Subtotal Parotidectomy and Unilateral Lateral Neck Dissection (Levels II, III, and IV) for Right Parotid Mucoepidermoid Carcinoma Involving the Deep and Superficial Lobes and Extending into Parapharyngeal Space

CHAPTER 1

I am Dr. Guy Slonimsky. I'm one of the head and neck surgeons at the Hershey Medical Center Otolaryngology Department. I'm Assistant Professor. I've been doing this for over seven years. Today's case was a very interesting one. We had a young lady with a parotid mucoepidermoid carcinoma which was involving the deep and the superficial lobe and going actually into the parapharyngeal space on the right side. She had a lot of pain and progression of the lesion over just a few months. This is why we also planned for her to have besides the parotidectomy also a neck dissection on that side and we also have our recon team available to perform an ALT flap to cover the defect. There are two parts. The first part is removing the parotid tumor while preserving the facial nerve. Because this tumor involves the deep lobe of the parotid, the plan is not for only superficial parotidectomy but to a subtotal or even total parotidectomy as we will remove most of her gland while preserving the facial nerve and we have the nerve monitoring team with electrodes over the facial nerve branches. The second part involves the neck dissection on the same side of the tumor along the lateral neck with removal of the lymphatic tissue while preserving all the neurovascular structures: the carotid, the internal jugular vein, and the cranial nerves along the lateral neck. Specifically for that tumor there is as I mentioned extension into the parapharyngeal space. The tumor is reaching the great vessels and also infiltrating the SCM and the digastric muscles. So, we also anticipate that part of these muscles will have to be removed in order to allow us to resect the lesion with adequate margins. This tumor involves the deep and superficial lobe of the parotid gland, so I anticipate significant difficulty with tracing the facial nerve and dissecting it free from the tumor. There is a possibility that the nerve will be encased by the tumor and also the skin overlying her parotid gland is very thin so there's a chance that we'll need to take some of the skin along as surgical margin to get it away from the cancer. Also as I mentioned, this extends beyond the angle of the mandible into the parapharyngeal space so we'll have to release that also from the neck and usually when you do that you get quite close to the great vessels and the hypoglossal nerve, the spinal accessory nerve, and it takes a different approach to a standard parotidectomy when you mainly go for the main trunk of the nerve start dissecting the parotid off. Most of the tumors are in the superficial lobe so basically when you peel the gland off the nerve with the tumor you're done with most of what you need to do. However, here this is a very large tumor involving most of her gland, so I anticipate challenges there from that perspective.

CHAPTER 2

Here we see the scans of the patient. A young lady with a right-sided parotid tumor. The left side of the screen is the right side of the patient. This is a low-grade mucoepidermoid carcinoma of the parotid gland and I'll start scrolling down. These are the axial slices here. You can see here the jaw, the mandible, and we start scrolling down and you can see that the entire part of the gland is involved with the tumor here. It goes down into the deep, the deep space of the great vessels compressing the internal jugular vein, sliding into the neck below the angle of the mandible. And this is the neck. There are no positive nodes in the neck; however, we'll do an elective neck dissection due to the size of the tumor and the possibility that it has high-grade component. So, this is the coronal view as if the patient is looking in the mirror. You can see as the earlobe starts to come into view and this is the mastoid bone, you can see the tumor comes into view. This is the sternocleidomastoid muscle. The tumor abuts the muscle compressing the great vessels of the neck, here. And here the mandible comes into view. This the area of the angle. The tumor is not seen anymore. This is the masseter muscle here. That's it.

CHAPTER 3

So, this is the planned incision. Modified Blair incision extending into the neck for the neck dissection. Going anterior to the ear canal around the lobule, over the mass, sliding down to the neck and we put it on an existing skin crease for cosmetic reasons, and when Dr. Bavir will join us, we'll start incising the skin and elevating the flaps.

CHAPTER 4

Incision. And try to pull that part of the skin away also. So, we open the fascia down to the fat. Sub-Q fat. Remember we talked about the platysma last time? Yes. All right. Okay, pull that skin. Now I'm going to connect the incision. We want to start over here. Pull that. Pull that piece of skin. Okay. Knife back to you. I'll take the knife back. Pull that your direction. See some more fascia that we can open. Have you seen parotidectomies before? I have not. So, extending the incision into the sub-Q fat to the level of this mass and the platysma and I think here you can see this white fascia there, this is the capsule of the parotid gland. It's a very thin layer, and it's important not to go through it because you want to elevate the flap off the parotid and not within the parotid.

CHAPTER 5

Bovie, please. Hold that skin a little bit apart. I'll just do a little bit of coagulation before we deepen our incision through the platysma. Remember we discussed presence of the platysma in the central neck and the posterolateral neck where the platysma is not present... Right. In these locations. All right. Double prongs. Give me a smooth Geralds, please, and a Burlisher. So, we're pulling the earlobe back to get it out of the field and to open the surgical space. Rich, I'm moving ahead really slowly. Sounds good. A knife, please. So, I'm trying to find the capsule of the parotid along my entire incision over the parotid gland to be able to elevate the flap off the parotid capsule. Once Dr. Bavir will join us he will take over. Okay, pull more superiorly, pull up. I'll show you where we are. Try to feel for a little bit. Here I did not go down to platys yet. I did not go down to platys here. You know that I usually like to find the capsule first. So, I think it's a little bit, tumor. I just opened the skin from just below so... What we'll need to do, we'll need to find our plane here and worse case you know we'll excise this, can I have a marker? Just mark beforehand what was above tumor in case we need to take it out after. So here and I think here. This will get us covered from that perspective. I don't think it will extend all the way here. So, here I started finding the capsule. I think it's that white layer there, you see? Yep. That part here. So, you know what to do, go from here known to unknown. Yep. This is really close to the skin, so... I think the skin we'll take as I'm marching. I would go from, this is where you already know where you are. You see, it's like, this is like between tumor. No, no, give it to me for a second. Yep. Sorry. You see where you have the silvery fascia here? Yeah, yeah. So, go from here. This will lead you better to where you need to go. And I'll just extend it superiorly and inferiorly. See the window open there? That corner? Point a little bit more towards the skin. You don't want to go into tumor. Nice. And remember... Can I get number 15? Yeah, exactly, blade. Cut close to the skin so you leave more tissue on the tumor side. Now, if you need me to help you with any instruments, let me know. I'm just trying... Nice, I think it's a good plane, right? I think so, I think just might be a little... Let me just, maybe, maybe I'll move her here for... And I'll tend the skin for you. Don't go too deep. Go to that window. This is a good window. Careful there. You might, 'cause what happens if you stretch that fascia you can tear it as well, right? This may be a little bit too deep. Come onto this for a second. Let me see this for a second. So, I suspect this might be in parotid 'cause there shouldn't be any muscle, right? So, you see this is, you went into the gland a little bit here. Yeah. Pull - I brought you back to the silvery fascia. Yeah. This is too pink, right? Don't wanna be there. Okay. Pull this up as well, thank you. So, we're continuing with the elevation of the flap. We're really careful because there is a tumor in that gland and we are careful not to go into tumor. There is part of the tumor which is already exposed and if we see that it is too close to the skin we will probably have to take some skin with us and it's perfectly fine 'cause we are going to reconstruct this with a free flap. Now, if you feel you are in good plane you can also take the blade. Yeah, the blade is... What about here? It looks almost fatty. Hold this and try to point it towards the ceiling, okay? Give me a Burlisher, please. This is the fascia, see? This. Here it's a little bit open so you need to stay on that. Through this here. Yeah. Yeah, so let's see how we can bring ourself back. Maybe curve this a little bit towards you. Yep. Now, there is a chance that when we are over tumor it might look a bit different, right? Yeah and it might be a little bit more... Feel like we should try to patch up over the mass, or maybe raise up inferiorly here and then the last thing can be connecting those two tunnels. I'm trying like the most here. Yeah. Here, so here you see, look at that small window. Yeah. I see fascia of the gland back there. Yeah. Pull up, please. Pull up on this? Hold this, take this away from me. Close to, yeah to the instrument. Yeah. In between, in between the legs of the instrument. I think we're kinda working in a hole, do you wanna... I see, I see parotid fascia deep on my end. Okay. There. Can I have the bipolar? And don't forget we have a flap. We have a lot of skin. So, I think here, you see this is fascia here. Yeah. Can I have the knife back, please? We left a little bit of tissue over it. Yeah. And it's fine. It's better getting away from the tumor not going in it. Mm hm, beautiful. Nice, nice, keep working with the blade. Perfect, you might need to put her there with this guy. Yeah. Another vessel. Can I get another 15, please? You want a fresh one? Yeah. Here, you see? This looks okay. So open a couple of windows. One, two, three. Yeah, three, I see, yeah. Try to go through that fascia. You were like going a little bit parallel. It gives away, right? So that's not... Yeah, there. This where we're still going to the tail, right? So, it's gonna be blurry. See, this is the fascia. Actually it's like elevated a little bit in the flap, you see? So, I'm bringing it back down. Yeah. Yeah. Okay, now... A little, got in a little area of this. Yeah, now we might be going in within fascia, right? Like parallel with it so we'll have to at some point go through it. Yeah. Beautiful. Try to tilt your, make your blade perpendicular to what you cut. I know you're like trying to... Yeah, so I had seen... I just, because I opened the window for you anyway, so I showed you what to go through. I mean, you're thinking one thing, I'm thinking another thing. Yes, yeah, yeah, yeah, we're just trying to both... SCM, you see it here? Nice. Beautiful. So you're doing great, you don't have to tell me nice, it's you. Yeah, through, okay. Okay. That's great auric. Yeah, so let's try and keep it down. Keep it down, trying to... Okay, this is like, you might come back in just open here a bit later. There's still benefit of keeping at least a long remnant of it in case it will sprout back and... Yeah, here do you wanna... There might be a small branch also climbing here. Climbing there. Yeah. Not so concerned about it, right? Now, I marked the EJ, okay? Yeah, EJ's up here, yeah. All right. Do we wanna try to do a nice broad move here now? Since we... Mm hm, yeah, yeah, yeah. Go ahead and raise the entire flap. EJ is down there. Yeah, you might have a small branch of the greater auric. Yeah. I don't think it's salvageable anyway so continue with the elevation of the flap into the neck, and Rich here is at some point gonna find the, what is he gonna find when he cuts here? Which muscle? Platysma? Platysma, perfect. Now, don't forget you wanna go through platys like in the midline of your incision and I think the vein, you can start seeing the vein. Yeah, right there. Here. Or not. Might be on the platys, right? Yeah. Most probably on the platys. Perfect. I like the work with the blade. Here. Here it is. Perfect. Very delicate. Perfect. Right on this muscle fiber here or it's tiny vein. Now, what you can do, you can follow the vein here a little bit the vein and the nerve. And try to pull all of it more like that. Yeah, now what I would, if I may suggest something. You're gonna spread along the vein? Just to do one or two spreads along the vein. Sure. Why not? It's easy, it's cost effective, and you can do one over the nerve also, here. Now remember just be reminded that here you're going back above tumor. You just feel where you start getting over the tumor so we don't go into tumor. No, no, stay below, yeah, you wanna stay here. So, here I'm holding the platysma muscle to assist Dr. Bavir here elevating the subplatysmal flap and I think we can move one of these here. Careful, careful. Okay. So let's see what opens, hold it bluntly, will help us figure out where we wanna go, right? So, here I see parotid fascia back, you see this small window? Yeah. Then you'll be able to work from the known to the unknown over the parotid. I would, let's work from here. Yeah. Here. Yeah, exactly. See, the fascia back. This looks like all normal parotid tissue. At this the superficial aspect. Yeah. Which is great for the flap elevation, right? Why won't you go from the known to the unknown, yeah. Because I think we're stuck down still here and we're gonna end up working in the hole. See what I mean, like... Okay. We do have to come through some of this more superficial stuff otherwise we're gonna be coming through large chunks 'cause I think we just, we need to catch up here. Okay. Yeah. You see what I mean? Okay, here let's see. Here it's starting to get a little bit, so, you see, I think we should be, I don't know what this... Let's see, open a little bit, yeah and you still have the fascia below us, right? Yeah. Nice, nice. The color's come better into view now. 'Cause I don't think this is part of parotid. No, no. Here, let's, let's, let's, get a little bit better retraction. Okay, let me see for a second. You are right. I think this is like the limit of the gland, you see? And then falling into a space there. Yeah. And this is why we stopped seeing the fascia because it's not there anymore and remember, we can also go along as when we elevate the nerve and do the distal borders once we know where the nerve is but I think this is the gland, right? Yeah. Here, we'll have masseter there. See if we can... Releasing right here might give it a little bit more... Okay, you tend the skin. Okay. Let's bipolar there when you're done. Now, one of the things, if you can do for us, whenever we're flying bipolar or Bovie-ing let us know if you see the face twitches. Let's bipolar all this, this is just gonna annoy us to death, right? Bipolar, please. Do you think is tumor here or... There is a little fat packet over top. Okay. 'Cause if you feel it it doesn't feel... So, we'll probably when we take the skin we'll take the one I marked. Is your greater auric so I think this band of fascia can be divided. See, like very superficial branches anterior, maybe throw them down. Or at least you know, cut them as high as you can. I'm gonna come on up here. In case we'll be able to leave them intact. Okay, come back to the vein, tent the skin out for you. So, we are seeing the contour of the gland. Sternocleidomastoid muscle, the external jugular vein, and the greater auricular nerve here running posterior to it. Dr. Bavir managed to preserve all these structures so you see this is platysma here. I would keep yourself below it. Yeah, I'm gonna come through up the top because I think that was a little feeding vessel to platys. Yeah. I think this is just platys, sprayed down like a few fibers so you'll have to go through them. All right, come a little bit more...? I feel here we can go a little bit more distally around the gland. It's gonna get a bit sticky here, right? Yeah. Or are we in something there? I don't think so. This, I don't like the way that looks. Yeah, it does look a little... Ratty. Looks like glandular tissue. But she has a lot of component to this mass. That are both solid and cystic. Yeah, this, oh yeah. Yeah, I think I'm more worried we're kind of coming in... Yeah, this don't look good so I'll keep away from that. Just come around over it, like here. And open a little bit. Yeah. You need that a little bit more here, careful. We have like two planes here. We were this, yeah this plane here. So, I'll come back to this one. And leave some of that stuff down there. Yeah, yeah. Yeah. Yes. I almost feel the jaw behind you. I think you have a nice plane right here that we can... Just be careful because you are starting to come out of the gland. Yeah. And the superficial branches can be there so we can leave this part for later. But here, stuck on it. Knob kind of coming off here. See this little bit of this mass, I think we can go through. This part here. I don't think we need to go much further. Here. Yeah, I was gonna say I thought there was a little knob anteriorly. Yeah, here this, now it opens. Nice, and we're back on capsule. Yeah. And here, you're in marg territory because my finger is below the mandible. Okay, so I would not cut there but this is holding you as well. This is more superficial. I think once we start opening a little bit here we'll be able to connect the dots there. We can also stim there and see if we're getting anything. Okay, nerve stim is on. We're at .5. Yes, there is something. Might be platysma. It's not truly marg. It's platys, you see the... But still, it means we have nerve there. Is it on .5? That's on .5. So, did you see all the twitches in neck? So, this probably the cervical branch of the nerve 'cause I didn't see the lower lip pulling so it's not the marg. She's not monitoring that. This is why she doesn't see it. How about we raise a little bit posteriorly? Just a little bit. Just so we get to there so you can have the opening here, 'cause we'll connect there eventually, right? Here's a little cystic... Yeah, yeah it's gonna be composed of many different types of tissues. Do you want me to cut with the blade? I think we're safe back here, aren't we? Yeah, blade, please. Yeah. So, raising a bit of the posterior flap. Here we can't... Take something with teeth. Gerald with teeth, Can we get a Gerald with teeth? So you see here, is it fat? Yeah. Feels okay? Do a little bit of the superior aspect. Take this, I cannot cut for you from where I stand. I need a step stool. Here, nice. Oh that was a ncie spread. Don't go into the mass. Careful, okay? You have a nice wispy stuff opening for you so use it. Yeah we'll see, I'm gonna be honest, It just kind of broke apart, that's why... Yeah. Don't press on it too hard because it will tear it. Not yet. Can I get a scalpel, please? Okay, let's do the rest from the SCM. Okay, can come out with these. You wanna... And I'll stand over here so I can help you. Okay, if you wanna work with the Bovie now, it's fine. It's kind of coming pretty wide here. Yeah, stay below the skin, okay? Yeah. Closer to the skin. Okay, now that's feel here. Do you feel the mastoid under this? Yeah. It starts here and then... It's a vein. Vein I can see. I'm gonna open. There just to give us a better view. Can I get a Burlisher, please? So, in order to open the posterior, what I suggest the best thing to do is to go down to the cartilage here, find the cartilage and then... Okay, I think we have it really... Okay, so start here but don't climb over the gland. Yeah, yeah, yeah. Too anteriorly, okay? Yeah. Because put your finger here. This is the cartilage of the canal is here so it's very easy to go... Yeah, yeah, yeah. To go through it by accident, okay? Okay, layer by layer. You see because the canal is actually going this way, right? It's not going straight. So, try and get... Straight down. Right here. I'm just trying to get down on the cartilage here. That's it. Don't worry. Right here? Mm hm. And now when you connect the dots you're actually opening in a better location. Yeah. From the ear canal perspective. Can you hold this please? Kittner, please. And now, I think if we do that now you can feel the cartilage. Okay, so you can get even a little bit closer to, below the pericon level. You can open superior a little bit to extend your field. Mm hm. So, this is the outer part of the cartilage of the external ear canal that we see here. The white stuff. Bipolar, please. Mastoid tip is under us here. Do we wanna find digastric? Let's start by at least delineating SCM on the back. Yeah. Okay, try to just take this vein... Yeah, take it with the Harmonic. Before it becomes a... A problem. Yeah. Do you want it clips or do you want Harmonic? I think Harmonic will be fine. But whatever you want, you operate. Harmonic, please. Small superficial vein. Dr. Bavir is ligating here with the Harmonic scalpel. Just reminder that you are a little bit in the muscle now. And it's okay. I'm just gonna come right here. I'm gonna just push the muslce a little bit. Can I get a Bovie, please? A little bipolar? The cutting bipolar? Yeah. You can. Just second. This tumor is really gelatinous. You see, this looks like tumorous tissue. Oh, I thought that was a vein we just took. Harmonic. It's part of it. This guy? Yeah but it's, the rest, this is like tumor so go ahead behind it. Can I get a Gerald with teeth, please? Can you load the cutting bipolars? She'll need irrigation. It'll be very hard to clear every microscopic piece of tumor here. I' think we're starting to get to nerve. We're waking up a little bit here. I mean, you still know we're at her pointer, so you can deepen your opening safely. Okay, and you see here you have probably a plane here. Can I have a Gerald with teeth? See here, there is an opening you created which is good. Extend it inferiorly. Might take a little bit cuff of muscle with you and it's okay. Nice, maybe try and, yeah, open that. If we can get like a blunt instrument there eventually into this wispy area. Yeah, let me see. Try to see if you have a plane in between the muscle or not. I'm not sure we have... Any more inferiorly here? Yeah, actually we can put Lone Star. Careful, two double-prong there. Ray-Tec, please. Okay, and come out to this. Another Ray-Tec, clean one, please. Okay, so we're protecting our skin a little bit but I still need to see the face so I'm putting two strips. We have a pretty nice little plane here. I'm just getting trying to get the nerve down. Okay. So yeah, keep opening there. Do you wanna do the work with the Bovie or bipole? Can I have the bipolar? Yeah. So, we're peeling the tail of the parotid off the SCM. This tumor is really sticky. There is a chance we'll need to take some muscle with us. Yeah, I think that there actually is a little bit of a nice plane here. Just don't, don't go into tumor, okay? Parallel to it all the time. Do you want to come anterior to it? Yeah, just don't go past the vein. Okay. Greater auric is essentially going into the mass there. I mean, we'll have to divide it eventually. I'm not sure it will assist with elevation but we should clip it before, right? Yeah. So clip, clip, and then we'll cut it. I'm just getting this off before I clip it, and then... I can keep a little bit more. How you doing Dr. Slonimsky? It's not me, it's Rich. Try to like preserve a little bit more nerve. Okay, can I get a... Just for the chance that it... Clip applier again? Higher chances of growing it back. And Metz to Rich, please. It's not easy. I'm not sure how much we can elevate it off here. Yeah, I wonder if just taking a cuff of the SCMs the safest thing. It is, but don't forget you don't know where your jug is and you don't know where your nerve is so I don't know if the best approach is to try and release as much as we can and then go for the nerve... Go for nerve. And work from there 'cause we can cut into the muscle and then we'll hit jug. So, I think what we can do safely at least is to elevate it off the mastoid, right? Jug will not be there, right? Can I have smooth Geralds and the bipolar? Hopefully we're not going into tumor. I think this is the vein we... Yeah, the other side. Harmoniced. So, you see I'm just pulling a little bit and I see this starts to open up a little bit for me. I'm just taking what it's giving me. I'm not trying to be too aggressive. That's that vein, right? That's the other side we Harmoniced. Should have listened to you and put a clip there. Should we start looking for nerve? Not yet, not yet. We're still lateral to SCM, right? Now to your point, the nerve might be pushed from below, right? So, you are right. So, this is lateral to muscle, should be okay. Trying to give us a little bit of more opening there. Open here a little bit. See, mobilized quite nicely. Don't grab to the center. Try to grab like the fascia. And now, maybe, maybe, maybe, maybe we can find a nice fascial plane. Yeah. Kittner, please. Burlisher. Yeah. So here, you see we're approaching tumor from below. We should still keep... Take a little cuff of muscle. Yeah, cuff of muscle with us so we can go back and open this but if this comes back as even low grade she'll need radiation. Yeah. We cannot, you know, even if we get negative margins here, what about our over carotid, right? Oh yeah. Can you guarantee that? You cannot, right? No. Let's open this. Okay and I think here we can probably do that. Like an approach to a parapharyngeal almost space tumor. Just stimulating. Okay, .5 still, no response is seen. Nothing on the face. No. Good. I think there's a little branch in the vein in there. Yeah, let's Harmonic that. Harmonic it? Harmonic, please. We're not giving up on the Harmonic, huh? Well let's see. This will be the test, right? Ready? As you see this tumor is very friable. Hey Laura? Yeah? Would you be able to clean the bipolars for us? Thank you. I think the next great... So, you see this is some tumor from below and I got a little bit too close. This is still tumor. I'm pushing with my finger. I wonder if this right here... I think we can go down because this we'll need to pull with us. So, you know, there's no point of elevating all that if we need, if this is tumor, just let me make sure it's not anything pulsating, right? This is only muscle, right? I think we may wanna release right here. Yeah, yeah, yeah, absolutely but this is where I left it until we know our depth here. And see this is holding us here. At least that, in my mind... This... You see how the muscle is? Because we went under muscle here, usually we go and you open the attachment here, right? So, we're a little bit coming from a different angle. This is very firm. Nerve stim, anything here? No. No. No responses. Uh, you know what? I think what I can do is I can you know elevate from here and cut, yeah, open that. Ready? This is part of the tendon of the muscle, so... Nice, we get some mobilization there, huh? Anything here? Uh no. No responses. You're sure? Yeah. I'm not seeing any responses there. We have a full return. Okay, we're still lateral to the mastoid, right? Are you still stimulating? 'Cause I have the bipolar on. We're not. Okay, I think that this is tumor that you can still come around and try elevate it. You might find accessories here or jug so be careful. And also that, right? If we manage to... Yeah, so that we can just flex it up. Yeah. Now, feel with your finger where you think it's taking you. Do we think that's just... And remember that you wanna use it in order eventually to release it off the mastoid, right? Yeah, yeah. So, when you open here do another like, start climbing up for us. Working like both directions inferiorly and superiorly. That's tendon right there. Yeah. And if you feel at some point you can find a plane which does not involve the muscle... Yeah. That will make our next steps easier. Okay. Can we move the Allises now down to here? On this muscle so that we can try to rotate the gland? Yeah, yeah if you don't think it will tear. Open this, yeah exactly. But go go, climb back towards the mass, okay? We don't want to take like tons of muscle because then we won't have orientation, right? We'll lose our planes there. So, this is nerve? This is the nerve we cut or...? Uh. What's that? No, nerve is here. I'm thinking duct. This is the superior. No. This goes to the neck. Oh, it's just, it's a muscle band, I think. Is it digastric? No, it's muscle band, oh so one other thing and you're right because we're going through the muscle it will be harder for you to find digastric. So, at some point, and I don't think there's tons of benefit of finding it here... Yeah. Because the mass is so big and pushing everything, so what's the plain of the digastric telling you? Not much, right? But at some point you'll have to dissect more interiorly and maybe, maybe see digastric, like elevate the vein, in between the vein and the muscle but we can also cut the vein and reflect it inferiorly. Yeah, I was gonna say I don't know if we want to cut the vein. Harmonic? Um. I think the vein will have to be ligated. Yeah. Clipped at some point. Yeah, I mean at the very least... It's, it, it... Just anterior, and if you're doing a... Yeah, just try to find it. If you need to do it now, do it now or if you wanna do it later, do it later. I don't think it's a deal breaker either way to do it now or later 'cause your dissection is going under it anyway, right? Yeah. So I'm gonna... Harmonic, please. Just isolate it here? And try, you see the mass is curving a little bit up? This is the lower jaw here already. What you wanna do actually is release towards the mastoid. This anterior part will not give you much. Hopefully we'll find it best and roll everything superiorly. Just a little bit more because then you'll have enough to start looking for the nerve. Can I get an Allis, please? You see this is tumor so keep a little bit away from it. Like, over here. This might be tumor as well, can you see that? Yeah. This is tumor as well so why won't you try and open. Is the nerve under or on top of the tumor? We don't know yet. Yeah, yeah, yeah. You can see the, did you end up taking some skin? I will have to eventually. I marked where the tumor was, yeah. I think we're gonna have to come through. Hard tendon here 'cause... Yeah, but remember this is tumor. Yeah. So, I don't know, maybe we should leave it for a little bit later, right? The back is right here so we can... Try open these fibers and just leave the tendon on it. Yes. Okay, and climb up. From the mastoid tip here. There's no way this digastric tendon... No, going all the way down here? No. So, I think here we should start our release here. I will need for the nerve dissection plagets with epi. What size? The half by three. Can I get a half by three plagets? And epi. So, I think there's still some opening we can make. Burlisher, please. Do we wanna get a Deaver in there? To pull this posterior? Not yet, we use the Cummings. But, put your finger here, this is the mastoid bone. So, you know that this level is still safe, right? So, do you have a McCabe? Yeah, I'm opening it. I think all that we can just put, pass the McCabe under, stim, and if it's negative then I can... Cutting bipolars, please. Do you want me to bipolar for you? Yeah, okay, can you push me the pedal? Thank you. All right, stimming. Okay. Please go up to one. We're far from the nerve. Just very fine, nothing is there. You can just open a small pocket and then... Stimming. Anything here? Okay. No, no responses there. Still nothing. Good. All right. Bipolar to me. So, what I'll do, I will just bring myself a bit closer to the cartilage. Yeah. This will minimize the risk of bleed and that is also safe to open. I think this is also safe to open. Usually I feel quite comfortable until I see the pointer but I agree, I mean we should be, at least for your first case as you know, be very careful. Be careful, don't apply too much force on the tumor. Okay, what about, okay. Might be a vessel there, right? Yeah it's just superior, ahh anterior. Nerve stim. Stimming. Okay, stim is on. We're at 1. No responses. Can we check right below? No. No responses. I think we need to open a little bit here. So that we can rotate? Yeah. Stim here just for a second. Stimming. Okay, stim is on. All right. No responses. Just keep in mind she has a delay so if you move it too fast... Yep. She'll not give you report of what you're... An accurate, yeah... Do you have epi too? You have it? You're asking me? No, telling Jen. Okay, let's keep on moving, you know, layer by layer. Yeah, I mean this is all on pointer, isn't it? Yeah, you're a little bit above it. Yeah, my point is we can take all of this so that we can rotate a little bit. Kittner, please. And this. Okay. Okay, let me just buzz this tiny... Can you clean this for us? We can you know, work in tandem, open a little bit from below. Can I have a Burlisher? Keep your thumb there. You don't see it from below but when you did that you opened that. Yeah, yeah, yeah. You opened that. Can I get the bipolar, please? Clip, and cut close to my lower limb, okay? Now, tumor comes into view. Here. You see? I think this is tumor. Yeah. But we can maybe do that. Yeah. I think something is still like... I do. I think you got some of this stuff that needs to go. It's all posterior. Give me a smooth Gerald, please. I'll try to come, I wanna keep some muscle on it. Do you want the epi? Carla if you want to come to this side, so you can see, that's totally fine. Do you want the strength from 1:10? or do you want it from 1:1 epi? No, they can work around us, but you're paying to be here. You know, just try to open this with a bipolar. It's a tendon, it's very hard for me to cut through. Yeah, in this corner, open this 'cause this what's holding us. Yes, come from above. Dr. Slominsky, do you want epi 1:10 or 1:1? 1:1, please. So, the challenge here is that this mass is stuck to the SCM and goes deep into the parapharyngeal space below it. Which does not allow us to mobilize the gland as we would like to in order to find the main trunk of the nerve. Okay and I think you know, that we can come across maybe this. This is going to go away anyway, right? This band here of muscle. Yeah, and this is mastoid. So, more here until you see the perios of the mastoid. So, if we pull this down... Anything here? No, nothing there. No responses. No responses. - [Dr. Slonimsky] Okay. Can I have the bipolar for a second? Okay. Wow. You know, I think my highest hope will be actually... The nerve comes out here. If the nerve comes out here actually to roll it down and not roll it up 'cause we have more to pull from below than from above. Yeah. So, if we can find the nerve trace to the pez and actually peel it off the lower branches. Yeah. Might be better. I think we should go for the what do you think? The main trunk? Yeah, I think so. Like here, we have enough here. This is the pointer, you see it here? Yeah. I need to get down here. So, what we'll do, we can put like an open Ray-Tec here for you but here I will start working for like nerve dissection approach. I'm just pushing away, this is the tragal pointer. You know what's the relation of the fascial nerve to the pointer? Why is it an important landmark? And I will put this pledget here, don't take it until I ask for a fresh one. One centimeter inferior, anterior, and deep. There is a Ray-Tec on the floor here. Yeah, I saw it. Some vessels in there. I'm not sure we can apply so much cauterization close to the nerve. Maybe it's not that large. Maybe if I come from above 'cause you opened a nice window here but it's not comfortable for you to go from below. Let's stim. Yeah, we're stimulating. Okay, stim's on. Okay, no responses. Okay. All right. Bipolar. So, back, I cannot pass it through but you cut from above. Yeah, I'm gonna... Try it from, yeah, ready? I got it. Kittner, please. Usually I open like a couple of windows and then I pass it under. And I think your vessel might be there. Stim. Can I stim, please? Stim's on. Stim that. No responses. Okay. Let us know when you're good. Bipolar, please. Are you done with stim, Rich? Yes. I would cook it slow 'cause there might be a vessel. Yep. Maybe as we go we should still try and release a little bit inferiorly. Bipolar, please. Because I don't feel we can push it enough from the mastoid. It's really stuck hard on the mastoid. But here maybe we can open that and take it off the mastoid here. That's actually finally coming around that... Okay, now I can put my finger a little bit below it but, it's still stuck on the mastoid tip, right? It's probably only fascia. Can I get the stim? Yes, exactly. This is only muscle that I'm grabbing here. Rotate it inferior. There is a structure. You can grab the stim. Yeah. And try to search, like fish for the nerve. The pointer is here. Yeah, so one centimeter interior, anterior, and deep. Stimulating. Okay, stim's on. No responses. Keep it on one, please. We're stimulating. Stimming, no responses. A lot of response there. Yeah, seeing a lot of responses there. All branches? All branches. It's like right next to tragal pointer, isn't it? Well it's inferomedial, you know? So it's, and it's in one. Hold this, please. So, I would make a spread. Give us, give me a Burlisher as well. Just one. So, stay close to the pointer. Yeah. Uh, I would not dig there. I think this is, where you were was a good window to look for it there. I mean, you might not be able to see it, but for example we can divide this, right? Yeah. And open a window wider. Nerve stim, please. Nothing here, right? Nothing there. Bipolar to Rich. So, I think we'll need to open a wide window because it's so stuck. It's so stuck. And even superiorly it will help us, right? To peel the gland down. Okay, go on. So you notice here we need to find the nerve right away, right? You can open, open here for example, you see this band is holding you. Another small Cummings. Carly, if you start to have your hands hurt just let us know. No, I'm good, thank you. Listen, she doesn't get tired. She did not take a break for how much was, like nine hours last week? We gotta get her to come into ENT. Yeah, it was a good move. Use it. Yeah, it just wasn't going anywhere. Stim on .5, please. 0.5? Nothing here, right? Stimming, no response. Okay. Divide that. Take the pledget. Let it come under your hands. Yeah, I'm not, we're close to nerve. We're not tracing it yet. Okay, well I can also swing up there if you want. Nerve stim, please. Response there in just the right auric. I think I saw it. Small response of what? And right... And the EMG's quiet? Yeah, the EMG is quiet. Nerve stim. Stimming. Okay, stim is on. No responses. No response. No. No. No. It's like where I want. Oh, you know what? No. No. Yeah, it's just too big. Can you go up to 1? It's weird because it's where I was before. On 1. 1. Careful. Yeah, we're at 1. No responses. No response. Full response there... I think it's more, so try and open a window, okay? We'll try and, go through there, no, no, actually go, yeah you wanna create another one and then go in from under here. You will stim, or I will stim and you'll cut. Yeah, if you stim, I'll cut. Stimming. Okay, stim is on. No responses. You can go down to .5. Okay. It's this guy right here? I don't think so 'cause it should stimulate on the .5. Try and open, you see this? That tissue here, maybe you'll need to make a move a bit inferiorly. You see this? Might be a vessel. Stimming. Stim is on. No, it's... It's a vessel. We're at .5, no responses. No. No response. A new, new pledget. Can we have a small Frazier tip suction? Oh, you think it's coming from that? Yeah, I think it's coming from... Okay, a small clip for that? See if I can, if I can reach it from that side. Nerve stim, please. Stimming. Okay. No responses. Yeah. No response. What do you think about coming from below and I will take my instrument out? Yeah. You good, can you get it out? Yeah, wait, don't worry. Don't tear that vessel. Nerve stim on 1, please. Okay. Nerve stim is at 1. Do you wanna clip that? No responses. Yeah, small clip. I'm not sure what this is... You think you're gonna...? Knife, please. Will they think it will work? Yes, it does. All right now let's put a pledget there for a second. Now, what's holding us is, are we, can we maybe, oh, this little bit here? Okay, now let's take the nerve stim and try to figure out where it's hiding. Can we have a nerve stim, please? Stimming. We're at 1, we have responses there, all branches. Okay, so it's just... No responses there. Nothing there. Good response there. Okay, okay. No responses. A little something in ocular. Okay. So, it's a little bit superior to the tragal pointer. That's odd. Try not to grab. Nerve stim at .5, please. Stimming. No response. Good, can make a nice move there. I was wondering if we can get her Cummings in a little bit lower. Probably, if you get it too close it's like compressing your field. I think we should be able to see it at that point. Soon. Stimulate in between where I'm... Can we get a nerve stim? 0.5, please. Stim's it's at .5. Small response of ocular there. Okay, how about if you can make another opening like that. Yeah. Just to broaden the field. It might maybe do another thing like inferior. Inferior. Just so it's... Yes. Nerve stim. I think we start seeing it. Anything here? No, nothing there. In here? No response. So once you find the nerve start following the superior branches, okay? Yeah, yeah. It's really pushed down a lot. Stimming. Okay, stim's on, .5. No responses. No response. Nothing. Can I get a kittner? Can I have a pledget parking here? Beautiful. Nerve stim. Responses there. They're small in amplitude. The nerve is compressed but also the trajectory, it's not just crossing your field it's coming at you. So, a lot of time what can happen, you can dig very deep towards the mastoid foramen. You can find the nerve there but then you have to start climbing like that and it's hard and in many cases what happens is it's coming this way but it will be more superficial in the gland here and you can find it there. So, you are actually working parallel to the nerve so you need to find this portion and start tracing that, okay? You shouldn't elevate yet. You should make spreads in that direction and maybe try and open a small window. Stimulate that. Stimming. No responses. No responses. Nothing there. Okay, I'll come out and let's try and find it again. I think, I think we are close 'cause it was .5, right? Yeah. No responses. Still nothing. No. Climb up a little bit. Is the EMG quiet? Yeah. EMG's quiet. We need to make this move inferiorly 'cause it's right... What do you think? I think it's right here. Okay, so this Cummings is a little bit compressing your field. I think if we expand the field this way we can get this Deaver and a set of Cummings in here and I can get a better, yeah. Stimming. All right, stim's on .5. No response. There are little responses. No response. Where did you get the responses? No response. It was here. Nothing there. I think I, she said like below the clip. No response. Depends where it's pointing. Can you go up to 1? I feel like making this move here. Yep. Just make sure that she still gets responses. Okay, stim's at 1. No responses. Still no response. Small response there, frontalis. But I think here we had all branches somewhere here. No responses. I don't think it was that far low. Nothing. No response. Still nothing. Small responses down there, in oculi. Now I want smooth Geralds, please. The nerve might be splayed so the paths could be pushed very far back. It's like under the mastoid, you know what I mean? Responses there. All branches? Oculi, small, very small response. Yes, still in that oculi, small response. I wanna get... Still smaller responses on oculi. Nothing there. No responses. I wanna find the main. Oculi there. All right, all of them. All branches? Lower branches right there. Yeah, that. Burlisher, please. Great. It's gonna be very hard to find it under there. Nerve stim, please. Stimming. Yep, response there. Frontalis. McCabe, please. So look, I think we should start to open the, the space, so you'll stim and cut. Yep. Stimming. Okay, stim's on at .5. No responses. Thank you. You know, I don't want just to trace a branch of the frontalis 'cause we're not gonna make much progress if we only start with such a small branch there, right? Stim. Stimulating. Okay, stim's on at .5. No response. So, this is the mastoid tip here. This is the pointer. I feel the main trunk is going to be hiding here but this might be all tumor. This is why it doesn't let itself push away as nicely as we want. You want me to stim that or... No, no. You guys identify the main trunk already? No, we're close but it's all, there's, the tumor's... Right on top of it. Yeah. It's on top of everything so I think here it's where it's like stuck the most. Push it, try to push it away from us. You feel that we will need to get ourself a little bit more released here hopefully. This is really stuck there in the foramen. No response. Nothing there. Small response there, oculi. Oris there. So, I'm trying maybe you know even this... Can I get an Army-Navy? You can bipolar this. Mm hm. Kittner, got it, okay. Here we might be close to accessories already. Another thing we need to worry about. Yeah, Burlisher, please. Just sliding over the tissue and tears it. That's all open, I think we're just not getting an traction down there. See if there's a last band of tissue that holds it to the mastoid. We'll need to maybe release. See like this band here. Can I get a McCabe, please? Feel that? It's going onto the foramen. This is in tumor, this is tumor. Let's stay on the mastoid. So, you're below muscle here so go above it. I think the opening should be down here. I think I was there and we were surounded by tumor, right? Nerve stim. Okay, so I feel like we're better released there. Anything? All right, responses there all branches. Okay, give me a Burlisher. Nerve stim. Responses, upper branches and lower. Responses in oris. Everything, all branches. It's not clean enough yet... Yeah, I was gonna say, I think nerve's in there or almost at pes. Nerve stim. What do you get there? 0.5, a little response there. Kinda like we gotta, we gotta dry it up 'cause... Yeah. All branches. Nothing there. Nothing there. I think it's below us. Give me Burlisher. Nerve stim. Responses, all branches. Give me a smooth Geralds, please. And I want a clean pledget, please. Here, take a look at that. So, I think we were over fat in the beginning. Yeah. My goal is to try to get to the pes and throw all this tumor down. Yeah, go up. Yeah, you're gonna take over soon, okay? Just put us on a trail here. It doesn't look very good. It looks a little bit too pink which I hope is not like tumor going into it. Nerve stim. Responses, all branches. Nothing there. No response there. Bipolar, please. Hold this, please. Hold it open like a book, yeah. Nerve stim. Anything here? Nope, nothing there. Bipole. Now, remember what's holding you is the fascia of the parotid so the first strokes you wanna open the fascia, right? I feel here I'm like, you see this is the tumor below me. See here, like a capsule. This looks like benign parotid above it. So, uh... Pull it this way. Nerve stim. Anything here? No, no responses. Bipolar. No responses. No responses. That's not right. Give me a Kittner. It's, I think it's infiltrated with cancer. You see I was like tracing over the nerve? It like stopped working and now I cannot see it very clearly. Nerve stim. Go up to 1, please. Okay. Nerve stim's at 1. No responses. Responses, all branches. Maybe we still have another layer. Yeah. You got responses all branches? Yeah, all branches. Were they... Lower amplitude in the lower. I don't feel good about this. I feel like the nerve is not very dissectible from surrounding tumor. Can you give her a little bit of a tilt away from me? All branches there. You see that guy here? Good responses? Yes. High amplitude. I think it's like, I started dissecting it and it like was sliding a little bit away from me and this is not nerve, this is just a piece of fat. Here. See it better now? It's still very stretched. Yeah. 0.5, please. Okay, stim's going to .5. Yeah, I was watching it. All responses, or all branches there. Anything? Nope, nothing there. Uh, response there, frontalis. Nothing there. Responses all branches. Bipolar. Suction. Maybe now it will decompress it. Let me go there. Around here. Have a little bit of spillage. Can you pull this away for me? No response. Uh, response in the upper branch right there. Here? Nothing there. Right there. In here. Are you on 1 or .5? 0.5. Here nothing? Nothing there. Okay, so let me just, we're leave this there, like superior to where she get the stimulation. Try to open the fascia here. Okay, now I see it. You see it like going here? Yeah, I see a little... Yeah, all that, so I think this. Responses in lower branches. Here? Right there. Oris. Oh my goodness. Oh, I think I know what's going on. It's like going here... And then coming down. This is a good sign. Lower branches you said? When you're done we can rotate everything down. At the very end it was oris and mentalis. How about here? No responses there. Response there. Here? Oris and mentalis there. Small response. And here? Nothing there. We were right. This is intact parotid but it has all the nerves in it. These lower branches. Nerve stim. Anything? Nothing there. Bipolar. Anything here? No. Nothing there. Close to that limb of the dissector. Here. Get closer. Open just what, it's in between my dissector limbs. Kittner, please. Okay. So now, maybe if we can lift that part up. Anything here? No, no responses there. Allis. So, we probably have the superior branches or the inferior branches like splaying that way. That way. There wasn't anything... And you see this is very... There wasn't anything here? I would recommend like continue doing what I did and try to at least get this off. And get this to go off with us. No, no to go off because it has nerve in it and then I think once this is released you'll be able to go back to more like the main trunk and peel it from superior to inferior, okay? I'll stim for you. Nerve stim on .5, please. Okay, nerve stim's at .5. Anything here? No, no responses there. Just, you saw something there that started opening for you like a plane of dissection. Yeah. I don't know that I want to go that close to it. Careful, this is so soft, yeah. I mean, in a sense you have no choice but follow it's capsule, right? Yeah. 'Cause you have the nerve just riding over it. I'm just being gentle. Can we retract there? Yeah, I'll put my finger here. Retract that guy, yeah. Thank you. Nice. I don't know that I want to... Anything? No, no responses. Okay, don't be greedy. Small steps, okay? Yeah. Patience wins the race. Slow and steady. I think I have enough. Anything here? No, no responses. Great, kittner, please. Should we dry this for you a little bit? Remember, the fascia is lending, if you wanna make a move just for fascia it will help you for the next step. Anything here? No, nothing there. And now you go one level below, right? And connect your planes there. Nice, climb up. Don't be greedy, small steps, okay? Yeah. Just... You don't have necessarily to pass point if you cannot... Trying to be gentle. Anything here? No, nothing there. So, we continue to dissect around the mass and separate it from what looks like benign remaining parotid tissue because we got signals that the nerve is running within that parotid tissue and our goal is to keep her face working. Besides removing the cancer. Anything here? No, nothing there. Can you go up to 1? Just, it's a thick bite so... All right, stim's at 1. No responses. Nothing. So, what's the sound of a response? Because I hear like different sounds. Yeah, there's like two different sounds. It'll get faster when it's a little bit of a stronger response. But then there's just like a lower response. Okay, wait, wait, wait, wait. This is tumor, you see this? Yeah. Maybe try to go around, okay? A little anterior. Yeah. Anything here? No, not seeing anything there. Look at the release you got from this. Now look, this is tumor, okay? Yeah. Coming anteriorly. Yeah. Senn, sharp Senn, please. Let's try to go over the capsule of that and to better no where we are. Nerve stim. Now, anything here? No, no responses there. Yeah, Kittner, please. See this band? I think if we get this divided... Now, what's interesting. So, her angle of the mandible is here so we might be below most of the branches. Yeah, I was gonna say we may luck out here. Give me an Allis, please. Stimming. No responses. Give me a Kittner, please. Look at that. You're almost here. Yeah, we're almost around. Bipolar, please. Careful, we don't know where the nerve is. Nerve stim. Remember, we don't know where the nerve is. Responses lower branches. You see? Oris, mentalis. Just you... No responses in oris and mentalis. Luckily it still works, huh? So, be careful. Oris and mentalis. Okay, so we have something here. So, I think our best approach is to go over the capsule of the lesion and push whatever looks like benign parotid away because all the nerves are there. Yeah, they're all... So we'll have... Intracapsular. I'm gonna... Yeah, so you see the plane there that opened for you. And this is the nerve, you see it? Stay there, stay there. 0.5, please. Okay. Spread. I saw it for a brief second. No responses. Responses, lower branches. Yeah, so I saw it here. Anything here? Yeah, oris and mentalis. Here? Nothing there. Nothing there. Okay, you see it? Wait, wait, wait, stop, stop, stop. This. Yep. Is this nerve? Uh no, no responses there. All right, it's somewhere down there. Response there. This might be nerve. Wait a second. Here? No, nothing there. All right. Nerve stim. Yeah, this is a good move. Stimming. No responses. Careful with your tips point, like point up when you cut. Going in, we'll probably actually find that later when we do our neck dissection. It's a... I think it's going here. Is this a Burlisher? No it's a... Oh, Allis, okay. So, we'll be able to trace this out of this benign parotid. Oh, it's the one that I put over the lake. Suction, please. Actually, we did compress it, can help us a little bit. We can put... Close it but I'm afraid, like here maybe? Yeah. Nothing there. Okay, 3-0 Vicryl, please. Oh, there's... You see the nerve? Nerve branch, yeah. Nerve stim. No responses. Can you hold that? That does look like a nerve though. Can I get the... Suction, please. Sterile water. Give me DeBakey, please. Just push it inside. So, we're closing, there's a small opening in the tumor's capsule. It just keeps leaking into our surgical field so we'll try to close it. Wanna do a horizontal mattress, maybe? We can do a figure-of-eight over it. Luckily it's not that liquidy. One more? Yeah, you can run it like to the other side and then we'll compress all of it. Yeah, might have another one. Yeah. Gonna tie this one, and then I'll throw another one. Actually we will not cut this one. Just run it again and use the same tail to... Okay. I think you know you close it enough so it doesn't spill 'cause it's quite thick. It's okay, it doesn't spill too much anymore. Scissors. Anything? Nothing there. It's under here. Oris and mentalis. Yeah. So, I think we will be able to, yeah go under there. Wait, wait, but it might be this. Anything? Nothing there. No response. No response. Yeah, it's deeper. Nothing there. Let's release here a little bit. We'll be able to bring this up. Anything here? Nope, nothing there. Wait, wait, I saw some, and we are at .5, right? Yep. Anything here? No, no responses there. That's not tumor, is it? Oh, we are actually below the mandible so it's not masseter. Yeah. I don't know if we maximized... Let's go back to what you suggested. So, this is the lobe of parotid pulled out. It's still very stuck. Let's continue releasing that. There's a tiny branch still encased in that. Can I get the Burlisher back? Thank you. Probably we can throw this down. Be careful, there's tumor under it. Yeah, I'm gonna come through this. Nerve stim. Stim's on at point 5. Really superficial stuff. Anything? No, no responses there. Kittner, please. Look at that. So, we're seeing the capsule of the tumor below us. Suction, please. Maybe even decompress it a little bit. I wonder if we can now connect the... Yeah, but where is the nerve that was running? It might be right here. Stim right here. Can you pass it in water? Yep. Is he okay? Yeah, nerve stim. Stim's on at .5. No responses. No response - response there, mentalis. Okay, it's in here somewhere. So, there's a tiny nerve that we can barely see. This is why we're relying on the stimulation. Anything here? No, no responses there. I think it's, it's that guy? Anything here? That was my thought was this guy right here. No, no responses there. I'm gonna leave it down anyway. No response. Yeah, your best bet is to open this fascia and hopefully the nerve will be left down. Anything here? No, no responses. You see this nerve? Be careful on it. Kittner, please. You know, just a second, leave it. Wait, why won't you go... Right here? Burlisher. No, no, go retrogradely, because you see there, right? So, why don't you go from here posteriorly back here. You see how it's turning there. Oh, it's really close to it, to the tumor. There is the fascia that we can probably, no, no, but now you're below it. Do you see, you see the course? You wanna open here and throw this down. Yeah. No, no, no. You're stretching it. You want to start above it. Yes. Like from here, go posteriorly. Do you have a Jake there? Wonder, can we do... It's really encased in the capsule. Yeah, I was gonna say, I don't know. We're certain that that's nerve? Yeah. Nerve stim. Response there, mentallus. Do I have to stim or you wanna? No, it's good. Kittner. Listen, if this is the lower branch, this might be it. Yeah, then if we can get all of that off then we'll be probably scot free. All this will peel quickly. Yeah. Do you wanna retrograde follow it back? I wanna open this and then we'll go back to the main trunk because we're getting closer to it from the superior aspect, right? Yeah, that's what I mean. It was like, follow it from... But I still feel that we can do that move... Yeah. Can I get the stim? Stim's on, .5. Responses all branches. Okay, so let's go back to the main trunk. I think that it's pulled up. Let me try first, give me um, what did I have before? The McCabe or Burlisher? You had the Jake. Jake. Still this branch is still not out of the field. There's another small one below it, do you see it? I can still, yeah exactly. Who is shifting? The leg. There's a big branch right there, look at that. Yeah, start simulating, might be a vessel. I'm actually happy there's... 0.5. Yes. Responses lower branches. Oris and mentalis. Okay awesome. I'm happy because it means that once we take it off this guy... We should be... We should be okay. So, yeah, go there and I'll cut for you. Bipolar. Do you have the pedal? Yep. Okay. Okay, you pull this. Keep on going that way. Looks like I'm getting some right mentalis EMP. Kittner, please. Is it still going on? Yeah. Oh, I might have got a little bit close to it. I wonder if we can make, remember that move that we wanted to make earlier where we were giving stim? Yeah. All right, EMG's fine. Thank you. Nerve stim. Anything here? Bipolar down here. Down here. Nothing there. Yes. Can I get the McCabe? Why don't you run over the nerve? Eh, I'm trying to think. See if you can open this fascia? Yeah, how to get... There might be a branch there, nerve stim. No responses there. Responses there, lower branches. Oris, mentalis. I'm gonna come through. Just don't pass point, okay. Yep. Point out, out, when you continue, when you finish your movement it should point up. Yes, you see, that's the move. Kittner, please. See the branch there? But let's continue, open up that, yeah. Yes, please. You see the vein here? Nerve stim. I'm gonna come right to it. No responses. You have a tiny vein here so cook it. Okay, if you can let, if you can release that branch you should be able to do that without grabbing tissue. Yeah. Nerve stim. This is risky now. You can crush the nerve under this so be careful, okay? As I see stimulation, wait, wait, wait. Got a small response at the end there. Come out and see, there's something we don't see very well. Let's push it away. Here? Yeah, yeah. Still stimulated, you see that? All right, so let's run along the nerve here. Put your finger here. Feel how you can bring your fingers together behind it. Yeah, I'm just wondering if... And see if we can open that corner. Do you wanna just take it away from jug? Yeah. There is, there's a band of tissue here. Put your finger here. I'm not sure what it is. Could be like the deep parotid fascia. Feel that? Parotid fascia stuck or it could be... Yeah. But it's not cancer, it's like... Kind of got pushed... The digastric pulled it, yeah that's a good thought. So, be careful. This is tumor, see there? Yeah, I'm just... Give me DeBakey, please. Okay, nerve stim. Stim's on at .5. No responses. Harmonic. It's a harmonic? Uh let me do something, okay? Sure. I feel like I'm not doing anything today. You dissected the... This is tumor. Yeah, good, good, good, good, good, good, good. Okay, now let's open here. Yeah. Hold on. There's still some, oh it's vein. It's vein but there's still a little bit tumor extending there. It's very devious, this tumor. Nerve stim. I just wanna see that this branch is nothing. Nothing? No responses. Vein retractor. Maybe a little bit too big. Yeah, we don't have enough exposed just yet. Oh, nice. Yeah, take this. Sorry, I'm gonna drive you crazy with that, you know? Yeah. I'll take that bipolar. I don't think we need to stimulate there. Okay? Yeah, just watch the... The vein? Yeah. Not to side wall it. Kittner, please. So, I believe that there are no more branches below this branch. Yeah, I don't think so either. The problem is connecting... Here to here. Yeah, maybe if I decompress that it'll be easier. I'll just suction all the content out. Maybe I'll put an Allis on it again. Yeah. Hopefully it will not fall. What does that remind you? What surgery? Sinus surgery. Or putting a tube. Oh, yeah. Also true. So, since we already punctured that I'll decompress it a little bit so it will be easier for us to go around it. Allis, please. All right, now we need to put something here, Rich. I'm not sure what, maybe the Cummings. Yeah. Cummings, please. Little one? No, medium, thank you. Now where's that nerve. You have to again find that nerve and... There's nothing in between? Just this giant gigantic one and... Hold that. All right, do you see the nerve? Yeah. There. I think you might have a better angle in terms of just coming, you know what I mean? That way. Okay, okay. Anything? No, no responses there. It's already, it's already torn anyway. Kittner, please. So... Oh, I see. Nerve stim. Wait, wait, yeah, stim, stim that. This is nerve. No responses. No, no. All branches there. This is nerve. Oh, I see. It's pulled, okay? Wait, wait, wait, wait, wait. It's coming down this way now. Yeah this is... It's coming up. It's coming from here and I think it's tented. Yeah. But we should be able to get it really all off with almost one move. yeah, it's, yeah, try and open this. Can I get a nerve stim? Anything? No responses there. But I wanna show also what it does. Be careful because the nerve is below us. Kittner, please. So here we have a little bit of a challenge. Nerve stim. You have it? Got it. On at .5. All branches there. Oh, does it run up the side of this? Yeah we need to, I'm not sure if this is tumor or not. Or just... I feel mastoid below me so... I feel like this is gonna be tumor because it's decompressed. You know what I mean? Yeah, but I mean the main trunk before the pes, like down here. Run along it here, try to open this thing that pulls the nerve down but you have to be careful because the nerve is running up here. I think the... No, no, no, no, no. You don't wanna come this way? Give me the Jake. No, I want you to... You wanna do this? No, no, no, I want you to try and run along the nerve and open that. Okay. You know what? I'm not sure it's doable. Maybe we should maybe cut through that fat a little bit. Try and take a Jake. Because this is really too blunt. Suction, please. So, we have a piece of, part of the tumor just stuck over the main trunk of the nerve. Which is the most critical point 'cause it can effect all the branches of the facial nerve. Yeah, so small steps, okay? Nerve stim, .5 please. No responses. Remember, the nerve is below so stay high. Don't pass point. Give me a smooth Geralds. I wonder if dissecting here... Here, it's just over mastoid. You don't think it's running up here? I think it's running below the nerve there. Once we release that then we should be okay. This is tumor, see below the nerve? Yeah... So try to get that... And then try to go between that and the inferior branches. You see how it tents? Yeah. I think if you can come here through that fat... Yeah. I think maybe from here to there. I'm just worried that this is tumor. Well, we're not sacrificing nerve for a low-grade tumor. Nerve is working so clinically she doesn't have PNI, right? Nothing there. Give me, give me a knife. There is tumor stuck to the nerve. Here, I got a plane there, open there. Don't move. Nerve stim. Anything here? Yes, lower branches. Oris and mentalis Also do you have anything here? Nothing there. It's nothing, okay. Divide this. I thought we'll do that and we'll be out of the woods but now we're stuck on the most critical part there so now let's start with easier, okay? You're almost there so let's start doing that. Like we went retrogradely... Yeah. On that other branch. Yeah. Okay, so we should go... If you're, if you are putting the note, if you're on it, I think you are. Yeah. Just have it reflecting all the challenges here. So, basically see this is the pes, so you see the superior branches and now you're below the inferior branches now my question is, what is that part? Is this anything still real here going down here? Or this is... I think it is. Remember I think we got stim that it's... Yeah, seem to release. Stuck here... Yeah. And then it comes up so we could, I had made a pocket right here that we could continue. Do you think there's a point of continuing like releasing here to leave that only, you see? Leave it only hanging on... Sure. Where the pes is and then we'll have better control of that part. Here, I think you can just stay close to, far away from the nerve. Okay. Okay, hold this for me. Careful, don't suction nerve. Give me a Kittner, please. What if we were to just trace the nerve up? Yeah, I'm just trying to release whatever we can. I'm gonna need some water through that. Go back here with that. Yeah, hold that. Let's irrigate a little bit. What happens if we just trace nerve? That was my plan. Off of that. The thing I wanted to do, I wanted to create this spot here where you know where you're going so when you divide what you talked about, that's it. It's off. How about this band? You see, this is also holding the gland. Nerve stim. So, you're saying up? No, no, I'm saying maybe... From here to here? Anything here? Nothing. Nothing there. I think you're... That's everything. So what I'm saying, give me a Jake, maybe, Rich... Yeah. This, start release here. Start open here. Okay, nerve stim. Nothing. Can make another move. You see another band of tissue? I'm thinking of trying to go from there to there, but you can also come... I wanna stay away from the nerve because I feel like if you dissect too close to it, so I'll go maybe from here and try to come out here. Yeah, you can divide that. Now, let's see. Now that the main trunk of the nerve is there. There's like something holding it... Yeah. Behind there. Is it the styloid? Is it...? You know, if we're off nerve then I don't mind just peeling it off. Yeah, yeah. But as long as we still have the main trunk... Also like terminal branch of parotid? Give me an Allis, please. Now you have to be careful not to crush the nerve with the Cummings there. The deep lobe is what's holding us. Where is our EJ? This is, is this our EJ? EJ's here. That's EJ right there. Yes. Okay, so it's not bothering us at the moment. No. All right. Give me the bipolar, please. Now, let's hope I don't hit the jug. So, this is muscle, right? We're below any branches. We're behind the angle of the mandible, SCM. You have to be mindful of the accessory, right? Yeah, I mean, we're still high, and I think you know, we can, this is muscle, right? You're just gonna take the tendon? Well we have to. You see, this is tumor. Nerve stim, put it on 2, please. I'm going for accessory. Stim's on 2. All right, no responses. No responses. There it is. Yes. Give me Burlisher. It's not, you're not monitoring that, so should be okay, right? Yes, sir. Nerve stim. Stim's on 1. No responses. Bipolar. That's it right there. I think so, right? This I can still open. Give me Burlisher. That's great news. Also the accessory is entangled with the mass. Nerve stim. Is it? Stim's on at 1. Small response, lower. Burlisher. It's really in it. Here it is. Nerve stim. Stim's on at 1. 0.5please. Okay. We're at .5. Very small responses in oris. Do you think we can... Burlisher. I see it. I see it all the way going down there. So I think we can... Bipolar, please. Yes, stim that first. Nerve stim. Anything? No, no responses. All right, here's the nerve. This, this guy. So now... There's still a deep component going there. Now we can open that part. Stimming. Stim at .5, no responses. Thank you. So, this might be a little level II lymph node. Yeah. What is that holding? Okay, that's holding that. Okay. All right. Our goal is to release the tumor so we can dissect it off the facial nerve more easily. Nerve is here. See the nerve? This is the accessory. Take a break. Okay, let's stim that then divide. If I hold here, you think you can stim it? I think so. We're stimming. No responses. Bipolar. Now we have more mobility. You said another Burlisher? No. Oh, I'm making stuff up now. Bipolar, please. We'll come back for this lymph node, our level II. Yep. You think we can stick that in there? It's on mastoid. Give me a pledget. No, I think it was good the problem is it's over tumor. Put your finger here. We still need to pull it from behind the mandible. So if I would cut there I would cut through tumor. Yeah. We still need to take it off the lobe, and I think maybe now we have more mobility maybe go back to the main trunk? Yeah. If we open that corner now we can peel it off and connect to that. Okay, let's do some hemostasis. All right, so this tumor really stuck hard to everything around it. Get sterile water? No, not now. Wait, wait, there, see this tiny branch here? It's compressed under. You know why it's hard to dissect it off? Because it just, it's a very thin wall of a capsule. It's not like a very solid thing. This is all going from behind the angle of the mandible. Maybe we should be able to release it from there, bring it up... Yeah. Because I cannot, even if you release the nerve here then what's next, right? Yeah. How do we take it off? So, do you want to go maybe... From inferior. You see, I have the nerve here so, and we have digastric here, so we probably can safely open there. Can I ask, what about if we developed a plane... Like follow it retrograde? From here to there. And peel all that fascia down and push it up. So, do you want to follow it retrogradely along that branch? Uh, yeah we... There's still some we can separate there. Or we can come from here or there. I mean, I'm just saying connect these two, like dot over the digastric and then... Yeah. Yeah, let's do that. Just... Give us a lady finger, please. Follow the nerve under digastric and then... No, I wanna peel it off the digastric. Bipolar. You see, this should be safe because the nerve is down here. See the nerve? Yep. And I think I maybe, so we know we're lateral to jug and this is digastric, right? Yep. So, we probably can do that. And peel it off the digastric. If we're lateral to digastric then it should be fine, right? Well, maybe I'll be able to get the deep portion, what do we see here? The jug, okay? So, I have accessories, I have the jug, I'm staying lateral to them. And here I'm lateral to digastric. Again. And there... Now, there's a tiny nerve here. This branch here. Yeah, but all of that should move. Hold that. And here I'm back on the mastoid. This is what was holding us. See, if I can release this here from below we only have to work from, a little bit from the nerve side. Feel that. Finally really soft on the mastoid tip there. Not all the way. Must remember that I'm coming towards the nerve from below, right? But I think the deep component is almost completely out. You know, if we come as close as we can to the nerve from below we know where, we see the nerve then we connect that. If you're looking so, make another move from below? We just need to know where the main trunk of the nerve is from above. Okay, because it's really, we're getting close. You see where my finger is? We're still two centimeters away, right? Okay, let me see. The main trunk's coming down, this is... I don't see very well. Right here. Can you hold this for us? Right? And the nerve was - can I get a Gerald with teeth? Army-Navy. Yeah, we need to retract the gland. So, I think we can either start actually dissecting nerve off like we've been talking about... Like that, please. Can I get a Gerald without teeth and a Burlisher, please? So, just to confirm, this is the inferior division, but the main trunk is... It's there, yeah. It's under us, there. Yeah, I think main trunk, so it's actually right here, hold on. Right there. Yes. So if we're able to just... And then we'll, yeah. I think our best move will be to work from here posteriorly. Nerve stim. Bipolar. No responses. Give me a knife because I tell you what my fear is, is that I should have cut up, is that we will push the nerve down there but then where do we go from there? Because we're behind the mandible. We're like above tumor. I wonder if we can push the nerve down from here. Yeah. And then connect there to there. But I think the main elevation will have to be from either here or from below. Yeah, I mean... Back to the nerve. My thought was like, yeah we should get it off of the nerve and give us some space and then go from that inferior side off of the mass, peel it off of the mastoid tip there and then we can develop all of that plane. That should be easy. Unless, do you wanna go from that side? I think eventually once you release enough of the nerve, you see it's over my finger? Yeah. We can divide this piece of tissue. You want to divide the fat? Well, it's parapharyngeal fat, I'm pulling it from below the mandible. Do you want me to do it? Give me a Kittner. I just think that that's tumor is the problem. Well, I told you, wait, wait, wait, let me push the nerve. We might leave some tumor behind. I feel like I might be able to just do this. Yeah, open, there's a little bit of fascia, yeah. Now, we can come back and berry pick. You know, small remnants of tumor but just let's get the main mass off. Wait, wait, she's sliding, hold that. Thank you. You can even maybe take a knife and just cut along the nerve. Along the nerve. You know like Dr. Gornberg does for like thyroids? Thyroids, yeah, yeah. Stim that, stim that. Can I get a nerve stim, please. Yeah, cut above yourself. Might bleed a bit 'cause I think there's a small vein there. So now putting instruments you see there's a window, I don't know if you can see it. Hold on, can I get a Gerald without teeth? There. There's a window. Now pass through, right. Nerve stim. This looks like benign fat, right? Yep. Anything? No responses there. Now, what you can do, close your dissector and push it away from the mass now divide that. Can I have a bipolar, please? So now you're protecting the nerve, right? Just be careful because it might come back at you from the deeper aspect, yeah. From the deep. Remember that movie, "Deep Blue Sea"? Deep Mystique? "Deep Blue Sea." LL Cool J. No. No, not familiar with that. Let me just, stand there for a second. Since my hand is already here, okay now I wanna do another move and you'll continue dissecting the nerve I just wanna release a little bit here. I just want to make the most of what you achieved by releasing the nerve there. Bipolar. And meet me here, okay? So vein here. I think this is stylohyloid, see it? Yeah, yeah. This is jug here. Think we can make another move here. And everything helps eventually. Give you some more... Huh? That's impressive. Oh thanks, it's quite a pain. Now, put your fingers from both sides. Yeah, we're just tethered... Very close, right? To get it out, right? Just the nerve, the main trunk. So, how about, why don't we open that? Yeah. Can I get a Burlisher? Do you see the nerve on the other side? No. Worked so hard. Yeah, it's really, it's here, right? Can I get a Cummings, please? How about you try to open that? Yep, give me... Let me, you want me to get that? No, no. Hold on, can I get the smooths? Thank you. The neck dissection's gonna be a walk in the park, huh? No, don't say that now. Do you feel like doing level Ib, II and III? Or do II, III, IV? Um, I don't know, what do you think? I think, I mean level IV is not highly concerning for me. Level Ib is like more close. Nerve stim, very careful, okay? No response. Yeah, nerve is superior to me. Give me a knife. Careful when it's divided don't fall on the nerve. Kittner. Why did it have to be stuck on the most important part? So, but I think now we make this move? And release from below. And release from below. Yeah. Now that we have a nerve. Yeah so yeah, start opening. I just wanna make sure... So, you know what? Maybe we can just bipolar there. If I can't... No, no, 'cause the nerve is, main trunk is right here. Yeah, but you see where it's going. What I can maybe open a little bit. Just a little there? Sure. Kittner. I'm not saying cutting here, but I'm saying... Yeah, come superiorly. Start releasing it from that part. I cannot see your tips. Yeah, let me just, I just wanna make sure we're not leaving cancer behind. Unless you wanna just debulk it and then... So, there's another option. Now that it's released from both sides to lift it up. And come, come take a look from below. So, you see we're actually hanging on the digastric also. Start it opening along the digastric, okay? Yeah. And take it superiorly? Yeah. No, no, start above. Give me a smooth Geralds, okay got it. Because remember, there's no point of, let me show you, I'll hold this for you. Come here. Yeah, go above the tendon, okay? Um, can I get... Give me that for a second. Listen, I just feel it's like in between my fingers. Yeah, the vessel retractor? Can you press the pedal? No, I don't. What do you say about here? I wanna release here as much as we can. Just like five millimeters we're stuck on, right? Yeah. I want you to come over here and hold it with both your fingers. You don't control it if you don't grab it from both sides. Don't pull it too hard because the nerve is still attached to it, okay? Yeah, yeah, yeah. So, it's attached to the stylomastoid foramen where the nerve is coming out from which is actually the worst part for us to be able to safely release the nerve. See like a small band extending superior to the nerve there. Okay. Or we're leaving a little tumor down. Well it's stylomastoid foramen. Yeah. What can you do? It's on the foramen. Okay, think now we're open a little bit better. You see the digastric coming in? Yeah. It's like in between the attachment of the digastric and the foramen. The edge, yeah. I'm on mastoid now so I'm getting a little bit away from tumor. Also, you don't wanna go into the jugular canal, right? Yeah. The jugular foramen. Okay. I'm confident in the digastric and using it to pull down so that we have counter traction. Yeah, can you like pull this down? Exactly. Thank you, this a great move. Oh, you saved the day. Have to be careful about the carotid somewhere down there. Try to pull more from here now. Kittner, please. Might be able to get a little bit of release here. Yeah, this is the band that I told you, which maybe go from above, okay? Nerve stim. Stim's on at .5. But it's soft. It's not like holding... Yeah, I don't know that it's... But it will at least release the nerve. So, anything here? No, nothing there. Oh, all branches there. Waoah, wait, wait, wait. Here? Nothing there. Can I get a right angle? All branches there. Here? Nothing there. Give me a Kittner, please. Listen, we have, you have to dissect this branch for me. Take a Jake, take a Jake and come from above. Yeah, I'm just... But you have the window there. Okay. Can I get a Jake, please? I think the thing is this window doesn't seem like it's a good plane. Like, I actually think we're in mass there. So you wanna try maybe, at least release the nerve from the more distal part? Yeah, I mean, it's just hard 'cause... But it will, yeah, yeah, do that bluntly. Do that bluntly. It will at least help us to push the nerve away and try to find out the boundaries of the mass. I'm tearing okay? on purpose because don't wanna cut through tumor. See, there's like the muscle tendon. When it gets into the stylomastoid foramen, it's a tendon. We might be hanging on tendon here. You see that guy? Give me a Jake, please. You know what? Nevermind, he got it. Yeah, this guy. This guy's what... That's rock hard, Dr. Slonimsky, just so you know. Well, we're on the stylomastoid foramen. Yeah, I don't... There's, and you're, just don't go into nerve by accident... Yeah. Make sure you're come above it. I'm trying not to apply pressure superior... Yeah, go closer to the mass, okay? Yeah. Nerve stim. I think that was the move. Bipole. That was the move. So, nerve is detached now. I see what you're saying, there's a little bit of tumor there but now when I see the nerve I can maybe come a little bit around it. Yeah I mean now all of this... Yeah, so open that for me. As long as you're not going through tumor. Do you think you can...? Can we stim there too? Kittner, please. You know what? Give me pledget and smooth Geralds. You want a new one? No, it's fine. So look, here. I'm pushing the nerve superiorly. This is what you should divide and then it will leave minimal residual tumor there. This is the nerve, you see it here? Yep. I'm going towards it but I'm not gonna go to it. Yeah. See you have this band? Now we will have to dissect this away, right? Yeah. Not sure if there's anything we can do there. You can probably pass the dissector from here. Here to there, yep. I'm gonna go posterior to the mass. Yes. Okay, and you can, you see? You still have more... Yep. That you can take there. I don't think, I think if I will, you see the nerve, right? The nerve's here. Yeah. Careful, no, no, no, no. Yeah. Go closer to the mass. Closer to the mass. What about this? I'll take this inferiorly so I can see nerve. Okay, now... And dissect away from that. I think we can... So, this is the inferior division running up there. Yeah. Nerve is not, okay I see. Stim first. Can I get a nerve stim? And cut it with a blade. All branches. No responses there. Cut, cut... Can I get the 15 blade, please? So now close it and push the nerve away and cut, yeah cut there. Kittner, please. Okay, nerve is all the way up, you see? Yeah, it's all up now. It's all out. Can you stim here? Nerve stim. No responses. No responses. All branches. Thank you. You're welcome. Tracing a little bit. So, I think it's the muscle that I feel like is this, but I try to go as superior as I can. Okay, I want you to stim instead of me and I want you to cut it off. Now, let's make sure we know where the nerve is. Give me a Kittner, please. You feel like taking you towards the foramen. Yeah. So let me, how about I push the nerve... Yeah, and I... Just be careful. Don't go towards the foramen too close because the nerve, you're gonna move the nerve back, okay? Yeah, I'm going to... Do you agree with this? I do. With the plan? I'm gonna take it here... Yeah. And see if I can rotate and pull it away from... You'll see, once you start opening it it will come. Yeah, I just wanted to... You saw, he took it off, not me, right? Yeah. Listen, I don't feel... Do you wanna mark like the deep aspect or is... I think the deep aspect's gonna be very clear to them. You know you would be surprised. Like, when you give them a tongue, right? You know, okay put your finger here very gently. You as well. That will be good. Can I get a silk, please? Silk stitch. You feel a bony structure? Yeah. You know what it is? You know what, feel it here, it's here. This. Oh, the styloid process? Yeah, it's the styloid process. Which what do you think about, there's a little tissue here. Can try and clean a little bit more but... Yeah. I don't know if it's worth it. So think about it, mastoid, styloid, stylomastoid foramen, facial nerve. ENTs are not very smart so we make head and neck surgery, all the anatomic structures, very simple. Nerve stim, please. Stim's on at .5. Good responses? Yeah. Beautiful. Good responses. Give me a, you know, you wanna send this for frozen? Just to see if it's worth chasing that. What, this little guy right here? Yeah, I'll take a piece of it. Give me smooth Geralds and some, and sharp scissors, please. Yeah. I'm gonna send a frozen tissue from right stylomastoid foramen. Question of tumor. I'm just going to go through here. If this is just muscle, then... This our like deepest margin from the foramen. Here, okay so it's here. Chad, can we get more Telfa, please? These two pieces, thank you. This should go for frozen. Nerve stim, .5. All branches. All branches? Yeah. Okay. Again, tissue from right stylomastoid... Foramen. Question of tumor / carcinoma. Look the angle of the mandible's here. It's completely posterior. Right? It was all like behind the angle. Yeah. I think the tricky part now is gonna be identifying our borders without the SCM. Why, you elevate the flaps, right? Because you did not completely elevate them. You have the jug, you have the accessories, you have digastric, put it up. No, no, I'm just saying to peel this off here. Like this isn't part of the... Oh, so you'll go back to the muscle. You see the accessories? You'll go back to the muscle here. Yeah. Yeah. You basically did most of your level II. Yeah. As you can see you just complete that. Yeah. I need to talk to Goyal.

CHAPTER 6

I'm gonna try and have him call in here. Okay, yeah. Where's the vein? The vein's right here. Interesting. Cut branch of the great auric, I don't know if it was direct stim. So, we'll do like level IV below the omo without dividing? Yeah, so it'll be right total parotidectomy, stitch marks... Yeah, do a subtotal. Or long stitch marks deep. Subtotal parotidectomy. Is this the vein? Oh no, it's AJ I think or like a a little anterior branch. I don't feel strongly about level Ib. If he wants us to find vessels then fine but it's still a difference than doing a full Ib dissection, right? Don't mess with EJ anymore, okay? No, EJ is good. Now, where's the angle of the mandible? Remember your height is not what you think it is because you opened the parotid so this is the angle. Wanna be able to see the submandibular gland. Now what we can do until he responds, you can do level II, III, right? Yeah. You can start your lateral neck. Should I do the knife for that? Well, remember, her chin is here. So, the gland is gonna be only somewhere around here. This, okay, her hyoid is here. I would figure raise just a little bit. Don't worry about it and don't go too deep into the fat 'cause you'll go into the gland. So, where is the platysma? Here, this? Platysma... Yeah, so you need to go like here, right? Let me just make sure. I think here you're a little bit in platys so you have a little bit of platys going down... So, you want me to come here. I think so. And between there. First stim. Wait, wait, wait, what about, I thought more about like here. You see? Platys is above you here. That was what I said, and then you told me to... Well you, well don't forget I'm standing in a very awkward angle. Yeah no, that's my fault. I should have just stuck to my guts. My point is you worked so hard to preserve the nerve, don't mess the marg over there, right? So maybe you start seeing fascia of the gland. Here maybe. I think this is my gland right here. This is gland, this is gland. But you don't need to do it. No. At least not now. Not until later. Because you have digastric, right? This is for later. We can divide this for later. Wait a second. Let's stim that. See something running here. Is the stim on? Stimming. Nothing? Anything? Good. Think we might be a little bit supraplatys here. You see, I see platys and then it's gone. Yeah. So, maybe this was... Why don't we just... I told you, just do... Yeah... We don't need to raise this anymore, do we? Yeah, just do, you have everything opened, do a level II, III, and IV and then if we have to explore for vessels we can go straight to them, right? We don't need to... Yeah. Delineate the gland that well. Now, okay so this is the anterior border of digastric, right? You'll need that for level, for level II. So, do this for level II. Yeah. How about, you think you can extend your skin incision a little bit? Yeah, maybe, it's, she's just got a... Yeah, so... Can I get a knife, please? Take it up to there. Just make sure it's a straight line. Thank you. Okay. I feel like level II, III, and IV is more adequate here. What do you think? Yeah, I think so. I mean, you were correct, but I think that he's still... Is that omo already? Or still SCM? I think it's still SCM. I think she's just got a big SCM. It's because we opened it here. Yeah. Right?So, I was gonna have Carly grab the... Yeah, start finding the anterior border. Hey, could we get a DeBakey? Then I grab over here and we'll make a little fat pad. That allows us to come right down on the muscle. Should we call the main specimen like also level II? Or we will add some level II from here? No, I think we're gonna at IIb 'cause this is spinal accessory so if you feel it here there's a little... So this is IIb and this will be IIa. Okay. Can you move and grab up here? Yeah, follow Rich. Yep. Beautiful. Now where's the jug? It's here, down here, yeah. Yeah, we're still a good deal away. Yeah, hold this please. Another Allis. Drop the vein, yeah. So now the window doesn't have muscle to rest on, okay? Yeah. No, no, why there? Well, I was gonna start here and bring it all the way up. No, why, keep opening here. You have muscle up to here so just release it from there. What is that? Is that... I was concerned there was some vessels along. Okay. Wait a second. That there, that there's some nerves along that we could... Yeah, give me a nerve stim. Wait, wait, wait, wait, wait, wait a second. Stimming. Yep. Yep. Getting some mentalis and oris. Yes, yeah. So look look, you see the nerve here? Yeah, that's... In here. So, I wanna show you something. You are much higher than you think because the angle of the mandible is here. Everything is opened. The parotid is opened. Yeah. So, you see the marg is actually here. So somewhere, it's probably that thing here. Yeah. So just keep in mind. You did such terrific work preserving the nerve... Yeah, let's keep it preserved. Yeah, keep it preserved. I do think I wanna just go along here. And you can maybe clip it here and throw it down from there. Yeah, because these... Or, you know alternatively, you can do your neck dissection from like under, once you open here, you see how it bifurcates? You can complete your neck dissection without even dividing it because you can go from here, you see digastric, right? We'll open this here, right? Yeah. Yeah, yeah. Just keep it from them running so they won't have any complaints. Okay. And just divide it here. Come across here. Divide this way? This way, so you can pull your SCM and then you don't mess with the nerve as well. Just we'll need to let them know that the nerve is here over the vessel. Nerve stim. I just wanna make sure there is no branch. Stimming. Nothing? No responses. Okay. Okay, now you can dissect the rest. I'm doing it for you as an exercise, okay? Just to challenge you a little bit. You have a window here also. Yeah, I just thought, saw that nice plane and I wanted to in it and then make a little boop. Can I put you on speaker? Yeah. Hey, so we're done with the parotid. Okay. It was tough. Nerve is intact, stimulating well. Nice. We're going for the, the neck is already open so it should be quick. Now, it was, most of it was very posterior behind the angle of the mandible so I feel more like doing II, III, and IV. Yeah, that was my, Emily and I talked about it recently as well and we were kind of in agreement that II, III, IV made the most sense. Okay, so for the vessels I mean it will be easier for you to come from behind. Everything is quite open, and find the facial artery. Yeah, that's no problem. I don't know what you mean by, I mean, I can come down if you want but usually I'll just lift the submandibular gland up a little bit and we'll find the facial... Beautiful. Okay because I'm not doing level Ib, that's my point. Yeah, yeah, yeah, you don't need to do that. Yeah, that's no problem. Okay, all right. Cool, awesome, thank you very much. Thanks. Do you want us, do you want us to, we can probably come down and then start looking at the defect and probably raise the rest of the flap. Did you end up taking a lot of skin? No. She'll just have more for volume. Okay, perfect. That sounds great. Yeah, okay. So yeah, I'll be down in a little bit and then we'll kinda, we'll finish up the flap and then we'll get ready for you. Okay. Okay great, thanks. Bye. Oh, we have to take some skin. Did you want to? Yeah. No matter what? Yeah, yeah, the one I marked. The pieces I marked. Yeah. Can I hand the permanent off? Did you need that for... Uh no, you can hand it off. Right, Dr. Slonimsky? What? The main? The permanent. She can hand it off. Yeah, yeah, the big chunk, yeah. Jan, I can give it to ya. Okay and now you can continue work from here. No, I understand. I just wanted to make sure that these EJ nodes follow... Okay now, go from - I don't want to forget to take the skin. That's my point. See that my mark was already erased but this skin where it's like very thin, yeah. Let me see, let go for a second. Can I have a Gerald with teeth, please. And give me a marker, please. Yeah, this is the epicenter, I agree where the skin's like a little bit purple. So I would go with this. What did you say like a penny or... Yeah. I would say... A pennickel, a pennickel. That's a quarter, a quarter isn't it? I don't know. Maybe, a nickel. Okay. Do you want a Gerald with teeth, please. You'll just have to name these two pieces differently. Posterior... Yeah. And anterior. So, this specimen will be permanent. This is skin over tumor. Skin over tumor. Posterior. Posterior, you said? Yes. Okay. This is the posterior. Same name, anterior. Skin over tumor, anterior. Anterior is up on the table. Because it's not over my forehead. Okay. Dr. Slonimsky you didn't want those... This feels great. Can we just start with IIb here since we have jug exposed, we've got accessory exposed... Yeah, yeah, yeah. Just take IIb... Yeah, make your life easier. Yeah. Allis, please. Now what you can do with the muscle, you can put that, pull it... Yeah, yeah. It's the easiest IIb you ever did, right? Yeah. Okay. Thank you. How do you retract here... A vein retractor. I did a Babcock, can I get a vein retractor? I liked the Babcock. It was nice. Yeah, but it's locking on the nerve. If something happens and it falls. Uh, can I get the Bovie, please? So, I usually take the bipolar and I work with the bipolar, yeah. Now, what you can do first, Burlisher, can just dissect the lymphatics off the jug. Off IJ. Okay, and then you need to reach the floor, okay? So follow the muscle. Like that, very gently because the nerve can also be stretched and although it will still be intact physically... Can I get an Allis? Nice. Beautiful. All right, don't mind me. Now remember, don't go to level V. Nope, once we get to the floor... Okay. Start curving anteriorly at some point. Yeah. Yes, exactly. Go back to the muscle. This is confusing because we cut the muscle so it... Yeah, so that... Usually you retract the muscle, right? So you know where your boundaries are, but right now you don't because the muscle is like already cut, right? Okay, take a good bite. Yeah. Remember where your jug is when you're coming back. Yeah, jug is right here. Now, we don't necessarily need to cut it out. You can throw it down there and then come back to it when you're doing your level III, okay? Remember that now it's a little bit different. You did not find your rootlets like you usually do, okay? No, no.Yeah, that's why... So be minded, yeah. That your plane might not be the one you used to work in. Yeah, start opening the corner. Yeah. Where's accessories, yeah. Right there. Yeah, okay. I like that we had the same thought at the same time. Oh my god. Like sharing a brain or something? That's not good. I'd love to share a brain with you, Dr. Slonimsky. It's a little bit of muscle coming up here. So look, this, look I'm trying to find maybe some rootlets there. This looks like a rootlet. Yeah, yeah, yeah. Stay above it. You know what, I'm gonna... Yeah, stay on the muscle. Now the problem is the jug is still, yeah, yeah, but... The jug is still attached. Is that jug again right there? Where is it? I don't think so. I think hold on, it's right here. Pull it again. Yeah, so let's see jug better, okay? Yeah, I would come, smooth Geralds, please. There's jug. Yeah, but basically you need to come from here, right? So, open on that along the nerve. Yeah. This will release the lymph nodes for you. Where's the bipolar? There? Yeah. Okay. Hold on. Oh, I'll take care of that. I got it. I have it. Can you clean the tips? Thank you. You got it? Yeah. Okay, feel like you're running along like a little bit in the, in the packet, yeah. In the packet. Yeah. Just bring yourself back to the jug at some point so... Yeah, the jug is here. So, I'm gonna... I'm gonna prime this corner here. Yeah. Where's the carotid? It's just... Carotid. It's more medial. Yeah. Far more medial. Okay. Since everything is already open... I think we just... I don't feel, you know, hypoglossus. Yeah, it's not... Will be somewhere here. When we take the packet off you just keep mindful that you're gonna, you might meet it on the other side. -Here, I'm gonna just dissect all this off the jug, so we have to find out medial side of this. And then you'll cut this. This will be a level II. I've gotta push through just in case there's something. There we go. Yeah, just work on that. Is this a rootlet? Might be a rootlet hiding there. Just stay above it. Just wanna make sure I'm getting that too. Just got it. Just, no don't pull carotid sheaths towards you, okay? Yep, I won't. Are we still airplaning? Yes. No, no, we're good like this. We still have all the, see might be some tiny rootlet there. There's no point of taking, these are the muscles, right? So, no point of taking them. Careful of the nerve. Vessel or... It's a vessel. Yeah, no I was gonna say I wonder if it's... Or a node. A lymph node. It's a tiny node, so, keep it with you, the DeBakey, please. DeBakey. Just take this node with you. Now remember, at some point I mean the nerve meets the muscle. Yeah. You have to truncate your level IIb, right? Yeah, no I think we're getting towards it. We are going to give you a right neck dissection, level IIb. Right neck dissection... Wait, wait. See this node? Take it. Grab it, will you? This node, yeah. Perfect. See the floor? All right, what do you wanna do next? Like work from here? I might come here and work this area. Yeah, exactly, go back to the normal. Yeah, the normal. Approach, okay. You see how high you are? This was only your level IIb. So still have IIa, III, and IV below you. Yeah, yeah. Just because every time when you do a parotid you are much higher than you think. I want you to grab this guy right here. Remember your vein here, okay? Bovie, please. Can I get a DeBakey? Allis. Another Allis. Army-Navy. Would you be able to hold both of these with your right hand and hold the Army-Navy for Rich? Like that. In that hand. You'll need to cheat a little bit under the omo, okay? Yep. There's a big vessel coming down there. I think the stent here that you met before. Yeah. Harmonic. Hold this. Could you stop head butting me? I'm GoPro-butting you. I understand that you're mad but... I'm very proud. You can see me tearing. Yeah, me too but mine are tears of pain as I get punched in the back of the head. Okay, just, go across this vessel. You know what, give me, Harmonic, I will work for you as long as... I was gonna... What was that twitch? You know? He's asking you. Could be a muscle fibers? Which muscle? The omo? Correct. See, I told you she knows. That's impressive. Why did the ulnar twitch, though? Sorry. Lift this small guy for me. Do you know why? Oh, what was the question? Probably won't do the trick. Okay now use the dissection, use, put something here. Yeah, could I get a... Now, this is holding you here. Don't stretch your external jug too much. Now, just be careful because you see the muscle is still like... Yeah, yeah, yeah. You're in the muscle. I'm just holding some tension here. This is your jug. I think you're already start seeing it here. Okay? Careful, you're very close to it. Nice. Wait, wait, wait a second. You know, is it better that we just divide the vein? Don't stretch it to death. Or do you want me to release it from here further so it can... Well, but remember we have this... Branch. Hey Dr. Goyal, I wanna show you something. Okay, yeah. For when you take the vein. Yeah, yeah. Nerve stim, please. So, this is the external jug. Yeah. And here, can you turn the stim on? This is the mentalis, the marg, can you turn it on? Yep. See? Yep. Stim's on. Responses. So just you know if you divide it just be careful because... Yeah, can you just take it down for me? The nerve is riding, yeah so where do you want us, here, here is okay... The vantage point ff the vein. This? Yeah, right below that. Below, so... Don't worry about it, it doesn't matter. You don't want like two branches? So you have two calibers, just below it? Yeah, right there's fine. Okay. Or just actually, actually I'll change if you wanna do it right at the, right at the branch on the other side of the branch... Okay. 'Cause then we can join it together if we want a bigger lumen. So, clip and clip. Two clips. Okay. Or I guess four clips, but yeah. Cool, thanks. And you're done now? He's doing the neck, he did level II already. Yeah, nice. Just III and IV. That's nerve there? Oh my god, listen, I had to dissect, we had to dissect all the way to the stylomastoid foramen. Oh nice. So this is the nerve. Yeah. We pulled it from below. I took some, I took some digastrics to the hyloid... Sure. Yeah still the hyloid and SCM all this is cookiebite we took with that... Oh, that's why, yeah, yeah, yeah. So it was in the SCM as well? It was stuck to the stylomastoid foramen. We had to dissect it all the way out there. So yeah I think for me that's just further evidence to say that we should do a neck. Yeah. Because it's acting that aggressively. So this is, where, can you point to accessory, Rich? So, when I took it off I found the accessory and jug here. Yeah, yeah. When I was pulling it off. Is that right? Yeah. Okay, cool. Please have medium clips available for us. Okay, can I get a medium clip applier? And you're below nerve, right? Can I get the medium clip, please? And keep a little bit of distance from the bifurcation so they have... Did they want a clamp on the bottom? What, okay, the nerve is above you? Yeah. Yeah, okay. Do they want a clamp on the bottom? No, they want to have both branches to be able to plug into. Okay. So you'll clip this one, then you'll clip the anterior one. Go from, you have a window there. Yeah, that's just... I'll move over. Should I throw that one, you'll cut in between? Sure. He didn't want a bulldog clamp, right? He said clips, right? I think so. He said four clips. Can I get the Metzenbaum? This will make it easier for you when it's like out of the way. Don't have to worry about any of that. Not anymore. Still hanging on something. Yeah it's, there's a little bit of fascia there. Okay. Can cut it. Scissors. Okay. Okay. See this node here? Move the front? What can I do? Get used to it, okay? Take it off. Maybe your head is not in the right place. Not give me a concussion? Okay so look at that. Go from the nerve. Just dissect this tissue off. Go from the nerve from above. Right, and then you can dissect that part off. Yeah. I mean this is in muscle here. Yeah, so you can, you can, you can just go across this if you go from the nerve. Why are you, are you behind the nerve? Yeah, I'm in front of the nerve. So, the nerve... Oh, so what's that? Is this a vessel? I think that's a little vessel or there could be a second branch. Is the stim on? Yes. 0.5 please. Stim's on at .5, no responses. That's like the vein of the Bavir. Wait, wait, wait, wait. On? Yeah, stim's on, no responses. No responses. Want Harmonic? Mm hm. Harmonic, please. Harmonic. Might be like part of the tendon, maybe like so. Yeah. 'Cause like I think that's just part of the muscle. We can... Good, 'cause you can divide this. Give me the Harmonic, please. That's... Yeah, I'll help you with that. Assist you with that. So we're not leaving a - no node left behind. Once you, I don't wanna do that because it's hot but once you open that corner that's it. This, you can bring this with your packet. This is a next level parotidectomy, man. Parapharyngeal space. Can add it to the note, you know? Yeah, now I think, now that I'm all the way away from, largely away from nerve. So in the future when you run your cases... Yeah. If you have parapharyngeal space tumor this your approach. Yeah, yeah, absolutely. You don't necessarily need to find the, the facial nerve... Yeah. But this is the approach. It's up through the neck. And the angle of the mandible. Sometimes you need to divide the stylohyloid. Yep, yeah, yeah. I think we're just, you know, we're working too hard and we can just... We can just truncate this. Yeah, cut this, yeah. Now don't forget, we don't do it like the classic way but don't forget now you can go back to the tract, okay? Yeah. You have your jug. You have the packet released, come behind... I just think we may have not gone all the way to the floor here. Find omo first. Hold on there's, the accessory's being pulled pretty bad. Yes, but you wanna come from here to here. Yeah, but you wanna come from here there, right? Yeah. So now go back to the track of doing the level, oh you're doing like the level II? Yeah. It just, I thought that most level II is already like up here. That was kind of what I thought too and then I was looking and I was like no we're not actually at floor. Okay, I see what you're saying. Okay. Posterior branches could be there, right? Army-Navy, please. Switch hands please. Maggie. Okay. Did that. Omo's here. Yeah. Yeah, that looks good. Now I don't want chyle leaks, okay? No chyle leaks. So do like III and a half. Perfect. I see a curve here. Okay. Was the belly moving? The trap. The trap, I think it's accessory moving back. Okay. That was probably accessory in V. I think here we're starting to see some of... Or to release the floor of the fascia. But this is, you have to open this corner here. You don't have much left on level II. Yeah, you're right. We can equal that. Give me a DeBakey, please. I'll help you pick this up. I know what you want. You want this, right? Yeah. Yes. Okay, posterior branch so climb more superficially. Can I have the Harmonic? It's not worth for this benign appearing tissue... Oh actually, yeah. To get the posterior branches of her... No, no. Please add this to level IIa that we'll give you. You wanna send this as one specimen or separate them? We'll separate. 'Cause you have the IIb, right? Yeah. Also, a lot of your level... This might be... Some of your level II is with the parotid. I think that's V Floor? This is V, yeah. Okay, that's good. Okay so let's take this node. You see this node under me? Yep. Okay, now I don't want you to start climbing yet because you still don't have everything opened... Inferiorly, yeah. Inferiorly, right? Right. We're only on the right side today besides Dr. Goyal which is on the left side. Careful, is this a vessel? Yeah. Yeah, I think that's all floor right there. Yeah. Now give me, give me a Schnidt. You are hitting my head. Sorry, right? Who is, yeah. Now I just wanna show you my move. If I don't divide, because you did not move. Now, what I'm doing, there's no point of retracting this skin and that also. Both, right? So, I thought it will be long enough, okay? All right, now keep in mind clavicle is here. The tip of this instrument is below clavicle. Okay? So, I don't want you to go with your dissection lower than here. Yeah. Okay? I mean, with us doing III and a half, do you wanna just come here? Here, you'll see and don't worry it will be IV. You'll see that when you're done doing that you'll say hey, everything's open to the clavicle. No, I'm just saying 'cause we're, we're not, we weren't intending to do it, through IV. You will do because you're retracting the omo. But from my experience if I tell you guys III and a half I end up with IV. If I tell you IV I end up with IV and a half. Kittner, please. So, it's my... We're down to floor right there. Can I get a Burlisher? So, I wanna show you how I'm doing the lower neck. Yeah. Give me a right angle, please. A blunt. Oh, okay. This feels, I don't feel like any bad lymph nodes there. Yeah, I was gonna say there's nothing that I'm feeling. Yeah, so another reason... That's fascia right there. To be conservative and not all crazy about this thing. So, what I do, I delineate, it's you now. That was you. Now, you're going to see the transverse vessel somewhere. Yep. Okay, what I do, I pass the dissector from jug laterally. Yep. Okay? And every move I do I do with the Harmonic on the lower neck, okay? Yeah, so as to prevent chyle leak. Yeah. Sorry, it's like I'm asking you to retract but actually, sticking my elbow in your face. Okay, here I want you to do it and I'll grab the Harmonic below your hands. Are you comfortable standing there or do you wanna stand over the head? No, I think I should be able to look around Okay, let's get an appendicial instead of that. Recognizing that there's a good amount of... Okay. I just wanna also be clear that we are... You're not going below that. Yeah. Not below here. You can maybe pull that. You still have the fascia. I mean, if you open the fascia even with a Bovie... Yeah, it's gonna make... Then yeah so, open the fascia there. Can I get the Bovie, please? But it's hard to tear through the fascia, right? To punch through. You have a frozen report. Yes? Yes, this is pathology, Dr. Wong calling back for frozen for your patient. We got the tissue from the right stylomastoid foramen. Yes. Which showed marked acute on chronic inflammation, negative for carcinoma. Thank you very much. Thank you. Hey, that's not bad. Well, it's only the frozen, man. You know how it works. Yeah, and still stay superficial, okay? Open layer by layer. You see because there are vessels hiding there. Do you know what vessels, uh... Can you... Do you want me to poke through? Yeah. Oh yeah, do you know what vessels are in the level IV of the neck, Carly? The vessels that we typically worry about? Is that like the thyrocervical trunk? Like those ones. Eh, that's close. Maybe, you can take maybe a sharper one once you open that to poke through. If not, let me try, yeah, let me try... To head butt me a few more times. Okay. This is just not... Yeah, it was a little bit hard. Yeah. It's not doing anything essential. Nice. Now take a look. Now you can see the muscles of the floor. Kittner. You see? Yeah. Here, now, wait wait, give me a nerve stim. On 1, please. On 1, please. You think so? Take your hand off and feel the patient's abdomen. No responses. No, thank you. All right. Oh, you know what? This is branchial plexus. Look at that shoulder. Yeah, yeah that's absolutely, yeah. This is why it's so important this is phrenic also, to not violate the floor. And remember I told you, you are low enough with so called III and a half, okay? 'Cause this is the brachial and you're posterior enough because you're like, hold this, okay so don't go too posteriorly, okay? Because this is already the brachial plexus. Another Army-Navy. So this, you see it slipped. This should hold that... Yeah, both. Okay, I can come from here. Open to this move. I'm just gonna... Sorry, I was pushing down there. Okay, now go back to... Hold on. See this little guy? Yeah, the color? Yeah, that was the... So you know what? Bring that up. Give me bipolar, please. Where's the pedal? You'll pull it for me with like a DeBakey, and I will skeletonize it out. Do you have the pedal? I do. Okay, pull that. I think I... You know what, give me DeBakey. No actually, you have the pedal? No, no, come out with this. Come out with this. On. Just because the brachial plexus... Yeah, yeah, yeah. On. You don't want it to be tented up. Yeah. I think the floor is all still down. Okay, on. On. Whoa, look at that. Yeah, yeah, yeah. On. That is a node, right? That's not TCV? That's just dilated. No this is... That's a node. No, no this is a vessel. It's pumping. No, I thought you were, I was talking about this guy. On. On. On. If we find the right plane, Carly... Here is the artery. You see the artery? Yeah. Here's the TCV, or TCA. Oh, you know what? It is pumping. Nerve stim. I think it's pumping. Nerve stim on at 1. No responses. Yeah, it's the artery. No responses. All right, where do you wanna stand? Where you are. Okay. Can I get a Burlisher? So, she doesn't have a lot of, a lot of it is elevated already. Yeah, yeah I honestly think that... Allis. Here's jug, here. Yeah. I like... You have some hiding here so let me, maybe pull this also. Can I get the Bovie, please? Now, your jug is up here. Wait this, you're down there. Be gentle with this. Now, what I want you to, actually I will, yeah, I will retract for you. You need to hold the DeBakey so you are able to... Tent it up? Yeah, okay. Also, if you release yourself here, whoops, sorry. You know what, I'll let you too - I'll let you release maybe a little bit before I grab it with an Allis. That. You have a nice plane below actually. You see the wispy stuff open there. Just like this? No, no, here, this is your right plane, you see? Oh, I'm sorry. Yeah and you can follow and climb this up. Why is there a weird color there? Like, it's not chyle, right? This yellow stuff coming. No, I don't think so. Just fat juice? Yeah. Okay. This is a rootlet, you see below here? Yes. Yeah, stay above it. This is your proof, you see the straps? Yep. So you know you're over rootlets, right? And you're back on the jug here. So almost done there. Yeah, I'm almost entirely off. Allis. Just be able to retract this for you. You'll include that. So your dissection will come all the way up here, okay? Yep, yep. Now let me just, this is gonna tear. Do you need retraction of the SCM or you think you're good? I think that that's okay. I'm just trying to see, 'cause I think ultimately, do you want me to...? Burlisher. Do you want me to knife the jug? No. Or do you want me to come from inferior to superior here? No. Burlisher. I was gonna just, I can define it inferiorly here. And also, okay just my request please don't blue line it. You see the silver fascia, keep it over it. Like open here. Okay. Keep the fascia over the jug. You can use the... You can use the Bovie for that. Yeah. Hi Dr. Funk. Hi, how's it going? Oh, just wonderful. You guys got it all out, huh? I'll show you. It's, so in order to take it out, we had to cut a piece of the SCM. Okay. So we traced, already traced accessories from below just to be able to pull it out from behind the jug. The angle is here. Okay. This is the, I also took a part of the, I think this is stylohyoid and this is the digastric actually and the nerve... And the nerve is right here. Oh. Is here, it was like... Did she lose any lower branches or... No, no it's all working. Wow. It was all pushed from below and we had to dissect it from the stylomastoid foramen from here. Can I have the nerve stim? So, this is like the main trunk. On. Stim's on at 1. All branches there. Wow, that looks great. Okay, yeah. Yeah. And I just told Dr. Goyal too when you are finding the vessels there is a branch, you see this guy running here? This is the marg, so it's like running here. Just be aware that it's above the clips. Is it above that clip or below the clip? Yeah, it's above. Oh, I see it. Yeah. I see it now. Yeah, but the gland should be below the digastric. The vein is gonna, cut. The vein is cut, okay. But there's another vein. No, no I asked them just to take it down. All right, I'm gonna define the superior extent here and then I think we can start coming all the way down. Okay. Does that sound good? Yeah, thanks. Okay. Are you done? Almost. Dr. Volenberg here did... What did he? Dr. Volenberg the other day, we were doing a neck, we were kind of at this point, maybe a little bit before, he came and said, ten minutes, get it out and like, kinda went and sat in the corner and it invaded carotid. And then what? It had invaded carotid. Not carotid? The jug, no? He took the jug, no? No, it was invaded the jug, we took the jug, and then it was also invaded the carotid. So, what did you do? We left it and... Okay, Burlisher, please. So, wait a sec. Why don't you still retract, Army-Navy, the omo? You need it, you cannot control the lower part. I was just working my way there. You see, and you have some lymphatics there still. All this. All that. I was trying not to blue line. So you see, you still have, well you did. You did blue line it here. I did blue line superiorly, I was trying to leave more fascia down. So, buzz here. Bovie, please. Below his hand, thank you. So Rich, do you see the difference? Look, blue lined, not blue lined. Yeah. Okay, just a little bit of fascia, that's all. Here now... What? Can I have the DeBakey, please. Just for a second, I wanna check something. Can I check something for you? Nice, okay this is what I want you to do. One thing you can do, you can either pull here or pull this superiorly. You see, not blue lined, blue lined? You see the tiny difference? Yep. Yeah, yeah. Especially if she has radiation you wanna leave some protection. Okay, attach yourself there. Careful there. This is not lymphatic tissue anymore so you can divide it. There's no point of chasing that. Can we rotate it and then just, yeah, yeah, that way and then we can... Is this omo? So, don't run in omo. No. Where is the omo? I think omo is being retracted, right? Yeah, but I think there's like a few fibers right here that... Yeah, I thought we were trying to get that. Yeah, you see. Yeah, yeah, yeah. There's like a little bit. Can you grab here? There you go. Just start here, it will be easier for you. Or use Harmonic or something that doesn't cause... Can I get a bipolar? Interruptions. Can I get the green bipolar, please? Now be careful, you're on jug here. You see this branch coming off? Yep. Um, wait a second, give me a Jake, please. Do you wanna dissect it off? Maybe clip it. A Jake? Yeah. Don't wanna cause a venotomy on the jug. Okay pull this, yeah exactly. Small clip. Can I get a small clip, please? You're pretty close. A little bit, no don't get too close because if it tears then it's a venotomy so go there. Are we sure that our clip is on the right side? That's the only thing. Yeah. Knife. Knife, or a Metzenbaum, maybe. Let's do another one here. Is this coming off the jug? Is this a vessel also? Yes. No, I think that's the clipped one. The one that we just clipped. Oh, we took. Yeah, yeah, yeah. Allis, please. There's another branch right here. Okay. Now when you come from the other side, is this carotid? Yeah, just be mindful of the hypoglossal, okay? Yep. Is this just, is it common facial? Yeah, it might be. It likely is. Can I get a Burlisher? Try to keep it, like dissect, cut. Yeah. Divide that, superior to it. Harmonic. Yeah, this is common facial. Accessory's down, that's digastric, hypoglossal's gonna be in the area, but... I think that... I think it is quite, the packet is peeling off quite superficially. Okay, you're okay with this coming through here? Yeah. And we're still lateral to digastric, right? Right, digastric is here? Yeah. Pull it up and... There it is. You feel the bifurcation there? Do you see it? Yep. Where? Nice. Okay, let's stim and verify. Can I get the nerve stim, please? So you see why I always like to find it, it's there, it's just there. On 1, please. Stimming. Okay, stim's on at 1. Tongue. Hypo... Responses there. Oris, mentalis. Thank you. Hypoglossus. That's right Hold this for us, please. You have the common facial, remember that you dissected it here but you still have another branch of it. You don't see it... Yeah, it's coming inferiorly. Coming down at you. Okay, yeah. Now wait, where is our nerve? Where is our... No, it's somewhere here, the nerve, right? The marg. Marg, no, it's up here. It's up here. Above the clips? Above the clips. Yeah, but still we're getting back to... I mean, we should be coming... Yeah, so exactly. So, let's come straight down. There's no point of climbing towards the face. Now, if she has marg weakness, we can blame Dr. Goyal. Here you go back to the straps, okay? Now, don't forget, neck dissection is not just along the jug. It's to the straps, okay? A hundred percent. Hold this. Did we give her IIa already? No, IIa is here. Okay. Why are you coming from lateral? From medial to lateral? Pull it up. Yeah, I think you have a little bit, you see, maybe some rootlets. Yeah, yeah. This guy is right, gonna be coming down. Take small bites so if you see the vessel, if it's coming at you. Can you hand me a smooth Geralds and a small clip? I'm afraid this guy might decide to open up. You're preserving ansa there? Yeah. Nice. Nice, nice, so nice. I'll go ahead and cut it, give it a 2-0. When you're done, survey the neck. Make sure there's no like ill-appearing nodes. Accessory's here. You want to send it all as one? Yeah, divide it so we know if she needs radiation? Hold that, please. So you see here, accessory runs and it's superficial to the jug. Let's run some Valsalvas, no bleed, no chyle. Can we get a Valsalva, please? Are you happy? I am. You should be. Army-Navy. You see that transverse cervical vessel? I don't see any of that like bleeding that I would necessarily pursue at the moment. Nice, I agree. This might be the thyroid, this might be the common facial, you see? Yeah. This would be superior thyroid. So, here we're done with the neck dissection so let's go over the anatomy. Internal jugular vein, spinal accessory nerve. Below my finger this is the carotid, okay? This is the posterior belly of the digastric and the stylohyoid muscles that were partially cut along with a cookiebite from the SCM to take the main tumor off. Can I have another Army-Navy? Thank you. Here we have the parotid bed with the facial nerve. Can I get the nerve stim? Let's see. Now, Dr. Bavir's gonna stimulate. And you can see the face twitching. Okay, I want you to put your finger here. Feel that pointy, what is that, do you know? Oh, I know what you're talking about. Oh, you think the styloid? No, the styloid is higher here. It's higher. Put your finger below here... This is another... This is the styloid. Okay. There is another bony protrusion here. Another bone in the neck that you don't typically think about. It's a landmark to find the accessory nerve that runs over it. This is that transverse process of C1. Dull Senn, please. Basin, please. End up having the full liter. Okay. Great, yeah. Focusing here also in that corner. Yeah. We didn't measure the tumor but I guess it's about like five over four centimeters. Maybe even more like six over four. Yeah, six over four. Or even more because remember it came out from down there. Yeah. That's a little marginal branch there. Let's see how this comes back together. Yeah, but she has a significant volume defect. Yeah. And once she gets radiation everything is gonna be sunked in on her jaw with no protection over the vessels because you took SCM here, right? So, she needs some soft tissue reconstruction. Okay. Nothing? Okay, so Emily, the marg is running here, okay? And I think this is the back of the gland. Okay. Like Goyal said, that you lift and you find the facial artery. I'm just making sure there are no other like branches are running here.

CHAPTER 7

The case overall went well. We met all the milestones and goals that we wanted to achieve. We managed to remove the tumor entirely while preserving the facial nerve and after we removed the tumor we stimulated the nerve and it was intact. All the branches were working with .5 milliamperes of stimulation level. It was quite challenging. As I mentioned before this lesion was wrapping around the angle of the mandible and going into the deep lobe of the parotid gland so it was also below, like deep and superficial to the facial nerve and it was actually quite adherent to the stylomastoid foramen. So we had to release the tumor from multiple aspects in order to be able to dissect it off the facial nerve while preserving the facial nerve. So, we had to utilize a little bit different approach from the standard approach of finding the nerve and dissecting along because at some point the tumor was so fixed to the mastoid tip, we cannot just dissect along the nerve without actually injuring or crushing the nerve. So, at that point after we identified the main trunk of the nerve, we started working around the gland to release it from the masseter muscle, from the SCM, we took also a piece of the SCM, and from the digastric to try and pull it from around the mandible to mobilize it. Once we got enough mobilization we came back to the main trunk of the nerve and started working from proximal to distal and release the nerve off the tumor, and then we went back to the inferior aspect to release a bit more from the mastoid tip towards the stylomastoid foramen and that way we could release the tumor entirely and as I mentioned before the nerve was functioning perfectly fine after the removal. After we removed the parotid tumor there was a big defect on the superior SCM. The digastric, we could see the carotid and the internal jugular vein, the spinal accessory nerve and the hypoglossal nerve in the surgical bed after the parotidectomy which is quite unusual for a parotidectomy 'cause usually you do not reach these structures with superficial, standard superficial parotidectomy. After that we moved on to a quite straight forward neck dissection level II, III, and IV of the lateral neck which all went well. We preserved vessels for the free flap reconstruction. The common facial vein, the facial artery, and the external jugular vein. From then, Dr. Goyal took over to close the defect with the ALT flap. First thing, never lose hope. There is always something else you can do and try. For example, this case as I mentioned was challenging because the tumor was stuck on the stylomastoid foramen. So, it was very hard for us to get access to the main trunk of the nerve because this is exactly where it's exiting the skull base. So then you should think outside of the box. How do I make the thing which currently is impossible into possible? And I think the first key aspect of a successful parotidectomy is being able to mobilize the mass within the parotid, mobilize it enough to allow you to dissect along the nerve. If you cannot do that you can also try retrograde dissection, meaning you can find a distal branch exiting the parotid gland and start working from distal to proximal and start peeling the tumor and the gland off but in a reverse fashion. And sometimes you can combine. So, for example in this case we also find a few distal small branches and started following them from distal to proximal and then came back to the main trunk and made a dissection from proximal to distal and then released a little bit from below so we can lift the tumor more with our hands and allow us to put a dissector in the new space that was opened there and then continue the dissection safely. Some of the distal branches of the facial nerve are extremely thin, maybe half a millimeter. It's very hard to see them without the magnifiers and you have to be really careful to preserve them. So, it's about planes, surgical planes, finding the best route to dissect along the nerves because all the head and neck surgeries about cutting out a tumor while preserving the vessels, preserving the nerves, preserving everything around it. This is the challenge working in a packed space of the neck. The last aspect is also to rely on your assistants. For example, I was working with Dr. Bavir which is our chief resident and I always, as an attending physician, always stop and ask, hey, what do you think? What can we do differently? Do you have any good idea here how we can proceed? It seems like we're a little bit stuck. And many times the residents have excellent ideas. You implement them, you move on, it also contributes to teamwork, to the atmosphere, to the understanding that we're here together. This is a case that we are doing together. This is a mutual task that we have to achieve. And teamwork, this is the key. It's the teamwork. We also have a medical student that assisted with retractions, which were extremely helpful. So, as I mentioned before this is a teamwork, and the brainstorming along the case, always try to think outside the box. Why am I stuck? What can I do differently?