Exenteration in patient with large adenoid cystic carcinoma
This is Richard Allen at the University of Iowa. This video demonstrates an exenteration in a patient with suspected adenoid cystic carcinoma of the left lacrimal gland. This lesion was neglected by the patient. A lid sparing exenteration will be attempted. The supraciliary incision has been marked on the left upper lid. 4-0 silk sutures are placed through the tarsus of the left upper lid and left lower lid to provide traction. The needle tip cautery is then used to make an incision along the supraciliary incision. Dissection is then carried out along the posterior surface of the orbicularis muscle. A Freer periosteal elevator is used to peel the skin and orbicularis layer from the underlying lesion. The lesion proves to be quite large. The globe is demonstrated. Hemostasis is obtained with the bipolar cautery. A subciliary incision is then made along the lower eyelid. Dissection is carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Laterally, the lateral orbital rim is palpated. The lid is released and the superior orbital rim is identified. It is determined that the mass will be debulked due to the difficulty in trying to get around it for the exenteration. The Bovie cautery is then used to excise the anterior portion of the tumor. Hemostasis is obtained with the monopolar cautery. Additional debulking is then performed with the monopolar cautery. This will allow easier access to the orbit. After the anterior portion of the tumor is debulked the orbital rims are identified. Additional dissection is then carried out medially to identify the medial orbital rim. Dissection is then carried out along the lateral orbital wall and the orbital roof. Additional debulking of the tumor is performed in order to expose the deeper portions of the orbital wall. Medially, the medial wall is identified. The orbital apex is then transected with Metzenbaum scissors. The socket is inspected. Hemostasis is obtained at the orbital apex. Due to the age of the patient it was determined that an extended exenteration with bone removal would not be performed. This procedure was performed more for palliation than anything else. There is enough redundant skin and orbicularis muscle to cover the socket. The orbicularis is closed with deep interrupted 5–0 Vicryl sutures. The skin will then be closed with interrupted and running 7–0 Vicryl sutures. At the conclusion of case, the patient is cleaned with wet and dry gauze. Erythromycin ophthalmic ointment is placed over the incision. A fluff is placed over the closure followed by a double eye pad.
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