Week 5

This week, I went to surgery with Dr. Jason Spector and saw a highly complicated procedure for an older patient with squamous cell carcinoma of the buccal mucosa and oral floor. The operation started at 7:30 am and finished after 5:30 pm, with at least one of three different OR teams working at all times. In terms of clinical immersion in an OR setting, this was probably about as efficient as you can get for exposure to multiple procedures at once. 

The day started with the patient awake and intubated through the nose. Normal OR practice is to intubate patients sedated, but because this patient was elderly and could not open his mouth, the anesthesiologists decided it was safer to intubate him awake. After intubation, the patient was anesthetized and they fit the him with a Foley catheter and feeding tube, which is fed through the mouth and retrieved from the stomach via a small hole made with a large gauge needle. 

The head and neck team then got to work on removing the mass from the patient's mouth. After several hours of work, they resected a tumor that looked like it was about 6-8 cm on its longest axis. The involved tissue spanned from the labial mucosa down to the mouth floor and would require significant reconstruction. Additionally, the head and neck surgeons also performed a neck dissection where they removed potentially involved tissue plus a 5cm margin. 

While the head and neck team were working in the mouth, Dr. Spector's team began preparing a skin flap from the patient's forearm to be grafted to the oral defect left by the tumor resection. This process was extremely intricate and methodical. The surgeons carefully separated the skin from the muscle, carefully avoiding important structures like tendons and ligaments, and preserving the radial artery and vein, which were transferred with the flap and plugged into an artery and vein in the neck.

Once the flap was ready, the blood vessels were left attached, and the site was covered with wet gauze and wrapped in towels until the head and neck team was done. Dr. Spector went to work on another OR case in the meantime. When the HN team was finished, the plastics team prepared the facial defect for the flap by exposing the vessels in the neck and thoroughly cleaning the site. They then severed the flap's vessels in the arm and moved it to the mouth. Working methodically but quickly, bearing in mind the time to ischemia for the flap, they threaded the vessels from the mouth, down through the neck, then sutured the flap into place to form a watertight seal.  

To attach the vessels, Dr. Spector and the chief resident used a surgical microscope and microvascular anastomosis coupler device to microsurgically attach the flap vein to the vein in the neck. They then attached the arteries with sutures. Finally, the team took a skin graft from the thigh, stitched it over the forearm defect left by the flap, and wrapped the forearm in a wound-vac dressing and cast. They put a silicone bandage over the graft donor site on the thigh and closed the wound in the neck. Pretty amazing.