Bilateral Sagittal Split Osteotomy (BSSO) – The Corridor of Uncertainty

I have been an unabashed fan of the commentary of people like Bill Lawry, Ian Chappell, Tony Greig, Geoffrey Boycott, and the great Sunil Gavaskar. Whenever India used to play abroad and our batsmen fell like bowling pins, only a couple of great men stood up – namely Dravid and Tendulkar. They used to train for the tours of England and Australia, 6 months in advance. The off stump and the area just outside it was called the Corridor of Uncertainty. This is the exact term I use for the BSSO.

This procedure involves the surgeon to work in a confined area of the ramus and angle of mandible, make the cuts, split the mandible and fix it in the new position. If you would like to come with me on the journey of one such procedure I performed a couple of days back, then please continue reading

The surgery begins with nasal intubation and a light throat pack. Too much head extension is not given as it may give a posterior cut due to the patient’s position. I infiltrate some local anaesthetic and wait for about 8 mins. During this time it is easy for me to be impatient and start cutting. While we wait, I brief my team about the steps ( I may have done this procedure a hundred times before but most/all of my assistants are seeing it for the first time) and connect the suction and electrocautery. My Rahul Dravid of instrumentation is my Synthes bone saw. It has got two modes- reciprocating and oscillating which help me in a precise cut. The incision is made and gentle blood oozes. I then dissect with cautery to minimize the loss and identify the external oblique ridge. The Forked Ramus retractor is then inserted to gain access to the tip of the coronoid. We engage the coronoid with a Kocher clamp and tie it to the head drape . The medial aspect of the ramus is dissected and the Lingula is identified. We pack it with gauze for a couple of mins to stop the tiny oozes. Then, I make all the observers pour their heads into the tiny headspace to see the exposure.

The cuts are then marked with a making pencil. I prefer the short osteotomy as taught to me by my Prof during my training in the Netherlands 2009.The Synthes saw now becomes a light sabre in my hands. I imagine I am Jedi Obie Van Kenobe and rest it obliquely against the medial aspect of the mandible and make it count. It cuts like a knife through butter. The saw is then moved in the same movement sagittally till the second molar. The mouth prop is removed and my team closes the jaw for me to make the vertical cut. I then use a pair of 10mm osteotomes to define the osteotomy. They are gently pried to see the cortex moving. I move on to the other side to do the same procedure. At the end of each step are half a dozen heads that are eagerly waiting to see the steps. Making sure everyone sees each step is a key element of my training, you can say it’s my USP.

As the right side is done, I turn my attention now back to the left. The Smith Spreader is now used and gently with the mere digital pressure, the mandible is split open. The gasp from my assistants is audible below the mask.. Makkhan, says Kunal. I use my usual SRK dialogue from KKKG to my advantage and say, Mera koi bharosa nahi Rohan, last-minute pe kuch bhi ho sakta hai.

I do the same procedure on the other side but the mandible refuses to budge. Inferior Border, sayKunal and I simultaneously. Swayambhu hands me a curved osteotome and I tap it. I can feel it cut through the border now. The spreader is handed over and the osteotomy is complete. A buzz goes through the OT now and the splint is called for. Our Orthodontist Monika has prepared an acrylic splint and incorporated E chains in it. She has been guided by the ever so humble Jayesh Rahalkar himself, Master Yoda Of Orthodontics and the ever smiling Sonali Deshmukh

The mandible is then stripped off of the attachment of the medial pterygoid which is crucial to the setback. The splint is placed and the excess bone is trimmed off with the help of a saw.

We now get the finisher Dhoni into the game, and that is our Synthes plating kit. The mandible is fixed with at least 2 screws on each side. This is the most crucial step and not the split. During the osteotomy and the split the only person who can cause an error is a surgeon himself. But this requires total co-ordination between the first and the second assistant to see that not only is the splint in the right position but also the condyles are in the fossa.

The splint is now removed and the movement of the mandible is checked passively.

Bilateral suction drains are placed and closure is done with a 4-0 vicryl. The maxillary third molars are removed at the same time to make sure there is no impingement on the surgical site. The throat pack is removed and the splint is fixed back in place.The patient is extubated and shifted to the ward. We do a post-op OPG and Lat Ceph. Is the surgery done? Yes, but my journey towards refinement continues.

This is the first surgery of this sort seen by my young team of Kunal & Deeisha, so closely in the last 2 years. Nishtha has seen a couple but has not scrubbed in for this kind of a procedure. Shilpa Bawane, Associate Prof who has been with me for the last 4 years has worked on this one for the first time. Not bad… it makes me feel like Karan Johar working on SOTY, delivering a hit with newcomers.As I move on to another mission on my mind, I know my team would be smiling for days to come. 


Nishtha Gadkari
July 24, 2019 at 5:34 pm

Couldn’t have put it any better, a perfect analogy of cricket and surgery!

Tusha Ratra
July 24, 2019 at 9:12 pm

“The one exclusive sign of thorough knowledge is the power of teaching “ …. this quote related to U Sir
Perfect combination of Cricket n Surgery

Dr Nidhi Dev
July 27, 2019 at 1:08 pm

Dear Pushkar Waknis sir… This piece is so like an anecdote and nothing like a description of a surgery! I had a brief mental visualization of D Y too as Kunal Jain and Deeisha Gupta (my seniors) were mentioned. I felt as if i myself was again observing u in ur OT! Superbly written!

Dr Deodutta Kamble
July 28, 2019 at 5:50 pm

Pushkar, you are a superb surgeon that I was always aware of, but to pen down the complete procedure in such a way that I felt as if I am there with you in the OT… That’s your new AWATAR and you are at the best in it too.
Wishing you a Grand Success in everything you do.

Keep it up and keep enlightening us in the same interesting and entertaining way.

Dr Deodutta Kamble (+91-9371013226)

Dr Anita Peswani
July 28, 2019 at 8:14 pm

Great work done by you Puskhkar Sir.Everything explained in such detail and yet with such effortlessness that it can be easily understood.Pls keep posting more such cases.

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