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PREOPERATIVE DIAGNOSIS:  Metastatic right neck squamous cell carcinoma.

POSTOPERATIVE DIAGNOSIS:  Metastatic right neck squamous cell carcinoma.

OPERATION PERFORMED:  Right modified radical neck dissection with sparing of the eleventh spinal accessory cranial nerve.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  Approximately 25 to 50 mL.

DRAINS:  Drains included a 7 mm Jackson-Pratt drain, which was left draining the right neck via a separate stab wound.

SPECIMENS:  Contents of the right neck, which included the internal jugular vein, right sternocleidomastoid muscle and a large 3 x 4 cm mass, which had been dissected from the carotid artery.

INDICATIONS:  The patient is a (XX)-year-old female with a history of laryngeal cancer, status post total laryngectomy 3 years prior, who recently developed a right neck mass over the last 3 to 4 weeks.  A fine-needle aspiration biopsy of the neck mass was reported to be consistent with squamous cell carcinoma.  The neck mass was located in the right anterior neck, anterior to the carotid sheath and just superior to the trachea stoma.  No other neck masses were felt.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and placed on the OR table in a supine position.  After having an endotracheal tube placed into the trachea stoma, the patient was prepped and draped in a sterile fashion.  A modified Schobinger incision was then made in the right neck, extending from just across the midline at the position of approximately the hyoid extending posteriorly over submandibular space about 2 fingerbreadths below the angle of the mandible to the tip of the mastoid.  A vertical limb was then dropped from the mid portion of the horizontal incision in a lazy S fashion down to the mid portion of the clavicle.  The incision was carried down through subcutaneous tissues and platysmal muscle with the use of electrocautery.  A subplatysmal flap was elevated anteriorly to the stoma as well as to the superior border of the clavicle.  A superior subplatysmal flap was also elevated to the level of the digastric muscles and posteriorly to the medial tip of the mastoid.  A posterior subplatysmal flap was elevated back to the insertion points of the trapezius muscles.  The skin flaps were held and sutured back in position with interrupted sutures of 2-0 silk.  Dissection initially began inferiorly along the clavicle, where the medial and lateral heads of the sternocleidomastoid muscle were dissected and divided.  After dividing the inferior portion of the sternocleidomastoid muscle, the internal jugular vein was identified.  The vein was cleared from the surrounding soft tissues and from the carotid sheath.  The carotid artery was identified along with the vagus nerve, making sure that the vagus nerve was free from the area of dissection.  The inferior portion of the internal jugular vein was then divided and tied with 2-0 silk ties and 2-0 silk suture ligatures.  The dissection then continued laterally along the superior border of the clavicle to the point where the omohyoid muscle was encountered.  This was then divided and tied also with 2-0 silk ties.  The tissue was taken down to the level of the scalene muscles where the fascia was then carefully elevated in a superior fashion.  During this elevation, the transthoracic artery was identified and divided with 2-0 silk ties.  Attention was then directed superiorly along the posterior-superior border of the sternocleidomastoid muscle.  The soft tissues were carefully elevated as the dissection was then directed inferiorly along the posterior border of the sternocleidomastoid muscle.  Here, the spinal accessory nerve was identified and then carefully traced into the sternocleidomastoid muscle, separated the muscle until the nerve was free.  The nerve was eventually traced going up toward the jugular foramen and then carefully retracted posteriorly as the superior portion of the sternocleidomastoid muscle was divided with the use of the electrocautery.  With the spinal accessory nerve now free, the dissection then continued inferiorly along the anterior border of the trapezius muscle down to the level of the scalene muscles.  Here again, the fascia was peeled off of the scalene muscles along with all of the surrounding lymph tissue, which was retracted superiorly and anteriorly.  As the dissection continued medially, the internal jugular vein was again encountered.  The dissection was then turned inferiorly where the internal jugular vein along with the contents of the neck were separated from the carotid artery as the dissection proceeded superiorly.  During the dissection, care was taken not to injure the vagus nerve.  As the dissection proceeded superiorly, the mass which had been previously identified in the suprasternal area was encountered.  It was noted to be very adherent to the carotid artery but with careful dissection it did separate.  As the dissection proceeded superiorly, the superior thyroid artery as well as the lingual artery were divided and tied with 2-0 silk ties.  Dissection was then turned superiorly.  The superior border of the sternocleidomastoid muscle had already been divided.  The posterior belly of the digastric muscle was identified and the contents of the neck were freed from this structure and then retracted anteriorly.  As the dissection proceeded anteriorly, the submandibular gland was identified.  The surrounding soft tissues were separated from the submandibular gland leaving the submandibular gland intact.  As the dissection proceeded anteriorly, the previously mentioned mass was once again encountered.  Here again, it was carefully freed from the remainder of the carotid artery with the contents of the neck and the internal jugular vein being retracted anteriorly.  As the dissection then continued medially, the remaining strap muscles on the right side of the neck were removed in toto with en bloc resection with the surrounding neck mass.  The mass did not extend to or involve the trachea stoma.  The mass was removed in its entirety.  After removing the neck mass, margins were sent to pathology from the fascia of the carotid artery as well as the deep muscle layers and all were reported as being free of any residual tumor.  The wound was then irrigated with copious amounts of normal saline solution.  Hemostasis was obtained with electrocautery, bipolar cautery, as well as with 2-0 silk suture ligatures.  A 7 mm Jackson-Pratt drain was placed within the depths of the wound, exiting the inferior aspect of the wound.  It was then sutured into position with an interrupted 2-0 silk suture.  The skin flaps were released and returned to their normal anatomic position.  The flaps were then closed in layers, first closing the platysmal layer with running sutures of 3-0 Vicryl and closing the skin with skin staples.  The procedure was then ended with the patient tolerating the procedure well.  The patient was transported to the recovery room in stable condition.

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