Standard Operation Procedure

Total Excision of Benign TumorPleomorphic Adenoma

整理 : 連秀仁 94/06/20

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

Chief complaint

A painless mass over right soft palate for 1 month. Referred from I-Lan hospital.

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.

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

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

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

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.

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