Commando Procedure

“commando” procedure involves the resection of the primary tumor, a part of the mandible and surrounding cervical lymph nodes. This procedure is commonly used for cancers affecting the tongue, floor of the mouth, larynx, pharynx, maxilla, mandible and palate. This term is coined ‘commando procedure’ as it’s a surgical attack on the diseased tissue. The head and neck surgery involves resection of the mandible with the floor of the mouth and the dissection of the entire lymphatic system of the neck along with the sternoclidomastoid muscle and internal jugular vein.

The procedure requires substantial amount of surgical reconstruction of the facial structures and is used mainly for cancers affecting the head and neck. ‘Commando Operation’ is a difficult surgery and mandates the need for an experienced medical team to manage the pre operative and post operative care. Turkey, Mexico, Jordan, India and South Korea are some of the countries where these procedures are available at relatively lower cost.

When do you need a Commando procedure?

The commando procedure is done for cancers affecting the oropharyngeal region.

  • Cancers of the head and neck follow a predictable pattern of moving from the head to the neck to the chest. Hence a composite resection improves the chances of preventing the spread of the malignancy.
  • Normally, cancers of the head and neck move only along one side of the body. Hence in addition to the removal of the tumor, the lymphatic channels of the neck are also dissected to halt the spread of the disease. This is referred to as neck dissection.
  • While conducting a composite resection for cancers of the orophryngeal region, it is of essence to remove the entire tumor, while preserving the functions, is of secondary importance. Hence, a composite resection is invariably more aggressive in nature to ensure that no disease part is left behind after the surgery.

    • Preparing for Head and Neck Surgery: Commando Procedure

    It is essential for any patient undergoing a composite resection of the head and neck to follow the below mentioned requirements,

  • Notify your medical team about all your routine medications and provide all details of your medical history.
  • Avoid aspirin, ibuprofen or any other medications that cause thinning of the blood, at least one week prior to the scheduled surgery. These medications tend to interfere with the blood clotting process and result in excessive bleeding after the procedure and thereby delay healing.
  • You are expected to not eat or drink after midnight, the evening prior to the scheduled surgery. You may however brush your teeth in the morning without consuming any fluids.

    • Understanding the commando procedure:

  • The surgical management of oral cavity tumors involves creating an opening through the lower lip and jawbone (mandible). The malignant tissue is then completely removed.
  • This may be accompanied with cordectomy i.e. removal of a single vocal cord for lesions in the vocal cord. The partial removal of the tongue is also advocated in some tumors that have transcended the primary location.
  • Following the surgery reconstruction is done by a plastic surgeon, using a flap of skin graft from the forearm, leg, abdomen or the thigh.
  • Occasionally, the jawbone is also resected if the tumor affects the jawbone (mandible).
  • The surgeon will oppose the two sides of the jaw bone again and stitch them together Post operative Care after commando procedure:
  • In variably after a major and extensive surgery of the oral cavity, patients face difficulty in swallowing. This is due to the swelling in the internal part of the oral cavity, caused by the surgery.
  • A temporary feeding tube is inserted either through the nostril or mouth, directly to the stomach. It is a simple Out patient procedure and is conducted prior to the surgical resection
  • In order to ensure that healing takes place actively, it is crucial that the patient maintains a good nutritional intake of food and liquids, through the tubes. Even after the tubes are removed, the patient is requested to notify the medical team if he finds it difficult to eat or drink
  • Immediately after the surgery, speech will be considerably impaired, which will subsequently improve over a period of time, with or without the assistance of a speech therapist.
  • Occasionally post operative radiotherapy is required.

    • Common post operative complications include

  • Bleeding may occur in about one percent of the cases. This is attributed to the extensive vasularity of the organs involved
  • Infection may occur, though the patient is given a post operative cover of antibiotics
  • Pain is inevitable considering the magnitude of the procedure. Pain killers mainly morphine derivatives are given to alleviate pain.
  • Fistula is also a common problem which is resolved by simple medications and rinsing. Surgical intervention is rarely required.
  • The patient may experience numbness and weakness, which is attributed to the pressure of the swollen tissue on the nerves. This will subsequently resolve, but occasionally it is a permanent defect.
  • The patient may occasionally suffer from hypersensitivity of the skin around the site of surgery, due to a neuroma. This takes years to develop and the neuroma can be surgically removed.

    • Radical hysterectomy

    Overview

    Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the uterus that connects to the vagina.

    Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most cervical cancer.

    When exposed to HPV, a woman's immune system typically prevents the virus from doing harm. In a small group of women, however, the virus survives for years, contributing to the process that causes some cells on the surface of the cervix to become cancer cells.

    You can reduce your risk of developing cervical cancer by having screening tests and receiving a vaccine that protects against HPV infection.

    Symptoms

    Early-stage cervical cancer generally produces no signs or symptoms.
    Signs and symptoms of more-advanced cervical cancer include:

  • Vaginal bleeding after intercourse, between periods or after menopause
  • Watery, bloody vaginal discharge that may be heavy and have a foul odor
  • Pelvic pain or pain during intercourse

    • Causes

    Cervical cancer begins when healthy cells acquire a genetic change (mutation) that causes them to turn into abnormal cells.

    Healthy cells grow and multiply at a set rate, eventually dying at a set time. Cancer cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from a tumor to spread (metastasize) elsewhere in the body.

    It isn't clear what causes cervical cancer, but it's certain that HPV plays a role. HPV is very common, and most women with the virus never develop cervical cancer. This means other factors — such as your environment or your lifestyle choices — also determine whether you'll develop cervical cancer.

    Types of cervical cancer

    The type of cervical cancer that you have helps determine your prognosis and treatment. The main types of cervical cancer are:

  • Squamous cell carcinoma. This type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. Most cervical cancers are squamous cell carcinomas.
  • Adenocarcinoma. This type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal. Sometimes, both types of cells are involved in cervical cancer. Very rarely, cancer occurs in other cells in the cervix.

    • Risk factors

    Risk factors for cervical cancer include:

  • Many sexual partners.
  • Early sexual activity.
  • Other sexually transmitted infections (STIs).
  • A weak immune system.
  • Smoking.

    • Prevention

    To reduce your risk of cervical cancer:

  • Get vaccinated against HPV
  • Have routine Pap tests.
  • Practice safe sex.
  • Don't smoke.

    • Whipple Procedure

    The Whipple Procedure, or pancreaticoduodenectomy, is the most commonly performed surgery to remove tumors in the pancreas. In a standard Whipple procedure, the surgeon removes the head of the pancreas, the gallbladder, part of the duodenum which is the uppermost portion of the small intestine, a small portion of the stomach called the pylorus, and the lymph nodes near the head of the pancreas. The surgeon then reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the small intestine during digestion. In another type of Whipple procedure known as pylorus preserving Whipple, the bottom portion of the stomach, or pylorus, is not removed. In both cases, the surgery usually lasts between 5-8 hours.

    After a Whipple procedure, the most common complication is delayed gastric emptying, a condition in which the stomach takes too long to empty its contents. Usually, after 7-10 days the stomach begins to work properly. If delayed gastric emptying persists, supplemental feedings by a feeding tube may be started. The condition usually lasts for another 7-10 days, but could last as long as a few weeks. The most serious potential complication is abdominal infection due to leakage where the pancreas has been connected to the intestine. This occurs in approximately 10% of patients and is usually managed by a combination of draining tubes, antibiotics, and supplemental tube feedings. Patients who have undergone the Whipple procedure may experience long-term effects including digestive difficulties.