standard operation procedure total excision of benign tumor pleomorphic adenoma 整理 : 連秀仁...
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Standard Operation Procedure
Total Excision of Benign TumorPleomorphic Adenoma
整理 : 連秀仁 94/06/20
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General data
Name: 林王美雲 Chart No.: 1683726-6 Ward No.: B108–16 Sex: Female Birthday: 32/03/21 Date of admission: 93/11/15
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Chief complaint
A painless mass over right soft palate for 1 month. Referred from I-Lan hospital.
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Present illness This 61 y/o female is a case of pleomorphic adenoma. Sh
e has a history of brain tumor s/p OP, femoral fracture s/p OP, hyperlipidemia, & angina under medication control. About 1 month ago, she went to I-Lan hospital for dental examination, and mass over right palate was found. Then she was referred to our OPD for further evaluation. A 1x2cm painless ulcerative mass with induration & intact surface over right soft palate was noted. An incisional biopsy was made on 93/11/04, and pathological results was pleomorphic adenoma. Under the impression of pleomorphic tumor, she was admitted to our ward for total excision.
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Past medical history
Pleomophic adenoma over right soft palate Left brain benign tumor s/p OP Left femoral fracture s/p OP Hyperlipidemia Ischemic heart disease
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Lab data 93/11/15 CBC:
WBC: 4100 /cumm L
RBC: 3.43 m/cumm L
HGB: 11.6 g/dl L
HCT: 33.6 % L
MCV: 98 fl H
PLT: 183000 /cumm
DC: SEG: 62.8 %
LYM: 27.1 %
MONO: 6.5 %
EOS: 2.6 %
BASO: 1 %
Electrolytes:CA: 8.8 mg/dl
BUN: 11 mg/dl
CREA: 0.9 mg/dl
NA: 143 mmol/l
K: 4.3 mmol/l
CL: 107 mmol/l
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Operative procedure 93/11/16 Under GA in supine position, patient was disinfected & drappe
d as usual. The tumor was identified with 1 cm safe margin, total excised w
ith electrosurgical knife, deepening to periosteum (17 was also removed)
Check bleeding Remove irregular bone with rongeur & smoothen with bur Irrigate with copious normal saline The wound was covered by local flap obtained from soft palate
nearby & buccal fat pad, sutured with 3-O vicryl Surgical stent relined with tissue conditioner was fixed to palat
e with wire Patient was sent to POR under stable condition
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Pathological report
Pathological diagnosis:
Mixed tumor (Pleomorphic adenoma)
Gross finding:
The specimen size is 4.3x3.2x1.5 cm. Focal ulceration of mucosa & well-defined gray tan firm submucosa mass (2.5x1.5x1.2 cm) are found. The mass is 0.2 cm from the nearest peripheral mucosal margin & the deep margin is not free.
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Post-OP
Post-OP antibiotic tx. Pain control Cold compression for 1 day (15min/hr) Gargling & irrigation with chlorhexidine Discharge under stable condition (93/11/22) Arrange OPD F/U