lymph node dissection

2. Neck Dissections:Neck Dissections:
Classifications,Classifications,
Indications, andIndications, and
TechniquesTechniques

3. The neck dissection is a surgical procedure
for control of neck lymph node metastasis.
This can be done for clinically or radiologically
evident lymph nodes or as part of curative
surgery where risk of occult nodal metastasis
is deemed sufficiently high.

4.  Status of the cervical lymph nodes
is important prognostic factor in SCCA of the
upper aerodigestive tract
 Cure rates drop in half when there is
regional lymph node involvement

5. Emil Theodor Kocher
Earned Nobel Prize in 1909 for
his work in thyroid and neck
surgery — the first ever
awarded to a surgeon.
1880 – Kocher proposed
removing nodal
metastases

6. 1906 – George Crile
described the classic radical
neck dissection (RND)

7. 1967 - Bocca and Pignataro
described the “functional neck dissection”
(FND)

9. Fascial layers of the neck
Superficial cervical fascia
Deep cervical fascia
– Superficial layer
SCM, strap muscles,
trapezius
– Middle or Visceral Layer
Thyroid,Trachea, esophagus
– Deep layer (also prevertebral fascia)
Vertebral muscles
Phrenic nerve

13.  Sternocleidomastoid Muscle
medial third of clavicle(clavicular
head), manubrium (sternal head)
Insertion – mastoid process
Nerve supply – spinal accessory
Blood supply –
1) occipital a. or direct from ECA
2) superior thyroid a.
3) transverse cervical a.
 Function –
 turns head toward opposite side
and tilts head toward the
ipsilateral shoulder

14. Origin – upper border of the scapula
Insertion – 1) via the intermediate tendon
onto the clavicle and first rib
2) hyoid bone lateral to the sternohyoid
muscle
Blood supply – Inferior thyroid a.
Function –
1) depress the hyoid
2) tense the deep cervical fascia
Surgical considerations
– Absent in 10% of individuals
– Landmark demarcating level III from IV
– Inferior belly lies superficial to The
brachial plexus, Phrenic nerve,
transverse cervical vessels
Superior belly lies superficial to IJV

15. Origin –
1) medial 1/3 of the sup. Nuchal line
2) external occipital protuberance
3) ligamentum nuchae
4) spinous process of C7 and T1-T12
Insertion –
1) lateral 1/3 of the clavicle
2) acromion process
3) spine of the scapula
Function – elevate and rotate the scapula and
stabilize the shoulder
 Surgical considerations
 – Posterior limit of Level V neck dissection
 – Denervation results in shoulder drop and winged scapula

16. Origin – digastric fossa of the mandible
Insertion –
1) hyoid bone via the intermediate
tendon
2) mastoid process
Function – 1) elevate the hyoid bone
2) depress the mandible (assists
lateral pterygoid)
Surgical considerations
“Residents friend”
Posterior belly is superficial to:
ECA, Hypoglossal nerve, ICA, IJV
– Anterior belly
Landmark for identification of mylohyoid
for dissection of the submandibular
triangle

17. Should be preserved in
neck dissections
Most commonly injury
dissection level Ib
Can be found:
– 1cm anterior and inferior
to angle of mandible
 Deep to fascia of the
submandibular gland
 Superficial to adventitia of
the facial vein

18. Originates in the spinal nucleus
Passes through two foramen
– Foramen Magnum – enters the skull
posterior to the vertebral artery
 – Jugular Foramen – exits the skull
with CN IX,X and the IJV
Occipital artery crosses the nerve
Descends obliquely in level II
(forms Level IIa and IIb)
 Penetrates the deep surface of the
SCM Exits posterior surface of SCM
deep to Erb’s point
Traverses the posterior triangle
ensheathed by the superficial cervical
fascia and lies on the levator
scapulae
● Enters the trapezius approx. 5
cm above the clavicle

19. Sole nerve supply to the
diaphragm
Supplied by nerve roots
C3-5
Runs obliquely toward
midline on the anterior
surface of anterior
scalene
Covered by prevertebral
fascia
Lies posterior and lateral
to the carotid sheath

21. Motor nerve to the tongue
Cell bodies are in the Hypoglossal
nucleus of the Medulla oblongata
Exits the skull via the hypoglossal
canal
Lies deep to the IJV, ICA, CN IX, X,
and XI
Curves 90 degrees and passes
between the IJV and ICA
Extends upward along hyoglossus
muscle and into the genioglossus
to the tip of the tongue
 Iatrogenic injury Most common site
- floor of the submandibular
triangle, just deep to the duct

22. “N” classification AJCC (1997)
Consistent for all mucosal sites except the
nasopharynx
Thyroid and nasopharynx have different
staging based on tumor behavior and
prognosis

23. NX: Regional lymph nodes cannot
be assessed
N0: No regional lymph node
metastasis
N1: Metastasis in a single ipsilateral
lymph node, < 3
N2a: Metastasis in a single
ipsilateral
lymph node 3 to 6 cm
N2b: Metastasis in multiple
ipsilateral
lymph nodes, none more than 6 cm
N2c: Metastasis in bilateral or
contralateral nodes < 6cm
N3: Metastasis in a lymph node
more than 6 cm in greatest
dimension

27. Level IA
Floor of mouth, anterior oral tongue,
anterior mandibular alveolar ridge, lower lip
Level IA
Floor of mouth, anterior oral tongue,
anterior mandibular alveolar ridge, lower lip
Level IB
Oral cavity, anterior nasal cavity, soft
tissue of midface, submandibular gland
Level IB
Oral cavity, anterior nasal cavity, soft
tissue of midface, submandibular gland

28. Level IIA & IIB
Oral cavity, nasal cavity, nasopharynx, oropharynx,, hypopharynx,
larynx, parotid gland

29.  With oral, tongue, retromolar trigone, and
tonsillar fossa subsites, the
jugulodigastric, submandibular, and
midjugular lymph node stations are
involved.
 With the floor of the mouth as the subsite,
the submandibular and
jugulodigastric lymph node stations are
involved.
 With the soft palate, base of the tongue,
oropharynx, supraglottis, and
hypopharynx subsites, the
jugulodigastric, midjugular, and
contralateral lymph node stations are
involved.
 With the nasopharynx as the subsite,
lymph node stations of the widest nodal
distribution are involved.

30.  Contralateral metastasis is found in the
supraglottis, the base of the tongue, and the
posterior pharyngeal wall palate.
 Bilateral metastasis is found in the
nasopharynx, the base of the tongue, the soft
palate, the floor of mouth, and the supraglottis.
 Multiple cervical metastases
(adenocarcinoma) occur with thyroid carcinoma,
breast carcinoma, and nasopharyngeal
carcinoma.

32. Academy’s classification
1) Radical neck dissection (RND)
2) Modified radical neck dissection
(MRND)
3) Selective neck dissection (SND)
Supra-omohyoid type
Lateral type
Posterolateral type
Anterior compartment type
4) Extended radical neck dissection

33.  Comprehensive neck dissection
Radical neck dissection
Modified radical neck dissection
Type I (XI preserved)
Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM preserved)
 Selective neck dissection

34.  All lymph nodes in Levels
I-V including spinal
accessory nerve (SAN),
SCM, and IJV
 Indications
 – Extensive cervical
involvement or matted
lymph nodes with gross
extracapsular spread and
invasion into the SAN,
IJV, or SCM

36.  Excision of same lymph node bearing regions as
RND with preservation of one or more
nonlymphatic structures (SAN, SCM, IJV)
 Type I: Preservation of SAN
 Type II: Preservation of SAN and IJV
 Type III: Preservation of SAN, IJV, and
SCM

37.  TYPE I TYPE II
 TYPE III

38. Indications
 – Clinically obvious lymph node metastases
 – SAN not involved by tumor
 Rationale
RND vs MRND Type I:
 5-year survival and neck failure rates for RND
(63% and 12%) not statistically different from
MRND (71% and 12%).
 No difference in pattern of neck failure

39. Indications
 Rarely planned
 Intraoperative tumor found adherent to the
SCM, but not IJV and SAN

40.  Rationale
Suarez (1963) – surgery specimens of
larynx and hypopharynx – lymph nodes do not share
the same adventitia as adjacent BV’s
 Survival approximates MRND Type I assuming IJV,
and SCM not involved
Neck dissection of choice for N0 neck

41. Cervical lymphadenectomy with preservation of one
or more lymph node groups
Four common subtypes:
 Supraomohyoid neck dissection
 Posterolateral neck dissection
 Lateral neck dissection
 Anterior neck dissection

42.  Also known as an elective neck dissection
 Indication: primary lesion with 20% or greater risk
of occult metastasis
 May elect to upgrade neck intraoperatively
 Frozen section needed to confirm SCCA in
suspicious node
 Need for post-op XRT

43. Indications
 Oral cavity carcinoma with N0 neck
 Subsites - Lips, buccal mucosa, upper and lower
alveolar ridges, retromolar trigone, hard palate, and
anterior 2/3s of the tongue and Floor Of Mouth.
– Medina recommends SOHND with T2-T4NO
or TXN1 (palpable node is <3cm, mobile, and
in levels I or II)

44. Indications
 Anterior tongue
 Oral tongue and
FOM that approach
the midline
 Adjuvant XRT given
to patients with
> 2positive nodes +/-

45. En bloc removal of the
jugular lymph nodes
including Levels II-IV
 Indications
 N0 neck in
carcinomas of the
oropharynx,hypophar
ynx, supraglottis, and
larynx

46. En bloc excision of lymph bearing tissues in
Levels II-V
Indications
 Cutaneous malignancies
 Melanoma
 Squamous cell carcinoma
 Merkel cell carcinoma
 Soft tissue sarcomas of the scalp and neck

47. En bloc removal of lymph structures in Level VI
 Perithyroidal nodes
 Pretracheal nodes
 Precricoid nodes (Delphian)
 Paratracheal nodes along recurrent nerves
 – Limits of the dissection are the hyoid
bone,suprasternal notch and carotid sheaths
 Indications
 – Selected cases of thyroid carcinoma
 – Parathyroid carcinoma
 – Subglottic carcinoma
 – Laryngeal carcinoma with subglottic extension
 – CA of the cervical esophagus

48. Any previous dissection which includes removal of one or
more additional lymph node groups and/or non-
lymphatic structures.
 Usually performed with N+ necks in MRND or RND
when metastases invade structures usually preserved
 Examples:
Resection of the hypoglossal nerve, resection of
digastric muscle, Carotid artery resection,
dissection of mediastinal nodes and central
compartment for subglottic involvement, and removal of
retropharyngeal lymph nodes for tumors originating in
the pharyngeal walls.

53. Schobinger

54. Flap raising
 Make the skin incision through
the platysma and elevate the
flap in the subplatysmal plane.
 Traction with the surgeon's
fingers and countertraction by
the assistant with skin hooks
 Elevate the posterior flap toward
the trapezius muscle.
 Identify and preserve the
marginal mandibular nerve at
the superior aspect of the flap.

55. The contents of the submental triangle
are then elevated from the inferior
border of the mandible and the
opposite digastric muscle off of the
mylohyoid muscle
Dissection in the proper plane allows
for an en bloc elevation of the
contents into the submandibular
triangle and to the posterior border
of the mylohyoid muscle.
Retraction of the mylohyoid muscle
anteriorly allows for identification of
the submandibular duct, which is
ligated and divided
The dissected contents of sublevels IA
and IB are then elevated over the
digastric muscle in continuity with
the nondissected portion of the neck

56.  The contents dissected from level I are
elevated caudally to visualize the
superior internal jugular vein..
 Identification of the SAN can be
performed anterior or posterior to the
SCM.
 If the SAN can be preserved, dissection
is then continued from near to IJV
towards the trapezius muscle, dividing
the SCM. If the SCM is going to be
preserved, the SAN must be carefully
dissected by identifying the nerve both
anterior and posterior to the SCM.
 A posterior to anterior dissection is then
performed beginning at the anterior
border of the trapezius muscle,
preserving the phrenic nerve and the
brachial plexus, located deep to this
fascia.
 The SAN must then be freed from the
soft tissues of the posterior triangle and
can be carefully retracted away from the
region of dissection with a vessel loop or
nerve hook. Dissection is continued to
the posterior border of the SCM.

57. .
 At this point, the posterior triangle contents,
with or without the SAN and SCM, have been
elevated to the lateral aspect of the IJV. If the
SCM is being resected, transection is
performed below the mastoid tip and above
the clavicle as in a RND.
 The nodes along IJV can usually be removed
en bloc with the remainder of the dissection
in a posteroanterior fashion, sharply incising
the fascia of the jugular vein with a scalpel
blade using a feather-light touch. If the IJV
requires sacrifice due to metastatic nodal
involvement or tumor thrombosis, the vein is
ligated and divided superiorly and inferiorly
following identification and preservation of
the vagus nerve.
 Dissection is continued anteriorly, elevating
the fascia and soft tissues up to the
infrahyoid strap muscles and the hyoid-
digastric junction.
 Preservation of a fascial layer superficial to
the carotid artery is usually possible, and
exposure of the carotid artery should be
discouraged unless necessary.
 Suction drains are strategically placed and a
layered closure is performed.

59.  Intraop.Cx
Hemorrhage
Nerve damage
Thoracic duct injury
Pneumothorax
 Post op. Cx
Hematoma
Wound infection
Skin flap loss
Salivary fistula
Chylous fistula 500 ml
Facial edema
Carotid artery rupture

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