from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import urllib.request
import os

# ── helpers ─────────────────────────────────────────────────────────────────

def set_col_width(table, col_idx, width_inches):
    for row in table.rows:
        row.cells[col_idx].width = Inches(width_inches)

def shade_cell(cell, fill_hex):
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), fill_hex)
    tcPr.append(shd)

def add_horizontal_rule(doc):
    p = doc.add_paragraph()
    p.paragraph_format.space_before = Pt(2)
    p.paragraph_format.space_after = Pt(2)
    pPr = p._p.get_or_add_pPr()
    pBdr = OxmlElement('w:pBdr')
    bottom = OxmlElement('w:bottom')
    bottom.set(qn('w:val'), 'single')
    bottom.set(qn('w:sz'), '6')
    bottom.set(qn('w:space'), '1')
    bottom.set(qn('w:color'), '2E4A7A')
    pBdr.append(bottom)
    pPr.append(pBdr)

def add_section_heading(doc, text, level=1):
    h = doc.add_heading(text, level=level)
    h.paragraph_format.space_before = Pt(14) if level == 1 else Pt(10)
    h.paragraph_format.space_after = Pt(4)
    for run in h.runs:
        run.font.color.rgb = RGBColor(0x2E, 0x4A, 0x7A) if level == 1 else RGBColor(0x1A, 0x6A, 0x5A)
    return h

def add_body(doc, text, bold=False, indent=False):
    p = doc.add_paragraph()
    p.paragraph_format.space_after = Pt(4)
    if indent:
        p.paragraph_format.left_indent = Inches(0.3)
    run = p.add_run(text)
    run.font.size = Pt(11)
    run.bold = bold
    return p

def add_bullet(doc, text, level=0, bold_prefix=None):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.space_after = Pt(2)
    p.paragraph_format.left_indent = Inches(0.3 + level * 0.25)
    if bold_prefix:
        run = p.add_run(bold_prefix)
        run.bold = True
        run.font.size = Pt(11)
        rest = p.add_run(text)
        rest.font.size = Pt(11)
    else:
        run = p.add_run(text)
        run.font.size = Pt(11)
    return p

def add_numbered(doc, text, bold_prefix=None):
    p = doc.add_paragraph(style='List Number')
    p.paragraph_format.space_after = Pt(3)
    p.paragraph_format.left_indent = Inches(0.3)
    if bold_prefix:
        run = p.add_run(bold_prefix)
        run.bold = True
        run.font.size = Pt(11)
        rest = p.add_run(text)
        rest.font.size = Pt(11)
    else:
        run = p.add_run(text)
        run.font.size = Pt(11)
    return p

def add_callout_box(doc, title, content, bg_hex="EBF4FA", border_hex="2E4A7A"):
    """Add a highlighted callout/tip box using a 1-cell table."""
    tbl = doc.add_table(rows=1, cols=1)
    tbl.alignment = WD_TABLE_ALIGNMENT.CENTER
    cell = tbl.cell(0, 0)
    shade_cell(cell, bg_hex)
    # left border accent
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    tcBdr = OxmlElement('w:tcBdr')
    left = OxmlElement('w:left')
    left.set(qn('w:val'), 'single')
    left.set(qn('w:sz'), '24')
    left.set(qn('w:space'), '0')
    left.set(qn('w:color'), border_hex)
    tcBdr.append(left)
    tcPr.append(tcBdr)
    p = cell.paragraphs[0]
    p.paragraph_format.space_before = Pt(4)
    p.paragraph_format.space_after = Pt(4)
    p.paragraph_format.left_indent = Inches(0.1)
    if title:
        r = p.add_run(f"{title}  ")
        r.bold = True
        r.font.size = Pt(11)
        r.font.color.rgb = RGBColor(0x2E, 0x4A, 0x7A)
    r2 = p.add_run(content)
    r2.font.size = Pt(11)
    doc.add_paragraph()  # spacer
    return tbl

def download_image(url, path):
    try:
        req = urllib.request.Request(url, headers={'User-Agent': 'Mozilla/5.0'})
        with urllib.request.urlopen(req, timeout=15) as r:
            with open(path, 'wb') as f:
                f.write(r.read())
        return True
    except Exception as e:
        print(f"  Image download failed: {e}")
        return False

def add_image_with_caption(doc, img_path, caption, width=5.5):
    if os.path.exists(img_path):
        p = doc.add_paragraph()
        p.alignment = WD_ALIGN_PARAGRAPH.CENTER
        run = p.add_run()
        run.add_picture(img_path, width=Inches(width))
        cap = doc.add_paragraph(caption)
        cap.alignment = WD_ALIGN_PARAGRAPH.CENTER
        cap.paragraph_format.space_after = Pt(10)
        for run in cap.runs:
            run.font.size = Pt(9)
            run.font.italic = True
            run.font.color.rgb = RGBColor(0x55, 0x55, 0x55)
    else:
        p = doc.add_paragraph(f"[Figure: {caption}]")
        p.alignment = WD_ALIGN_PARAGRAPH.CENTER

# ── download images ──────────────────────────────────────────────────────────
IMG_DIR = "/tmp/workspace/orbital-exenteration-guide/images/"
os.makedirs(IMG_DIR, exist_ok=True)

images = {
    "recon_temporalis.jpg": "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_6a0dc032870aa6b1103219e3a5a4a6c24c714e33b18b1f06e556e137a144d277.jpg",
    "recon_forehead_flap.jpg": "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_2b7fe69f3e969a39bc89d0ad4110c34e00348a479c948158cb589377561403ac.jpg",
    "recon_ALT_flap.jpg": "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_39cc81da905aed6eac6a7e8e42eadd186bfc54257d78cb9357b763083ddb7a3c.jpg",
}
downloaded = {}
for fname, url in images.items():
    dest = IMG_DIR + fname
    ok = download_image(url, dest)
    downloaded[fname] = dest if ok else None
    print(f"  {'OK' if ok else 'FAIL'}: {fname}")

# ── build document ───────────────────────────────────────────────────────────
doc = Document()

# Page margins
for section in doc.sections:
    section.top_margin    = Cm(2.0)
    section.bottom_margin = Cm(2.0)
    section.left_margin   = Cm(2.5)
    section.right_margin  = Cm(2.0)

# Default Normal style
style = doc.styles["Normal"]
style.font.name = "Calibri"
style.font.size = Pt(11)

# ── COVER ────────────────────────────────────────────────────────────────────
doc.add_paragraph()
title_p = doc.add_paragraph()
title_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
title_run = title_p.add_run("ORBITAL EXENTERATION")
title_run.bold = True
title_run.font.size = Pt(26)
title_run.font.color.rgb = RGBColor(0x2E, 0x4A, 0x7A)

sub_p = doc.add_paragraph()
sub_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
sub_run = sub_p.add_run("Surgical Reference Guide for Residents")
sub_run.font.size = Pt(16)
sub_run.font.color.rgb = RGBColor(0x1A, 0x6A, 0x5A)
sub_run.bold = True

doc.add_paragraph()
info_p = doc.add_paragraph()
info_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
info_p.add_run("Ophthalmology / Oculoplastics | Head & Neck Surgery / ENT\n").font.size = Pt(11)
info_p.add_run("PGY 1-2 Resident Training | August 2026").font.size = Pt(11)

add_horizontal_rule(doc)
doc.add_paragraph()

# Scope note
add_callout_box(doc,
    "Scope:",
    "This guide covers the indications, surgical anatomy, step-by-step technique, frozen section use, reconstruction options, complications, and post-operative management of orbital exenteration. "
    "It is intended as a quick-reference companion to operative experience, not a substitute for direct supervision.",
    bg_hex="FFF8E1", border_hex="F57F17"
)

# ── TABLE OF CONTENTS ────────────────────────────────────────────────────────
add_section_heading(doc, "Contents")
toc_items = [
    "1.  Overview & Definition",
    "2.  Anatomy Review",
    "3.  Indications",
    "4.  Contraindications & Special Considerations",
    "5.  Pre-operative Workup",
    "6.  Types of Exenteration",
    "7.  Step-by-Step Operative Technique",
    "8.  Intraoperative Frozen Section Biopsy",
    "9.  Reconstruction Options",
    "10. Complications",
    "11. Post-operative Management",
    "12. Prognosis",
    "13. Key Teaching Points",
    "14. References",
]
for item in toc_items:
    p = doc.add_paragraph(item, style="List Number")
    p.paragraph_format.space_after = Pt(1)
    for run in p.runs:
        run.font.size = Pt(11)

doc.add_page_break()

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 1: OVERVIEW
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "1. Overview & Definition")
add_body(doc,
    "Orbital exenteration is the surgical removal of the entire orbital contents — globe, extraocular muscles, "
    "orbital fat, lacrimal gland, and typically the eyelids. It is a radical procedure reserved for life-threatening "
    "or locally destructive pathology when no organ-preserving option is feasible. It should only be performed "
    "with curative intent."
)
add_callout_box(doc,
    "Key Principle:",
    "Orbital exenteration sacrifices vision and orbital anatomy permanently. The decision must balance oncologic "
    "necessity against functional and psychosocial consequences — always involve the patient in a thorough informed consent discussion.",
    bg_hex="FDECEA", border_hex="C62828"
)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 2: ANATOMY
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "2. Anatomy Review")
add_body(doc, "Structures removed in exenteration:")
structures = [
    ("Globe", "containing lens, vitreous, retina, choroid, sclera"),
    ("Extraocular muscles", "superior, inferior, medial, lateral rectus; superior and inferior oblique"),
    ("Orbital fat", "fills extraconal and intraconal space"),
    ("Lacrimal gland", "located in superolateral orbit"),
    ("Orbital periosteum (periorbita)", "fibrous lining of bony orbit; key frozen section decision layer"),
    ("Eyelids", "in standard exenteration; may be spared in lid-sparing variant"),
    ("Optic nerve", "ligated at orbital apex / optic foramen"),
]
for name, desc in structures:
    add_bullet(doc, f" {desc}", bold_prefix=name + ":")
doc.add_paragraph()

add_body(doc, "Critical neurovascular structures at the orbital apex:")
apex_items = [
    "Superior orbital fissure (SOF): cranial nerves III, IV, V1, VI + superior ophthalmic vein",
    "Optic foramen: optic nerve (CN II) + ophthalmic artery",
    "Ciliary ganglion (adjacent): vagal stimulation via traction can cause bradycardia/arrhythmia",
]
for item in apex_items:
    add_bullet(doc, item)

add_callout_box(doc,
    "Resident Pearl:",
    "Always inject lidocaine around the SOF and optic foramen before ligation to prevent autonomic-mediated cardiac arrhythmias from traction on the ciliary ganglion.",
    bg_hex="E8F5E9", border_hex="2E7D32"
)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 3: INDICATIONS
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "3. Indications")

add_section_heading(doc, "3a. Oncologic Indications", level=2)
add_body(doc, "Exenteration is indicated when tumor invades orbital contents beyond the periorbita:")

ind_table = doc.add_table(rows=1, cols=3)
ind_table.style = 'Table Grid'
ind_table.alignment = WD_TABLE_ALIGNMENT.CENTER
hdr = ind_table.rows[0].cells
for cell, text in zip(hdr, ["Tumor Type", "Scenario Requiring Exenteration", "Specialty"]):
    shade_cell(cell, "2E4A7A")
    p = cell.paragraphs[0]
    r = p.add_run(text)
    r.bold = True
    r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    r.font.size = Pt(10)

rows_data = [
    ("Sinonasal SCC / Adenocarcinoma", "Invasion through periorbita into fat, EOM, or optic nerve", "ENT / H&N"),
    ("Sebaceous gland carcinoma", "Diffuse pagetoid spread; extensive eyelid/orbital involvement", "Ophthalmology"),
    ("Squamous cell carcinoma (eyelid/conjunctiva)", "Orbital invasion; failure of prior excision", "Ophthalmology"),
    ("Adenoid cystic carcinoma (lacrimal gland)", "Perineural spread to apex; recurrence after local excision", "Both"),
    ("Malignant melanoma (conjunctival/uveal)", "Orbital invasion; other modalities failed", "Ophthalmology"),
    ("Maxillary sinus carcinoma", "Total maxillectomy with orbital extension through floor", "ENT / H&N"),
    ("Basal cell carcinoma (sclerosing/recurrent)", "Orbital invasion at medial or lateral canthus", "Ophthalmology"),
    ("Mucormycosis / Zygomycosis", "Invasive fungal sinusitis with orbital/intracranial extension not controllable by debridement alone", "ENT / Both"),
    ("Rhabdomyosarcoma", "Recurrence after chemoradiation; life-threatening disease", "Peds / H&N"),
]
for d in rows_data:
    row = ind_table.add_row().cells
    for cell, text in zip(row, d):
        p = cell.paragraphs[0]
        r = p.add_run(text)
        r.font.size = Pt(10)
doc.add_paragraph()

add_section_heading(doc, "3b. Non-oncologic Indications (Rare)", level=2)
for item in [
    "Intractable pain from a blind, phthisical eye (end-stage)",
    "Severe orbital infection with necrotizing fasciitis unresponsive to all other management",
    "Massive orbital trauma with unsalvageable contents",
]:
    add_bullet(doc, item)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 4: CONTRAINDICATIONS
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "4. Contraindications & Special Considerations")
for item in [
    "Non-curative intent (exenteration rarely palliative; individualize)",
    "Bilateral disease where exenteration would render patient totally blind — multidisciplinary review required",
    "Unresectable disease (carotid encasement, bilateral skull base involvement, extensive brain invasion >2 cm)",
    "Patient refusal after full informed consent",
    "Medical co-morbidities that preclude general anesthesia (relative)",
]:
    add_bullet(doc, item)

add_callout_box(doc,
    "Special Situation:",
    "In invasive mucormycosis, orbital exenteration may be lifesaving if fungal spread is rapid, even without established oncologic criteria being met. "
    "Current evidence suggests orbital preservation with aggressive debridement may be sufficient in selected cases — always consult infectious disease + neurosurgery urgently.",
    bg_hex="FFF3E0", border_hex="E65100"
)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 5: PRE-OP WORKUP
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "5. Pre-operative Workup")
add_section_heading(doc, "5a. Imaging", level=2)
for item in [
    "CT orbits with contrast: bone erosion, periorbita integrity, sinus involvement, skull base",
    "MRI orbits (fat-sat + contrast): soft tissue extent, EOM invasion, optic nerve, perineural spread",
    "CT chest/abdomen/pelvis or PET-CT: distant metastases staging",
]:
    add_bullet(doc, item)

add_section_heading(doc, "5b. Pathologic Confirmation", level=2)
for item in [
    "Incisional biopsy of primary tumor prior to exenteration",
    "Discuss with pathology for intraoperative frozen section availability",
]:
    add_bullet(doc, item)

add_section_heading(doc, "5c. Multidisciplinary Planning", level=2)
for item in [
    "Ophthalmology, Head & Neck Surgery, Plastics/Reconstructive Surgery — joint operative planning",
    "Radiation oncology: role of adjuvant radiotherapy (adjuvant RT improves local control in positive margins)",
    "Anesthesia: plan for significant blood loss; arterial line + large-bore IV access",
    "Prosthetics / Maxillofacial team: plan for orbital prosthesis or obturator",
]:
    add_bullet(doc, item)

add_section_heading(doc, "5d. Informed Consent Points", level=2)
for item in [
    "Permanent loss of vision and the eye",
    "Significant facial disfigurement",
    "Need for orbital prosthesis or reconstructive surgery",
    "Risk of incomplete tumor clearance and need for adjuvant treatment",
    "Psychosocial impact; refer to support services pre-operatively",
]:
    add_bullet(doc, item)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 6: TYPES
# ─────────────────────────────────────────────────────────────────────────────
doc.add_page_break()
add_section_heading(doc, "6. Types of Exenteration")

types_table = doc.add_table(rows=1, cols=4)
types_table.style = 'Table Grid'
types_table.alignment = WD_TABLE_ALIGNMENT.CENTER
hdr = types_table.rows[0].cells
for cell, text in zip(hdr, ["Type", "Structures Removed", "Eyelids", "Indication"]):
    shade_cell(cell, "1A6A5A")
    p = cell.paragraphs[0]
    r = p.add_run(text)
    r.bold = True
    r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    r.font.size = Pt(10)

types_data = [
    ("Total (standard)", "Globe, EOM, fat, lacrimal gland, eyelids, conjunctiva, periorbita", "Removed", "Eyelid/skin involvement by tumor"),
    ("Lid-sparing (subtotal)", "Globe, EOM, fat, lacrimal gland; periorbita resected", "Preserved (lid margins/tarsal plates sacrificed)", "Orbital contents involved but eyelid skin uninvolved; lids cover defect + osseointegrated implants"),
    ("Extended", "All of above + adjacent bone (orbital walls, roof), sinus structures, maxilla, skull base", "Variable", "Tumor extends into adjacent bony structures"),
    ("Total maxillectomy + orbital exenteration", "Maxilla en bloc with orbital contents", "Removed", "Maxillary/sinonasal tumor invading orbital floor and contents"),
]
for d in types_data:
    row = types_table.add_row().cells
    for cell, text in zip(row, d):
        p = cell.paragraphs[0]
        r = p.add_run(text)
        r.font.size = Pt(10)
doc.add_paragraph()

add_callout_box(doc,
    "Decision Point:",
    "Use intraoperative frozen section of the orbital periosteum to guide whether lid-sparing exenteration is sufficient vs. total exenteration required. "
    "If frozen section confirms tumor has NOT penetrated the periosteum, the periosteum can be resected and repaired without adversely affecting oncologic outcome (Scott-Brown's).",
    bg_hex="EBF4FA", border_hex="1565C0"
)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 7: OPERATIVE TECHNIQUE
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "7. Step-by-Step Operative Technique")
add_body(doc, "The following describes total orbital exenteration as part of total maxillectomy, the most commonly encountered scenario in combined ENT/ophthalmology practice.")
doc.add_paragraph()

steps = [
    ("Patient Positioning & Prep",
     "Supine, head elevated 15-20 degrees. General anesthesia with endotracheal intubation. "
     "Prep face and neck; wide draping to allow access to facial skin, oral cavity, and neck. "
     "Arterial line monitoring recommended."),
    ("Incision Planning",
     "Weber-Ferguson incision with subciliary extension for total maxillectomy approach. "
     "Skin incisions placed from medial to lateral canthi for isolated orbital exenteration. "
     "Mark incisions with surgical pen before injection of epinephrine."),
    ("Skin Flap Elevation",
     "Skin flaps raised off the upper and lower orbicularis oculi muscles. "
     "In total exenteration, eyelids are excised en bloc with specimen. "
     "In lid-sparing approach, lids are dissected free and preserved."),
    ("Periorbital Dissection",
     "Superior orbital periosteum (periorbita) incised along the orbital rim. "
     "Subperiosteal dissection performed circumferentially along the orbital walls — roof, lateral wall, medial wall, floor — "
     "back toward the orbital apex. The quadrant continuous with the maxillectomy specimen is left last."),
    ("Lidocaine Injection at Apex",
     "MANDATORY: Inject lidocaine 1% with epinephrine around the superior orbital fissure (SOF) and optic foramen "
     "BEFORE ligation. This prevents autonomic-mediated cardiac arrhythmias from traction on the ciliary ganglion."),
    ("Ligation at the SOF",
     "Neurovascular structures at the SOF (CN III, IV, V1, VI, superior ophthalmic vein) are carefully identified, "
     "ligated with suture or hemoclips, and divided."),
    ("Optic Nerve & Ophthalmic Artery",
     "Optic nerve identified at the optic foramen. "
     "Both the optic nerve and ophthalmic artery are ligated with suture and divided. "
     "Send optic nerve stump for frozen section to confirm clear margin."),
    ("Extraocular Muscle Transection",
     "All six extraocular muscles divided at the orbital apex using scissors or electrocautery."),
    ("Specimen Removal",
     "Remaining soft tissue attachments at the posterior orbit divided with heavy Mayo scissors. "
     "In total maxillectomy cases, the entire specimen (maxilla + orbital contents) is removed en bloc. "
     "Pass specimen immediately to pathology for orientation, frozen sections, and permanent sections."),
    ("Margin Assessment",
     "Obtain multiple frozen section biopsies from: anterior orbital fat margin, periorbita edges, "
     "optic nerve stump, and any suspicious area. Re-excise until clear margins are confirmed."),
    ("Hemostasis",
     "Electrocautery and surgical packing. The SOF and optic foramen bleed significantly — "
     "have bipolar cautery and bone wax available. Packing with surgicel or hemostatic gauze."),
    ("Reconstruction",
     "See Section 9 for reconstruction options. Perform in collaboration with reconstructive surgery team."),
]

for i, (title, content) in enumerate(steps, 1):
    p = doc.add_paragraph()
    p.paragraph_format.space_before = Pt(6)
    p.paragraph_format.space_after = Pt(3)
    r1 = p.add_run(f"Step {i}: {title}")
    r1.bold = True
    r1.font.size = Pt(11)
    r1.font.color.rgb = RGBColor(0x2E, 0x4A, 0x7A)
    body = doc.add_paragraph(content)
    body.paragraph_format.left_indent = Inches(0.3)
    body.paragraph_format.space_after = Pt(4)
    for run in body.runs:
        run.font.size = Pt(11)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 8: FROZEN SECTION
# ─────────────────────────────────────────────────────────────────────────────
doc.add_page_break()
add_section_heading(doc, "8. Intraoperative Frozen Section Biopsy")
add_body(doc,
    "Frozen section biopsy is intraoperative histopathological examination of surgical margins. "
    "Specimens are cryostat-sectioned and H&E stained within 15-30 minutes, enabling real-time margin decisions."
)
doc.add_paragraph()

add_section_heading(doc, "8a. When to Use Frozen Section in Orbital Surgery", level=2)
fs_indications = [
    ("Orbital periosteum margin", "To decide if orbital contents can be preserved vs. exenteration needed. "
     "If no tumor penetration through periorbita → resect and repair periosteum, spare orbit. "
     "If tumor penetrates periorbita → exenteration required."),
    ("Optic nerve stump", "Confirm clear margin at the orbital apex at time of exenteration."),
    ("Soft tissue surgical margins", "All edges of exenterated cavity — medial, lateral, superior, inferior."),
    ("Periorbital fat / EOM interface", "In limited-involvement cases where orbital preservation is attempted."),
    ("Nasal cavity and sinus margins", "During craniofacial resection — multiple frozen sections taken at all mucosal edges."),
]
for title, content in fs_indications:
    add_bullet(doc, f" {content}", bold_prefix=title + ": ")

doc.add_paragraph()
add_section_heading(doc, "8b. Frozen Section vs. Mohs Surgery", level=2)

mohs_table = doc.add_table(rows=1, cols=3)
mohs_table.style = 'Table Grid'
mohs_table.alignment = WD_TABLE_ALIGNMENT.CENTER
hdr = mohs_table.rows[0].cells
for cell, text in zip(hdr, ["Technique", "Principle", "Best Use"]):
    shade_cell(cell, "2E4A7A")
    p = cell.paragraphs[0]
    r = p.add_run(text)
    r.bold = True
    r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    r.font.size = Pt(10)

mohs_data = [
    ("Standard Frozen Section",
     "Margins of excised specimen examined at time of surgery; positive → re-excise that edge; negative → reconstruct same day",
     "Standard periorbital tumors; orbital margin assessment"),
    ("Mohs Micrographic Surgery",
     "Layered excision; each layer examined frozen; tumor map built; further tissue taken only where tumor persists; "
     "maximizes tumor clearance while minimizing normal tissue sacrifice",
     "Sclerosing BCC, recurrent SCC, medial/lateral canthal tumors, tumors with diffuse or finger-like extensions"),
]
for d in mohs_data:
    row = mohs_table.add_row().cells
    for cell, text in zip(row, d):
        p = cell.paragraphs[0]
        r = p.add_run(text)
        r.font.size = Pt(10)
doc.add_paragraph()

add_callout_box(doc,
    "Resident Pearl:",
    "The irregular contours around the eyelids and extension of tumors into orbital fat can make frozen section interpretation technically difficult. "
    "Communicate closely with your pathologist about orientation of specimens and the clinical question being asked.",
    bg_hex="E8F5E9", border_hex="2E7D32"
)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 9: RECONSTRUCTION
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "9. Reconstruction Options")
add_body(doc,
    "Reconstruction goals: obliterate dead space, provide vascularized tissue, maintain facial contour, "
    "allow prosthetic rehabilitation, minimize donor site morbidity."
)
doc.add_paragraph()

recon_table = doc.add_table(rows=1, cols=4)
recon_table.style = 'Table Grid'
recon_table.alignment = WD_TABLE_ALIGNMENT.CENTER
hdr = recon_table.rows[0].cells
for cell, text in zip(hdr, ["Option", "Type", "Advantages", "Best For"]):
    shade_cell(cell, "1A6A5A")
    p = cell.paragraphs[0]
    r = p.add_run(text)
    r.bold = True
    r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    r.font.size = Pt(10)

recon_data = [
    ("Split-thickness skin graft (STSG)", "Graft", "Simple; short operative time; prosthesis-friendly surface", "Medically frail patients; patients planned for orbital prosthesis"),
    ("Temporalis muscle flap", "Regional pedicled", "Reliable vascular supply; nearby donor site; fills orbital cavity well", "Moderate defects; good if free flap not feasible"),
    ("Paramedian forehead flap", "Regional pedicled", "Excellent color/texture match to facial skin; strong vascular pedicle (supratrochlear A.)", "Isolated orbital exenteration defects"),
    ("Free rectus abdominis flap", "Free microvascular", "Large soft tissue volume; reliable perforators; obliterates large cavity", "Soft tissue only defects; combined maxillectomy + exenteration"),
    ("Free DCIA flap (deep circumflex iliac artery)", "Free microvascular", "Bone + soft tissue; restores bony orbital framework; best cosmesis/function", "Total maxillectomy + exenteration requiring bony reconstruction"),
    ("Free scapula flap", "Free microvascular", "Bone + soft tissue; flexible geometry for orbital reconstruction", "Combined bony + soft tissue reconstruction"),
    ("ALT (anterolateral thigh) flap", "Free microvascular", "Large thin pliable skin paddle; long pedicle; minimal donor site morbidity", "Large combined midface + orbital defects"),
    ("Orbital prosthesis (after STSG or spontaneous granulation)", "Prosthetic", "Acceptable cosmesis without major reconstruction; allows tumor surveillance", "Selected patients; esp. with osseointegrated implants placed at exenteration"),
]
for d in recon_data:
    row = recon_table.add_row().cells
    for cell, text in zip(row, d):
        p = cell.paragraphs[0]
        r = p.add_run(text)
        r.font.size = Pt(10)
doc.add_paragraph()

# Insert reconstruction images
if downloaded.get("recon_temporalis.jpg"):
    add_image_with_caption(
        doc, downloaded["recon_temporalis.jpg"],
        "Fig. 1 - Temporalis muscle flap transposed to fill orbital cavity after exenteration for SCC. "
        "Multiple non-absorbable sutures anchor the flap to orbital margins prior to skin grafting.",
        width=5.0
    )

if downloaded.get("recon_forehead_flap.jpg"):
    add_image_with_caption(
        doc, downloaded["recon_forehead_flap.jpg"],
        "Fig. 2 - Paramedian forehead flap reconstruction of right orbital exenteration defect. "
        "Left: surgical markings; Center: flap transposed; Right: 4-month post-operative result.",
        width=5.5
    )

if downloaded.get("recon_ALT_flap.jpg"):
    add_image_with_caption(
        doc, downloaded["recon_ALT_flap.jpg"],
        "Fig. 3 - Anterolateral thigh (ALT) free flap reconstruction following right orbital exenteration "
        "and midface resection for advanced cutaneous SCC. Note microsurgical anastomosis to superficial temporal vessels.",
        width=5.5
    )

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 10: COMPLICATIONS
# ─────────────────────────────────────────────────────────────────────────────
doc.add_page_break()
add_section_heading(doc, "10. Complications")

add_section_heading(doc, "10a. Intraoperative", level=2)
for item in [
    "Hemorrhage: from ophthalmic artery, SOF vessels, ethmoid arteries — have bipolar + bone wax available",
    "Cardiac arrhythmia / bradycardia: from traction on ciliary ganglion at apex — prevent with lidocaine injection",
    "CSF leak: if dura violated during craniofacial extension — repair with fascia lata or dural graft matrix + pericranial flap",
    "Carotid artery injury: during extended resection — rare but catastrophic",
    "Incomplete resection / positive margins: rely on frozen section to guide re-excision intraoperatively",
]
    add_bullet(doc, item)

add_section_heading(doc, "10b. Early Post-operative (0-30 days)", level=2)
for item in [
    "Hematoma / seroma in orbital cavity",
    "Flap failure (partial or total): monitor free flap with Doppler q1-2h post-op",
    "Wound dehiscence: especially at skin graft edges",
    "CSF leak (if skull base involved): head elevation, lumbar drain, early neurosurgery review",
    "Infection / orbital cavity sepsis",
    "Eustachian tube dysfunction (if maxillectomy component): conductive hearing loss",
]
    add_bullet(doc, item)

add_section_heading(doc, "10c. Late Complications", level=2)
for item in [
    "Local tumor recurrence: most common failure pattern in sinonasal malignancies (up to 67% of failures are local)",
    "Exposure of bony orbital walls with graft or flap loss",
    "Contracture of orbital socket: interferes with prosthesis fitting",
    "Epiphora / dacryocystitis: if nasolacrimal duct not addressed",
    "Chronic sinusitis (if sinus cavities communicated)",
    "Psychological morbidity: depression, body image disturbance — refer to support services early",
]
    add_bullet(doc, item)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 11: POST-OP MANAGEMENT
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "11. Post-operative Management")

add_section_heading(doc, "11a. Immediate (ICU / HDU, 24-48h)", level=2)
for item in [
    "Free flap monitoring: hourly Doppler assessment; flap checks by nursing q1-2h",
    "IV antibiotics: typically 24-48h perioperative",
    "Head elevation 30-45 degrees to reduce edema",
    "Nasogastric feeding if oral feeding not possible post-maxillectomy",
    "Pain management: multimodal analgesia; avoid NSAIDs in first 48h if significant bleeding risk",
]:
    add_bullet(doc, item)

add_section_heading(doc, "11b. Inpatient (Day 2-7)", level=2)
for item in [
    "Wound care: gentle saline irrigation of orbital cavity twice daily",
    "Oral hygiene: chlorhexidine rinses if oral cavity involved",
    "Obturator insertion (if palate/maxilla resected): fit temporary obturator at 5-7 days",
    "Speech and language therapy (SALT) referral",
    "Physiotherapy: jaw exercises to prevent trismus",
    "Psychiatric / psychological support referral",
]:
    add_bullet(doc, item)

add_section_heading(doc, "11c. Outpatient Follow-up", level=2)
for item in [
    "Definitive prosthetic fitting: 4-6 weeks post-op once edema resolved",
    "Osseointegrated implants (if placed): allow 3-6 months integration before loading prosthesis",
    "Adjuvant radiotherapy: referral within 6 weeks if positive or close margins",
    "Oncology surveillance: MRI +/- CT q3-6 months for 2 years, then annually",
    "Multidisciplinary tumor board: present final pathology and margins",
]:
    add_bullet(doc, item)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 12: PROGNOSIS
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "12. Prognosis")
add_body(doc, "Prognosis is strongly dependent on tumor histology, margin status, and extent of disease:")
for item in [
    "Sinonasal malignancies overall: 5-year absolute local control ~50%; 10-year ~31%; 15-year ~21%",
    "Orbital involvement despite exenteration significantly worsens survival",
    "Negative margins: strongest predictor of survival",
    "Failure pattern: predominantly local (up to 66.7% of recurrences in skull base series); distant ~46%; regional ~17%",
    "Advanced-stage disease (Class IV defects): typically poor prognosis; reconstruction secondary to feasibility assessment",
    "Adenoid cystic carcinoma / olfactory neuroblastoma: better long-term survival but late relapses possible for decades",
    "SNUC (sinonasal undifferentiated carcinoma) / sinonasal melanoma: very poor prognosis",
]:
    add_bullet(doc, item)

add_callout_box(doc,
    "Clinical Implication:",
    "Even after exenteration, orbital involvement is associated with significantly poorer survival. "
    "Preoperative imaging and intraoperative frozen section are used to identify patients who can safely retain the orbit — "
    "but attempts to preserve orbital contents that result in positive margins lead to orbital recurrence.",
    bg_hex="FDECEA", border_hex="C62828"
)

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 13: KEY TEACHING POINTS
# ─────────────────────────────────────────────────────────────────────────────
doc.add_page_break()
add_section_heading(doc, "13. Key Teaching Points for Residents (PGY 1-2)")

teaching = [
    ("Always check frozen section of the periorbita",
     "Before committing to exenteration, perioperative frozen section of the orbital periosteum determines whether "
     "the globe can be saved. If tumor has not breached the periosteum, resection and repair are sufficient."),
    ("Lidocaine at the orbital apex is non-negotiable",
     "Traction on the ciliary ganglion at the superior orbital fissure can cause severe bradycardia. "
     "Inject lidocaine 1% +/- epinephrine around the SOF and optic foramen before any manipulation."),
    ("Exenteration only with curative intent",
     "This is a life-altering operation. If resection is not curative, the morbidity of exenteration is not justified. "
     "Palliative exenteration is rare and requires very careful MDT discussion."),
    ("Plan reconstruction before you operate",
     "Reconstruct with the least complex option that achieves the goals. "
     "Bony defects require bone + soft tissue (DCIA/scapula); soft tissue only can use rectus or temporalis. "
     "Lid-sparing exenteration: the preserved lids provide excellent natural cover for osseointegrated implants."),
    ("Margins drive outcome more than radicality alone",
     "Radical resection including exenteration does not guarantee survival if margins are positive. "
     "Frozen section control of all margins — not just the orbital periosteum — is essential."),
    ("Psychosocial support starts pre-operatively",
     "Loss of the eye is devastating. Early psychiatric and support service referral, clear discussion of prosthetics, "
     "and patient-centered communication are as important as the surgery itself."),
    ("Adjuvant radiotherapy matters",
     "Refer for RT within 6 weeks if margins are positive/close, or for high-risk histologies (SCC, adenoid cystic). "
     "RT significantly improves local control in the post-exenteration setting."),
]

for i, (title, content) in enumerate(teaching, 1):
    add_callout_box(doc,
        f"{i}. {title}",
        content,
        bg_hex="EBF4FA" if i % 2 == 0 else "E8F5E9",
        border_hex="1565C0" if i % 2 == 0 else "2E7D32"
    )

# ─────────────────────────────────────────────────────────────────────────────
# SECTION 14: REFERENCES
# ─────────────────────────────────────────────────────────────────────────────
add_section_heading(doc, "14. References")
refs = [
    "Cummings CW et al. Cummings Otolaryngology: Head and Neck Surgery, 7th ed. Elsevier, 2020. "
    "Ch. 94: Total Maxillectomy with Orbital Exenteration (pp. 1748-1750).",
    "Lee KJ. Essential Otolaryngology: Head & Neck Surgery, 11th ed. McGraw-Hill, 2022. "
    "Ch. 49: Craniofacial Resection Steps 24-25 (pp. 891-893).",
    "Gleeson M (ed). Scott-Brown's Otorhinolaryngology, Head & Neck Surgery, 8th ed. CRC Press, 2019. "
    "Management of the Orbit (pp. 7430-7444).",
    "Kanski JJ, Bowling B. Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed. Elsevier, 2023. "
    "Frozen Section & Mohs Surgery (pp. 2585-2588); Orbital Exenteration (pp. 6446-6449).",
    "Sabiston DC (ed). Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 21st ed. Elsevier, 2022. "
    "Split-Thickness Skin Grafts and Orbital Reconstruction.",
    "Schwartz SI (ed). Schwartz's Principles of Surgery, 11th ed. McGraw-Hill, 2019. "
    "Nose and Paranasal Sinuses (p. 3307-3308).",
    "Bailey & Love's Short Practice of Surgery, 28th ed. CRC Press, 2023. Maxillary Resection (pp. 2224-2239).",
    "Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 8th ed. Wolters Kluwer, 2022.",
]
for i, ref in enumerate(refs, 1):
    p = doc.add_paragraph()
    p.paragraph_format.space_after = Pt(4)
    p.paragraph_format.left_indent = Inches(0.3)
    p.paragraph_format.first_line_indent = Inches(-0.3)
    r = p.add_run(f"{i}.  {ref}")
    r.font.size = Pt(10)

# ── Footer ───────────────────────────────────────────────────────────────────
add_horizontal_rule(doc)
footer_p = doc.add_paragraph()
footer_p.alignment = WD_ALIGN_PARAGRAPH.CENTER
fr = footer_p.add_run("Orbital Exenteration Surgical Reference Guide | PGY 1-2 Resident Training | August 2026")
fr.font.size = Pt(9)
fr.font.italic = True
fr.font.color.rgb = RGBColor(0x77, 0x77, 0x77)
discp = doc.add_paragraph()
discp.alignment = WD_ALIGN_PARAGRAPH.CENTER
dr = discp.add_run("This document is for educational purposes only. Clinical decisions must be made under direct consultant supervision.")
dr.font.size = Pt(8)
dr.font.italic = True
dr.font.color.rgb = RGBColor(0xAA, 0xAA, 0xAA)

# ── Save ─────────────────────────────────────────────────────────────────────
out_path = "/tmp/workspace/orbital-exenteration-guide/Orbital_Exenteration_Resident_Guide.docx"
doc.save(out_path)
print(f"\nSaved: {out_path}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/orbital-exenteration-guide/build_guide.py'