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return to: Salivary Gland Surgery Protocols; Large parotid stone (sialolithiasis) with ductoplasty removed via transfacial approach case example; Sialolithiasis
Modified Operative Note (below photos): Combined open/endoscopic removal of right parotid stone
Procedure:
Sialodochoplasty (complex) with open approach to right parotid duct with stone removal and:
micro-ductal repair (8-0 nlone and 6-0 prolene) of Stensen's duct over 5 FR Cook Dilator
kenalog 10 (2.5 cc) instilled through catheter at end
Facial nerve dissection (buccal branches) and preservation
Right parotid sialendoscopy with initial effforts at laser vaporization converted to the above
Modified Operative Note: Combined open/endoscopic removal of right parotid stone
Procedure: Sialodochoplasty (complex) with open approach to right parotid duct with stone removal
micro-ductal repair (8-0 nlone and 6-0 prolene) of Stensen's duct over 5 FR Cook Dilator
kenalog 10 (2.5 cc) instilled through catheter at end
Facial nerve dissection (buccal branches) and preservation
Right parotid sialendoscopy with initial effforts at laser vaporization converted to the above
Preop Dx: Right parotid sialadenitis with sialolithiasis
Postop Dx: Same
Anesthesia: General OETT
Findings: Right parotid duct readily cannulated with 0.015 inch guidewire - over which the three smallest Marchal dilators were sequentially used to accommodate initially a 0.8 diagnostic Zenk scope and then 1.3 mm Marchal readily identifying stone but not able to advance 1.6 mm Zenk scope to the stone. Initial efforts to fragment the stone with drill and Holmium laser (through 1.3 mm Marchal scope) were unsuccessful in adequately fragmenting the stone - hence conversion to open as per above (see photos). Nerves stimulator used throughout to preserve nerve and at end to confirm integrity - upper segment of playtysma muscle partially transected to get access. Initial placement of 4 Fr Cook dilator successful in obtaining access to duct - with 5-0 French then used after stone removed (and after final sialendoscopy done to hilum with copious irrigation showing no residual stone. Laser energy: 0.3 Joules rate of 5 per second with 1.5 watts administered with total energy = 0.1 kilojoules
Procedure Details
After informed consent was reviewed, the patient was brought to the operating room. She was intubated by Anesthesia. The bed was rotated 180 degrees. The patient was prepped and draped in standard fashion including a throat pack, oral prep, and gel skin prep. A timeout was performed. The patient was correctly identified. The procedure began with sialoendoscopy of the right parotid duct. A 0.015 guidewire was placed, followed by Marchal dilator, followed by 0.8 mm diagnostic endoscope. The stone was encountered. The diagnostic scope was removed and a 1.3 mm scope was placed with the working channel. The drill attachment was used to drill the stone to no avail. The laser was used in an attempt to break down the stone and this was also unsuccessful. At this time, the decision was made to change to an open approach. The scope was removed and a 4 Fr Cook dilator was left in place, and then attention was turned to the facial incision, which had been injected with plain epinephrine 1:100,000 prior to the procedure. A modified Blair incision was made with a 15 blade. Dissection was carried down to the parotid fascia and using a Shaw scalpel, this plane was elevated anteriorly until we were anterior to the stone, which was palpable. The buccal branch of the facial nerve was identified and preserved. The parotid duct immediately adjacent the buccal branch of the facial nerve was identified. The microscope was brought in and an incision in the duct was made with a 15 blade. A large stone was mobilized and removed. Next, sialoendoscopy was repeated (transoral) and irrigation was noted to be flushed out of the duct from within the mouth and no additional stones were encountered. The sialendoscope was advanced beyond the site of the stone to a normal hilum with no further stone remnants identified. A 5 Fr Cook salivary dilator was placed transorally past the opening in the duct over which a ductoplasty was performed using microvascular instrumentation and an 8-0 nylon suture with care to avoid transgression of ductal lumen in performing the closure. A second layer of 6-0 Prolene suture was then completed. Kenalog 10 was instilled through the 5 Fr. Cook dilator which had been placed in the mouth with a small leak was noted and an additional 6-0 Prolene suture was placed. An additional milliliter of Kenalog was injected to a total of about 2.5 mL. Next, the incision was closed in 2 layers with 3-0 Vicryl suture, followed by 5-0 nylon suture after a Penrose drain was placed and hemostasis was confirmed after a Valsalva was performed. The patient was turned back to Anesthesia and brought to the PACU in good condition. She had intact facial nerve movement as noted in the Postoperative Care area.