 mL. At this point, a silk suture was placed just adjacent to and inferior to the Stensen's duct. The duct orifice was positively identified via loupe magnification and expression of clear saliva on palpation of the parotid gland.

The head was prepped and draped after dilute Betadine solution was used intraorally and topically on the face. Exposure of the left buccal region improved by either a bite block or a Molt retractor.

A mucosal graft was then designed to lie below Stensen's duct and to span from the oral commissure back to the retromolar trigone with a healthy cuff of nearly 1.5 cm of gingival buccal sulcus preserved inferiorly. A 15-blade was used to incise sharply down through the mucosa and submucosa, but just superficial to the buccinator muscle. This graft was incised circumferentially in an ellipse and then starting anteriorly with a Cushing forceps for retraction. Trusler-Dean scissors were used for blunt and sharp dissection, focusing on leaving the buccinator muscle intact and down, and elevating a submucosal graft. This was carried out anteriorly to posterior and handed off to be kept on the back table for later preparation. Bipolar cautery was used to provide hemostasis in the muscle bed.

On the back table, the graft was thinned, starting first with Stevens scissors followed by meticulous thinning using a 15-blade. The buccal graft was rinsed in saline and then handed off to the Urology Team for reconstruction.

Attention was returned back to the muscle bed where closure was enacted employing alternating simple and vertical mattress 3-0 vicryl sutures. An initial simple 3-0 vicryl suture was placed at the wet oral commissure. Vertical mattress sutures were placed using 3-0 Vicryls with attention to obliterate any potential space by having the deep portion of the vertical mattress to include a bite of the buccinator at the midpoint of the defect. This closure was carried out in anterior-to-posterior fashion without cutting any of the sutures initially except the first simple oral commissure suture which was cut to decrease risk of tearing mucosa with the retraction on the uncut sutures providing improved access for placement of the deeper sutures. To place the posterior-most sutures without tension, the bite block or molt was removed for the final placement. After placement of the vertical mattress sutures, simple interrupted sutures were placed in between each of the vertical mattress sutures. Once the wound was closed, interrupted sutures just through the mucosal layer were placed, intervening the vertical mattress sutures. Care was taken in the vicinity of Stensen's duct and no sutures were placed in this vicinity, including no vertical mattress or deep sutures.

Alternative endings:

A. The size of the graft precluded full closure of the defect posteriorly warranting careful attention to hemostasis in the region left open to heal secondarily including application of tannic acid.

B. The wound came together.

Common ending: The suture marking Stensen's duct was removed, the throat pack was removed this portion of the procedure was ended and the patient was turned back over to Anesthesia from our standpoint. Urology continued their work.

References

Arlen AM, Powell CR, Hoffman HT, Kreder KJ. Buccal mucosal graft urethroplasty in the treatment of urethral strictures: experience using the two-surgeon technique. ScientificWorldJournal. 2010 Jan 8;10:74-9. doi: 10.1100/tsw.2010.16. PMID: 20062954; PMCID: PMC5763984.