Download presentation
Presentation is loading. Please wait.
Published byBarbara Pitts Modified over 9 years ago
1
Standard Operation Procedure Total Excision of Benign Tumor Pleomorphic Adenoma 整理 : 連秀仁 94/06/20
2
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
3
Chief complaint A painless mass over right soft palate for 1 month. Referred from I-Lan hospital.
4
Present illness This 61 y/o female is a case of pleomorphic adenoma. She 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.
6
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
7
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
8
Operative procedure 93/11/16 Under GA in supine position, patient was disinfected & drapped as usual. The tumor was identified with 1 cm safe margin, total excised with 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 palate with wire Patient was sent to POR under stable condition
10
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.
11
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
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.