Preoperative Preparation And Operating Room Setup

The patient should be prepared as for any major operation. All routine laboratory tests must be performed, including electrocardiogram and chest radiographs. Preoperative evaluation is accomplished by the anesthesiologist prior to surgery. Premedication is used according to the anesthesiologist's choice. Prophylactic antibiotics are given according to the usual protocol. The patient's neck and upper chest are shaved and prepared for the operation.

The patient is placed supine on the operating table with a pillow or inflatable rubber bag under the shoulders to obtain the proper angle for surgery (Fig. 4-1). This is generally obtained when the occiput rests against the upper end of the table. Elevating the upper half of the operating table to approximately 30 degrees will decrease the amount of bleeding during surgery. The patient's lower face, ears, neck, shoulders, and upper chest are prepared with surgical solution, and the patient is draped in layers (Fig. 4-2). Four towels are placed and affixed to the skin. Two of the towels are placed horizontally, one from the chin to the mastoid over the body of the mandible and the other across the upper chest from the shoulder to the midline. The remaining two towels are placed vertically, from the mastoid tip to the shoulder, except for unilateral procedures where the second vertical towel is placed in the midline. A sheet is placed over the patient's chest and legs, and an open sheet covers the entire patient except for the field of operation. The Mayo stand is prepared with the suction tubing and cautery cords secured in place (Fig. 4-3).

Two assistants are usually present: one in front of the surgeon and the second at the patient's head. The scrub nurse stands on the right side of the patient facing the head of the table (Figs. 4-4A,

Figure 4-1 Patient prepared for surgery with a pillow under the shoulders to obtain adequate neck extension.

4-4B). The anesthetist sits at the patient's head with the machine to the opposite side of the surgery. Few general instruments are needed for the operation (Fig. 4-5).

General endotracheal anesthesia is always used. Muscular relaxation is not a priority but the surgeon must be aware of the patient's condition to know the degree of contraction that can be expected when approaching the main nerves in the neck. A bloodless field will decrease the operating time and help the identification of neck structures. We do not routinely use infiltration of local anesthetics.

Figure 4-4 (A) Picture showing the surgical team for a right-side functional neck dissection. (B) Operating room setup for the operation.
Operating Room SetupInstruments Operating Room

Figure 4-5 General instruments used in functional and selective neck dissection. (A) 1, scissors; 2, knives (#10, #15); 3, needle holders. (B) 1, atraumatic and toothed tissue forceps; 2, suction tips; 3, monopolar forceps. (C) 1, Volkmann retractors; 2, Howarth raspatory; 3, Desmarres vascular retractor; 4, Deschamps ligature needle; 5, skin hooks; 6, Farabeuf retractors; 7, Langenbeck retractors. (D) 1, straight Pean's forceps; 2, large and small Duval forceps; 3, large and small Allis forceps. (E) 1, right-angle forceps; 2, large and small curved Pe an's forceps; 3, Dandy hemostatic forceps; 4, mosquito forceps.

Figure 4-5 General instruments used in functional and selective neck dissection. (A) 1, scissors; 2, knives (#10, #15); 3, needle holders. (B) 1, atraumatic and toothed tissue forceps; 2, suction tips; 3, monopolar forceps. (C) 1, Volkmann retractors; 2, Howarth raspatory; 3, Desmarres vascular retractor; 4, Deschamps ligature needle; 5, skin hooks; 6, Farabeuf retractors; 7, Langenbeck retractors. (D) 1, straight Pean's forceps; 2, large and small Duval forceps; 3, large and small Allis forceps. (E) 1, right-angle forceps; 2, large and small curved Pe an's forceps; 3, Dandy hemostatic forceps; 4, mosquito forceps.

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