Hyderabad, September 2020: The team of Oncologists at Apollo Cancer Institutes, Hyderabad, performed the first mandible or jawbone reconstruction of a COVID recovered patient with a massive cancer tumour in the lower jaw, using 3-D virtual computer technology, in the Telangana state and probably for the first time in the country. The 45 years old male patient Mr Rajesh Kumar (name changed), hailing from Hyderabad, presented himself with an extensive cancerous growth on the floor of his mouth and a badly mangled mandible or the lower jawbone, at Apollo Cancer Institute on 24th July 2020. He was suffering with it for the past 3 months and delayed taking treatment due to COVID prevalence. He was detected to be COVID positive two weeks prior to reporting to us, at another private cancer centre and was refused surgery there. On investigation at Apollo Hospitals, he was found to be asymptomatic for COVID and the CT chest did not show any COVID related lung changes. He was re-tested after a week, was found to be negative and a surgery was planned on him.
The surgery involved removal of the extensively spread cancer in the floor of the mouth along with the central segment of the mandible and excision of lymph nodes on both sides of his upper neck. The removal of the central arch of the mandible would result in debilitating effects on the overall structure, speech and swallowing, which would decapacitate the patient and life could become traumatic besides impacting his livelihood. To mitigate the functional disruption of the jaw and reduce disfigurement, the team of Specialists headed by Dr Umanath Nayak, Senior Consultant Head & Neck Surgical Oncologist, and aided by Dr B Rahul, Reconstructive Surgeon, Apollo Cancer Institutes, Hyderabad; performed a mandible reconstruction surgery with a vascularized segment of bone harvested from the fibula, using specialized computer software, the 3-D virtual planning, on 3rd August 2020.
The software aided in contouring Fibula, one of the minor bones in the leg, which is straight too, to the shape of the jaw with high precision. CT scans of the affected jaw and the fibula were fed into the computer and acrylic models and surgical guides were prepared which were then used in the operation theatre to provide a precise match. During the surgery after the removal of cancer and adjoining central part of the mandible, the remodelled segment of the fibula was fixed to the remaining portion of the jawbone with titanium plates and screws. The blood supply to the transplanted bone was restored by connecting its artery and vein to blood vessels in the neck using very fine (10-0) nylon sutures under a microscope. The entire procedure lasted around 10 hours. The patient recovered from the surgery with no major complications was discharged with good cosmetic and functional outcome.
The team of specialists confronted multiple challenges in treating this patient, including the advanced stage of cancer, the resulting disruption in form and function of the jaw and the timing of the surgery, considering the COVID status of the patient. Prolonged surgery in COVID patients can often lead to major complications and a 3-week waiting period is generally recommended from the time patient has tested positive or shows the first signs of infection, however for this patient any delay was detrimental due to cancer proliferation, says Dr Umanath Nayak. The redeeming factor which offset all the impediments was the virtual surgical planning, it enabled precise contouring of the anterior mandibular arch and significantly reduced operating time, he adds.
The surgery was performed by a team of specialists comprising of Dr Umanath Nayak, Senior Consultant; Dr Buggaveeti Rahul, Consultant; Dr Abhishek B, Junior Consultant; Dr Ashwin Shastri, Fellow and Dr Ankita K, Fellow; Department of Head & Neck surgical oncology, Apollo Cancer Institutes, Hyderabad.
