Partial Glossectomy

CHAPTER 1

Do we want to intro our patient here?This may be too big.Do you think a molt would help us out first?No, it’s okay. I think we are good, right there.Okay, can I see...Can I have something to point with please?All right, so you can -this is actually where I took the biopsy from. Before Itook the biopsy, it was perfectly round like that,and the interesting thing aboutit is that you can see it's actually quite well encapsulated.It's not -and it wasn't actually ulcerated. So it was just -I actually was notexpecting the diagnosis of metastatic breast cancer.I was actually thinking it was somethinglike a leiomyoma or potentially asmall salivary gland tumor that - I was actually expectingsomething more benign just because of its appearance,but it doesn't have the typical appearanceof Swain. And it really actually was not painful for her.It - it interfered withher eating a little bit and with herarticulation and a little bit, you know, of somepain when you just directly touched it,but in general, it wasn't hurting her.So - can I see DeBakey's please?I was hoping for something benign, and then it cameback as metastatic breast cancer which was...How much of a margin do you want to getaround this? I think we can get a centimeter. We need to…

CHAPTER 2

Can I - actually, can I see measuring tape real quick?Let’s get some dimensions on this.And then you can see,she's already had a good blanche of her tonguefrom where I did the local.A centimeter and a half,and if we are counting where you biopsied,I think about a centimeter and a half all the way around.Yep. And so -So you wantto get centimeter margins? Yeah, I think we need tobecause I'm - I just don't want this to come back. Okay.I'm - I'm going to justkind of touch in a couple places to give myself a…Can I have a Army-Navy please?I think that's a little close here. Yeah, that's better.Much better. Yeah.Go right above the teeth, yeah. Good.All right, go for it now.

We just start here and work our way around.And then where’s that Army-Navy?Can one of you get the smoke, please?Just suck the smoke.Why don't you use - yeah, or just use the towel clamp.This one’s much nicer than that other one.Here’s one.Can I have a rat's tooth? And then here let - now I can pickit up for you. No, you have to hold the smoke.No - you have to hold the suction. No, no, not - not you,them. One of the two of them canhold the suction. Can one of you guys hold the suction?And you have a rat’s tooth? Okay.It doesn’t look like it extends deeply, does it? It does not.It doesn't feel like it.I think that’s good. I don’t think youwant to go anymore superficial than that though. Okay.And then, watch it. Here’s - here’s yourincision on the other side.Can we make the room cooler, please?Suction, there.Do you have a bipolar?Who has the pedal?And you don't need to go any deeper than thatcuz if you look a centimeter - yes, just stay... A centimeter deep?Yeah, this way, toward me a little bit.You can take the suction from me, please.Thank you.Are you pinning this?Pinning it? Uh, no.Bipolar.Suction.Okay.Will you hold her lower lip out?I don't want her to get burned.There we go.And I just confirm that we're not undercutting on this side.Do you have a 3-0 or 4-0 silk I can use for marking?I have a 2-0...That's fine.

So the name of this specimenis leftlateral tonguestitch anterior.Left lateral tongue, stitch anterior. Yes.Is that for frozen?No, it’s for permanent. Permanent.Do you want to take frozen margins?I do want to take frozen margins. Okay, can I seeDeBakey’s please?Do you just want me to do four quadrants? Yes.And then can I have some Stevens, please?Thank you.Can you cut this, please?No - down here is fine. Right here?Uh, underneath.Yep.

CHAPTER 3

The first frozen -The first frozen section marginis going to be anterior dorsal.Yes, ma’am. Yes, this is all left lateral tongue.Let me get her lip out of the way. Yeah, thank you.Can I take this? Yes.Anterior dorsal tongue, left, for frozen.Here's the specimen.And then,can we get a little rinse, please, on the instruments?Just some saline or something.Is that frozen or research?No. These are for frozen section.These are frozen sections. You'll need tocall the research people to comeand get whatever they need to from themain specimen. That's usually how they do it.Here's a pair of pickups with teeth. Thank you.Melissa, the next -the next specimen is gonna be posterior dorsal.Posterior dorsal.Just make sure I don’t have too much char in there.That’s part of it.Just, if you want -take - just call the next one - no,call the next one just posterior. And we'll gofrom like there to there? Yeah, because we've alreadydone - we - so that way you get the proportion the same.Okay. This next one is going to beleft lateral tongue, posterior.Get a little rinse on your pickups and instruments.Rinse.So we do that to make sure that anypotential malignant cells aren’t contaminatingour other specimens.I'm sorry Melissa - what did you say?So I have posterior dorsal, left tongue,then left lateral tongue, posterior.Correct. These - this is all left lateral tongue,right? Because that’s the name of the -that’s the name of the specimen. And thenwe have anterior dorsal, posterior dorsal, posterior.The next one is going to be ventral anterior,and then ventral posterior.That’s the rest of the posterior specimen.Posterior. Correct.Yeah. And then I’ll take a rinse, please.And then we have twomore. We’ll have ventral anterior and ventral posterior.Okay.I'm going to take the anterior first then? Yes.About right there. Yep, that’s good.This is the ventral anterior specimen.And then a rinse.And then the last one - ventral posterior.Again, all of them left lateral tongueand then just the names of the individual margins.There to there.Okay. Posterior. This is the ventral posterior.And then I will see the bipolar, please.Suction.Watch her lip.

CHAPTER 4

Do you want to close with Vicryls or chromics?Oh, I think Vicryl is good because it’s a decent size.Just I - I might just do some horizontal mattress sutures justfor tensile strength.Do you think that’s ok? Yeah,but that’s why I want to use the Vicrylrather than the chromic just becauseit’s one thing to do it on the...Mucosa. On the mucosa,on something that doesn’t move as much,but your tongue movesall the time when you speak and when you’re eating.And so if you wantthe wound to stay closed,you really need to use something like Vicryl.Because unless it’s a very small biopsy,I think the chances are much higherthat things will open upif you just use chromic rather than Vicryl.We can go ahead and close while we’re waiting on frozens?Yes. Can we have the Vicryl,please? Do you have a 3-0 Vicryl?Do you have it on a taper needle?

CHAPTER 5

And can I have a pair of DeBakey’s, please?Oh hang on, I’m going to use something else.Can I have the Army-Navy again, please?Hang on - you want to travel a little more. Yeah that’s it.Thanks.There you go.I’ll come back and get that front part.Scissors, please.Why don’t you start up top?It might actually make it easier. You can just backhand it.That way you can sew with the knot on top.Okay. And I think it’ll beeasier for you. Sounds good.And plus I'm thinking, with the knot on top, shedoesn’t have any teeth. It won’t bother her as much.Yeah, whereas here it mightget involved in the teeth.Very considerate, Dr. Puscas. Or get caught in between.Well I also don’t want her complaining, “take these out,”before she's healed.You know, people just tend to play with them allthe time when they're in their mouth.Now, if we had to do some,you know, very large cancer resection, it wouldnot be worth it. But this is... This is pretty low morbidity.Yeah, she should heal quickly, and this will help herfeel better. Especially when you get primaryclosure on something like this, the painafterwards isn’t as much as leaving like an open, granulatingwound.Yes - yes, we - cuz it was -it was nice and superficial, so we didn’t haveto worry about cranial nerve 12 and injuring that.This lady has a history ofmetaplastic breast cancer,and it has metastasized to her tongue. So these arejust margins. We want to make sure we got it all.I think we did.Now, Priya, could she pop up with another lesionin 3 months? Yes.And I think at that point, that's a different conversation.Can I see another Vicryl, please?You don’t want me to -do you want me to run anything on the surface at theend or do you just want to leave it like this - kinda everted?I think this will be fine. Okay.I think you need two more. Yep.And then the one up front.It’s just the history of it cuz the oncologist is the one whotold me. She said that metaplastic breastcancer just doesn't respond very well. Here, let me hold this.Yeah, that actually can be more advantageous.This was a - this is a first for me. I've taken care ofpatients with renal cell cancer that has metastasized to thetongue but not breast cancer.I noticed in the literature that this was actually more commonthan I was expecting it. Yes, although I - me too.Still uncommon but more - more than I expected.Quite embedded in there.I’ll hang out and wait on the frozens.Can we have some irrigation, please?It’s protected. Thank you.Then can we get some marcaine, please?

CHAPTER 6

You just kind of go in and inject along the way backfrom each side? Yep, all the way around, yep.We’re now injecting quarter percent marcaine plain forpostoperative analgesia. The marcaine has amuch longer half-life than the lidocaine, and sopatients will often do well theday of surgery if you use somethinglong-acting like marcaine. It works very wellfor patients who’ve just undergone any kind oforal or oropharyngeal procedures such astonsillectomy.Maybe a little in the back there.Okay. Okay.I used five.All right, her tongue is a little swollen -I think from the marcaine and from thelidocaine that we gave her. Yeah, she gotDecadron preoperatively. Yeah, so should be okay.And now what we cando is get her to sit up and that may also help with the...We can lower the bed and then put her in somereverse Trendelenburg. That would be great.And then do we also have some... Give it justa second in case we need to get more from somewhere.And then do we have some bacitracin, please?