What is Commando Surgery?
Commando surgery, short for Combined Mandibulectomy and Neck Dissection Operation, is an advanced surgical procedure used in the treatment of aggressive or advanced-stage cancers of the oral cavity. These include cancers that affect the tongue, floor of the mouth, mandible (jawbone), or surrounding tissues, and may also involve the lymph nodes in the neck.
This surgery is typically performed when the cancer has invaded the mandible or nearby lymph nodes and aims to achieve complete tumour clearance. It is often followed by reconstructive surgery to restore oral function and appearance. Due to its complexity, Commando surgery requires a multidisciplinary approach and is considered a supra-major procedure, offering patients a potentially curative option with improved chances of long-term survival.
Why is it called "COMMANDO"?
Though the term “commando” may sound dramatic, it reflects the combined and aggressive nature of the procedure, which aims to remove both the primary tumour and the regional spread in a single surgical session. This coordinated approach is often necessary for tumours that have invaded the jawbone and spread to nearby lymph nodes.
What are the Indications for Commando Surgery?
Commando surgery is primarily indicated for advanced-stage cancers of the oral cavity and oropharynx, especially when the tumour has invaded the mandible or shows regional lymph node involvement. It is commonly recommended when there is a need for aggressive surgical clearance to improve survival and reduce the risk of recurrence.
This procedure is often performed as a first-line (upfront) treatment in operable tumours that have not yet received radiation or chemotherapy. However, it may also be used as a salvage surgery in patients who have previously undergone radiotherapy or chemoradiotherapy, particularly in oropharyngeal cancers like those of the tonsils and base of the tongue.
Key Components of Commando Surgery
Commando surgery is a multi-step procedure that involves the complete removal of cancerous tissues and surrounding structures, followed by surgical reconstruction. Each step is tailored to the tumour’s location, extent, and involvement of adjacent tissues.
Removal of the Primary Tumour
Depending on the cancer’s location, the affected part of the oral cavity, such as the tongue, buccal mucosa, floor of the mouth, gums, or tonsils, is surgically removed to ensure clear margins.
Mandibulectomy (Jawbone Resection)
If the tumour involves the mandible, a portion of the jawbone is removed. This can be a segmental mandibulectomy (removal of a section of bone) or a marginal mandibulectomy (removal of the bone’s rim).
Lymph nodes in the neck are removed to eliminate regional spread. In some cases, nearby structures like muscles, veins, or nerves may also be sacrificed if involved.
Post-tumour removal, reconstructive surgery is performed to restore speech, swallowing, facial contour, and oral function.
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When is Commando Surgery Recommended?
Commando surgery is not a first-line treatment for all cases of oral or head and neck cancer. Instead, it is reserved for specific clinical situations where the cancer has progressed to a stage that involves multiple structures, particularly the jawbone and the lymphatic system in the neck. It is a strategic and curative option when the disease cannot be managed with simpler surgical methods, radiation, or chemotherapy alone. Below are the most common conditions or scenarios where a commando operation becomes inevitable:
● Oral Cavity Cancer Involving the Jaw or Floor of the Mouth
When a tumour originates in or invades the mandible (lower jaw) or the floor of the mouth, there is a significant risk that simple excision will leave behind microscopic disease. In such cases, mandibulectomy is essential to ensure complete removal with adequate margins. Simultaneous removal of the affected neck lymph nodes is done to prevent or treat regional spread.
Tumours in these areas are close to bone and soft tissue boundaries, making it easy for cancer to infiltrate bone or muscles. A composite resection, like commando surgery, allows removal of both bone and soft tissue en bloc, reducing recurrence risk.
● Squamous Cell Carcinoma of the Tongue, Mandible, or Buccal Mucosa
Squamous cell carcinoma (SCC) is the most common type of oral cancer. It often affects areas like the tongue, inner cheek (buccal mucosa), and lower jaw, and tends to spread to cervical lymph nodes early. When SCC involves both the primary site and lymph nodes, a commando procedure is indicated to manage both in one surgery.
This approach is preferred because it avoids the need for separate surgeries, reduces treatment delays, and allows for immediate reconstruction of removed structures.
● Lymph Node Metastasis in Head and Neck
Even if the primary tumour seems manageable, the presence of enlarged or cancerous lymph nodes in the neck (especially in levels I to III) calls for a neck dissection. When combined with a primary tumour that also involves the jaw or nearby structures, the full commando operation becomes necessary.
Cervical lymph node metastasis is a key prognostic factor in oral cancer. Removing these nodes increases survival chances and provides accurate staging for further treatment.
● Failed Response to Radiation or Chemotherapy
Sometimes, patients undergo radiation therapy or chemotherapy as initial treatment, especially for inoperable tumours or to shrink the tumour before surgery (neoadjuvant therapy). However, if the cancer persists or progresses, surgery becomes necessary, and often, the extent of the disease requires a commando surgery for effective control.
Prior radiation makes tissue more fibrotic and difficult to dissect, and tumours may become more invasive. Commando surgery in such settings is challenging, but often the only curative option.
Pre-Surgical Evaluation and Diagnostics
Before undergoing Commando surgery, thorough pre-surgical evaluation and diagnostics are essential to assess the extent of the disease, plan the surgical approach, and ensure the patient is fit for surgery. A multidisciplinary team, including oncologists, surgeons, and radiologists, will collaborate to create a tailored treatment plan. The key components of pre-surgical evaluation are as follows:
Imaging Studies
Imaging plays a critical role in understanding the tumour’s size, location, and involvement with surrounding tissues. The following imaging modalities are typically used:
It provides high-resolution, cross-sectional images of the tumour and surrounding structures, such as the mandible, soft tissues, and lymph nodes. This helps assess the tumour’s depth, extent, and possible invasion into adjacent bones or nerves.
Primarily used for soft tissue assessment, MRI is particularly valuable in evaluating areas like the tongue, floor of the mouth, and base of the tongue, which are often affected in oral cancers.
It is used in advanced cases to help evaluate whether the cancer has spread to distant organs or identify any unseen primary tumours or regional metastasis.
Essential for assessing bone involvement, particularly when the tumour affects the jaw or maxilla. These X-rays provide a clear view of the mandibular structures and help in planning mandibulectomy.
Biopsy and Histopathological Examination
Before surgery, confirming the cancer diagnosis through biopsy is crucial. The doctor may recommend:
If suspicious lymph nodes are present, FNA is performed to assess the presence of metastatic cancer cells.
For the primary tumour, either excisional or incisional biopsies are performed, depending on tumour accessibility, to confirm the type of cancer, usually squamous cell carcinoma in head and neck cancers.
General Health Assessment
Given the complexity and scale of Commando surgery, pre-surgical tests also include:
Blood tests to evaluate liver and kidney function, coagulation status, and overall health.
Cardiac and pulmonary assessments to ensure the patient can tolerate surgery, especially if they have underlying health issues.
Nutritional evaluation to optimize the patient’s nutritional status, which is crucial for faster healing and recovery.
Reconstruction After Commando Surgery
The choice of reconstruction method depends on the size and location of the surgical defect, the extent of tissue removed, and the patient's general health. Additional procedures done during Commando operation:
A temporary tracheotomy is routinely performed at the operation in anticipation of post-operative soft tissue swelling, with the risk of obstructing the airway.
Feeding can be established either through a nasogastric feeding tube, which may be passed during the procedure, or a planned percutaneous gastrostomy feeding tube.
The primary reconstruction techniques include:
Local flaps involve tissue taken from an area near the surgical site. These are typically used for moderate-sized defects and are generally easier to perform, as the tissue remains attached to its original blood supply. Common examples include:
Buccal Flap: Tissue from the inner cheek is moved to cover defects in the oral cavity.
Tongue Flap: When part of the tongue is removed, the remaining part can sometimes be used to repair the area.
Local flaps are ideal for smaller, less complex defects, providing a functional and cosmetic repair with minimal additional recovery time.
For larger defects, a regional flap is used, where tissue from a nearby area is completely detached but still connected to its original blood supply. The delto-pectoral flap and pectoralis major flap are commonly used, especially when larger tissue volumes are required for reconstruction.
This involves taking tissue from the chest and upper arm region, which is useful for covering larger defects in the neck and oral cavity.
A larger flap that can cover extensive tissue loss in the neck and facial region.
These flaps are more suitable for larger defects where local flaps are insufficient, but can result in a longer recovery time due to the size of the tissue used.
For extensive defects, particularly those involving large portions of the mandible or soft tissue, free flap reconstruction is often employed. This technique involves transplanting tissue from a distant area of the body to the defect site, with the tissue being fully detached and reattached using microsurgery to connect blood vessels. Common types of free flaps include:
Often used for mandibular reconstruction, as it provides both bone (for jaw restoration) and soft tissue (for mucosal lining).
A versatile option, providing thin, flexible skin used to reconstruct the oral cavity, tongue, or neck.
Used for reconstructing larger defects, particularly when thicker tissue is needed.
Typically used for neck reconstruction, especially when larger amounts of soft tissue are required.
Free flap procedures are highly effective but require a longer recovery time due to the complexity of the surgery. They offer excellent functional and aesthetic outcomes, particularly when large amounts of tissue need to be replaced.
Additional Procedures Done During Commando Operation:
A temporary tracheotomy is routinely performed at the operation in anticipation of post-operative soft tissue swelling, with the risk of obstructing the airway.
Feeding can be established either through a nasogastric feeding tube, which may be passed during the procedure, or a planned percutaneous gastrostomy feeding tube.
Post-Operative Care After Commando Surgery
After a Commando surgery, proper post-operative care is essential for recovery and minimising complications. Close monitoring and personalised interventions help ensure the healing process goes smoothly. Here are post-operative tips after commando surgery:
Drainage and Fluid Management
Drains are placed in the neck or oral cavity to prevent fluid buildup and infection. These are typically removed after a few days based on the patient's condition.
Pain is managed with opioids initially, followed by NSAIDs as recovery progresses. Effective pain control is crucial for recovery and rehabilitation.
Ventilation and Respiratory Support
A temporary tracheotomy may be performed to secure the airway during recovery. Ventilatory support is used if necessary, especially if the airway was affected during surgery.
Monitoring and Complication Detection
Patients are monitored closely for any signs of infection, bleeding, or airway compromise in the ICU or recovery room. Early intervention helps prevent complications.
Due to difficulty swallowing, patients may need NGT or PEG tubes for feeding. These are gradually phased out once swallowing improves.
Physiotherapy and Rehabilitation
Physiotherapy helps regain mobility, particularly after neck dissection, by reducing stiffness and improving movement in the neck and jaw.
Oral cancer surgery can have significant emotional and functional impacts (e.g., speech, appearance). Providing psychological counselling and support pre-surgery is vital for the patient’s emotional well-being.
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What are the Benefits of Commando Surgery?
Commando surgery offers several important advantages in the treatment of advanced oral cavity and head and neck cancers. As a comprehensive surgical approach, it is designed not only to remove the cancer but also to manage its regional spread and allow for timely reconstruction.
While the procedure is extensive, its potential to significantly improve outcomes makes it a valuable treatment option, especially when performed as part of a multidisciplinary cancer care plan. Below are the key benefits of Commando surgery:
Comprehensive Tumor Removal: The procedure allows for complete excision of the primary tumor along with involved bone and lymph nodes, improving the chances of cure and long-term survival.
Effective Regional Disease Control: By including a neck dissection, the surgery addresses potential lymph node spread, reducing the risk of regional recurrence.
Accurate Cancer Staging: Removal and pathological examination of lymph nodes provide detailed staging information, guiding the need for further treatment like radiotherapy or chemotherapy.
Opportunity for Immediate Reconstruction: Functional and aesthetic reconstruction can be done in the same surgery, helping patients regain speech, swallowing, and facial structure.
Suitable for Salvage Situations: Commando surgery remains a viable option even after prior radiation or chemoradiation, especially in recurrent or residual tumours.
Risks and Complications of Commando Surgery
While Commando surgery offers the potential for curing head and neck cancer, it does come with risks and complications that must be managed carefully.
After surgery, speech and swallowing can be temporarily impaired, requiring speech and swallowing therapy.
Damage to nerves like the facial nerve, lingual nerve, or hypoglossal nerve can lead to facial paralysis, numbness, or difficulty speaking and swallowing.
Extensive resections may cause temporary or permanent facial disfigurement, impacting appearance and self-esteem.
There’s a risk of infection, bleeding, or flap necrosis, particularly with reconstructive surgery, requiring close monitoring and possible interventions.
The emotional impact of surgery, changes in appearance, and loss of function can lead to anxiety, depression, or PTSD, requiring psychological support.
Recovery After Commando Surgery - What to Expect?
Recovery after commando surgery (also called comprehensive head and neck surgery) for oral cancer or head and neck cancers is a lengthy and multifaceted process. Given the extent of the surgery, recovery involves physical healing, functional rehabilitation, and psychological adaptation.
The timeline and specific needs can vary based on the extent of the surgery, the patient's general health, and the presence of complications like radiation therapy or chemotherapy. Recovery after Commando surgery can be a lengthy process, involving several stages of healing, rehabilitation, and emotional support.
1. Immediate Postoperative Phase (First 1–2 Weeks)
Most patients remain hospitalized for 1–2 weeks. Pain management, fluid drainage, and monitoring for complications like infection or bleeding are crucial during this phase. A feeding tube may be necessary if swallowing is impaired.
2. Early Recovery Phase (3–6 Weeks Post-Surgery)
Wound healing begins, and the patient may start speech and swallowing therapy. Swelling in the face and neck is common but gradually improves. The use of a feeding tube may continue until swallowing improves.
3. Long-Term Recovery (3–12 Months)
Long-term rehabilitation focuses on speech, swallowing, and physical recovery. Physiotherapy helps with mobility, especially if the spinal accessory nerve has been affected. Emotional and psychological support may also be necessary to adjust to physical changes.
How Artemis Hospital Provides the Best Commando Surgery Procedure in Gurgaon?
Artemis Cancer Centre: A Hub for Multidisciplinary Oncology Care
The Artemis Cancer Centre integrates medical oncology, radiation oncology, and surgical oncology under one roof, ensuring a cohesive treatment approach for patients undergoing commando surgery. This multidisciplinary setup facilitates personalised treatment plans tailored to individual patient needs. The centre is equipped with state-of-the-art facilities and staffed by a team of internationally trained oncologists, ensuring high standards of care.
Advanced Surgical Techniques and Technology
Artemis Hospital employs cutting-edge technology, including the Da Vinci Xi Robotic Surgery System, to perform minimally invasive surgeries. This system offers enhanced precision and control, leading to smaller incisions, reduced pain, and faster recovery times for patients undergoing complex procedures like commando surgery.
Expert Surgical Oncology Team
The hospital's Surgical Oncology (Head & Neck) unit is led by experienced professionals such as Dr. Biswajyoti Hazarika and his team, who specialise in treating cancers of the head and neck region. Their expertise ensures that patients receive the most effective surgical interventions tailored to their specific conditions.
Comprehensive Supportive Care Services
Artemis provides a holistic approach to cancer care, offering services like pain management, nutritional counselling, psychological support, and rehabilitation. These services are crucial for patients recovering from major surgeries and contribute to improved quality of life during and after treatment.
International Patient Services
Understanding the needs of international patients, Artemis offers comprehensive support, including assistance with local accommodation, airport transfers, and post-discharge care. This ensures a seamless experience for patients travelling from abroad for treatment.
Reviewed ByDr. Biswajyoti Hazarika
Chief - Head & Neck Surgery
Artemis Hospitals
Frequently Asked Questions
What is commando surgery full form in cancer treatment?
Commando surgery stands for Combined Mandibulectomy and Neck Dissection Operation. It is performed to treat advanced oral cancers by removing the tumor, affected jawbone, and nearby lymph nodes.
What parts of the body are removed in Commando surgery?
Commando surgery involves removal of the cancerous part of the mouth or tongue, a portion of the jawbone (mandibulectomy), and lymph nodes in the neck (neck dissection).
Is Commando surgery a major surgery?
Yes, Commando surgery is a major and complex procedure that requires general anesthesia, extensive tissue removal, and often reconstructive surgery.
How long does Commando surgery take?
The surgery typically takes 6 to 10 hours, depending on the extent of cancer spread and the need for reconstruction.
What is the success rate or survival rate of Commando operation surgery?
The survival rate depends on the stage and location of cancer, but early detection and complete resection can offer a 5-year survival rate of 50–70%.
Will Commando surgery affect my ability to speak or swallow?
Yes, it can affect speech and swallowing temporarily or permanently depending on the location and extent of tissue removed. Rehabilitation can help improve these functions.
Can Commando surgery lead to permanent facial changes?
Yes, facial changes may occur due to jawbone removal and tissue loss, but reconstructive surgery can help restore appearance and function.
Will I need reconstructive surgery after the commando procedure?
In most cases, reconstructive surgery is recommended to restore the structure and function of the jaw and oral cavity.
Can cancer come back after Commando surgery?
Yes, there is a risk of recurrence, especially if the cancer is aggressive or was diagnosed late. Regular follow-up is essential.
Will I need speech or physiotherapy after surgery?
Yes, speech and physiotherapy are often required to regain normal speech, swallowing, and shoulder movement after surgery.
Where can I get Commando surgery near me for oral cancer?
You can get Commando surgery for oral cancer at Artemis Hospitals, which offers specialised treatment in head and neck oncology. To know more, get in touch with us to schedule an appointment for your head and neck treatment.
Does Artemis Hospital in Gurgaon perform Commando surgery?
Yes, Artemis Hospital in Gurgaon performs Commando surgeries for oral and head-neck cancers with a multidisciplinary team.
How do I consult a head and neck surgeon at Artemis Hospital?
You can book an appointment with a head and neck surgeon at Artemis Hospital via our website, by calling our number +91 9800400498.
What is the cost of Commando surgery near me in Gurgaon?
Commando surgery cost in Gurgaon may vary depending on several factors, such as the medical consultations of the surgeon, the type of surgery, the severity of the disease, the cost of diagnostic tests, etc. Get in touch with us to get an estimate on Commando Surgery Cost in Gurgaon.
Who is the best oral cancer surgeon for mandibulectomy near me?
Artemis Hospitals has some of the best oral cancer specialists in Gurgaon who are experienced in mandibulectomy and oral cancer treatment. Contact us to book an appointment with some of the best medical specialists in Gurgaon.
