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Dense Submandibular Stone Unable to Adequately Fragment with Laser

last modified on: Fri, 09/08/2017 - 11:48

Dense Submandibular Stone Unable to Adequately Fragment with Laser

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Modified Operative Note:

Informed consent was reviewed with the patient, and the patient was brought back to the main operating room and laid supine on the operating table. Pre induction time out was completed. General anesthesia was induced and the patient was orally intubated by our Anesthesia colleagues without difficulty. The bed was rotated 180 degrees from Anesthesia. A multidisciplinary time-out was performed. A throat pack was placed and the oral cavity was prepped with dilute Betadine and the face and neck and endotracheal tube prepped with betadine and draped in routine sterile fashion.

 

The operating microscope was used to examine the right submandibular duct. Using a Rosen needle, the duct was gently dilated and a 0.015 guidewire was inserted atraumatically into the right submandibular papilla and advanced. Marchal dilators were advanced over the guidewire to provide additional dilation. The Kolenda 5-French salivary access dilator was then advanced over the guidewire. Diagnostic 0.8 sialoendoscope was then inserted through the Kolenda access dilator to examine the duct. A stone was identified at the hilum that was large and attempts to extract the stone endoscopically were performed as discussed in pre operative consultation with the patient. A 1.3 and 1.6 sialendoscope were also used.

 

We used the holmium laser at a setting initially at 0.3 joules; however, this was increased to 0.5 joules at a rate of 5 pulses per second.  Power 1.5 -2.5 watts. All laser precautions were used.  Attempts for laser fragmentation were performed. We did release several small fragments, which were then removed using a combination of irrigation and endoscopic forceps. Additional attempts to marsupialize the stone with the endoscopic forceps were performed.  The stone was firm. We did progress towards near fracture with the use of the holmium laser; however, we were unable to fracture to a significant size that we could actually extract it. Additional attempts with using an endoscopic basket were then performed. This did remove small fragments of debris; however, we were not able to mobilize the stone adequately via this approach despite 2 hours of endoscopic work.

 

We therefore proceded with submandibular gland excision. This progression aligned with the patient's preferences preoperatively that after significant attempts endoscopically that we would proceed with an open submandibular gland resection.

 

The Kolenda salivary access dilator was left in place during submandibular gland excision to permit evaluation of the duct remnant with the sialendoscope at the termination of the procedure.

 

We injected 1:100,000 epinephrine into right neck crease that was about 2 fingerbreadths below the angle of the jaw. Using a #15 blade, we made our incision and incised through the platysma. The Parsons McCabe facial stimulator was used to confirm the superior elevation of the marginal mandibular branch of the facial nerve. Using blunt dissection with hemostats, we identified the inferior border of the right submandibular gland. We performed the 'shell out' technique to remove the submandibular gland, dissecting directly on the gland. We did this with a combination of hemostats, Stevens', and bipolar cautery. We identified the facial vessels lateral to the gland and ligated them with 3-0 silk ties. We identified the mylohyoid muscle and retracted this cranially. We identified the lingual nerve and preserved it. We identified the submandibular duct with large stone at the hilum. We put 2 Hemoclips on the submandibular ganglion and additionally 2 Hemoclips on the submandibular duct. Prior to placing Hemoclips on the duct, we used 3-0 Vicryl sutures at the duct to allow stenting. We then cut the submandibular duct and removed the gland and duct and passed off for pathology.

 

Prior to clipping the submandibular duct, we reintroduced the 1.6 sialendoscope into the Kolenda salivary access dilator to ensure that all stone and fragments were removed from the remaining duct. The duct was flushed completely and examination of the duct revealed no residual stones. Two Hemoclips were placed on the duct where it goes under the lingual nerve. The wound was irrigated with sterile saline. Hemostasis was achieved with bipolar cautery.

 

A quarter-inch Penrose drain was placed into the wound and secured with a 3-0 nylon. The platysma was closed with 3-0 Vicryl interrupted sutures. Approximation of the deep dermis was performed with interrupted 4-0 Monocryl. The skin edges were approximated with a running 5-0 nylon suture. Bacitracin was applied, followed by fluffs and burn netting. The Kolenda salivary access dilator was removed. The oral cavity was suctioned from final irrigations and debris. The throat pack was removed. The patient was turned back to Anesthesia for emergence and extubation and escorted to the Postoperative Care Unit in stable condition.

Laser, total energy used : 1.28 kJ.