neck dissection part 2

Neck dissection
Part 2
Dr. Padmasree Patowary

Contents
• Introduction
• Historical perspective
• Anatomical considerations
• Classification of neck dissection
• Incisions

• Revision of classification of neck dissections
• Generic steps of all neck dissection
• Radical neck dissection
• Modified or functional radical neck dissection
• Supraomohyoid neck dissection
• Controversies
• Recent advantages
• Conclusion

PHILOSOPHY OF STELL AND MARAN:
AGGRESSIVE FIRST, CONSERVATIVE LATER

Radical
neck
dissection
Removal of lymphatic tissues in levels I to V
along with the SCM, IJV, and spinal
accessory nerve (SAN)
American Head and Neck Society neck dissection classification

Modified
radical
neck
dissection
Removal of lymphatic tissues in levels I to V
with preservation of one or more non-
lymphatic structures:
Type I: Preservation of SAN
Type II: Preservation of IJV, SAN
Type III: Preservation of SCM, IJV, SAN

Extended
neck
dissection
Removal of additional lymphatic tissue
and/or non-lymphatic structures not
normally removed in a radical neck
dissection
Selective
neck
dissection
Preservation of one or more lymphatic
levels as well as non-lymphatic structures
normally removed in a radical neck
dissection

Generic steps for all neck dissections
• Painting and drapping.
• Positioning of the patient.
• Choose appropriate incision according to the surgeon
preference.
• Adequate exposure and therefore suitable access to
the complete operative field.

Radical neck dissection
Radical neck dissection is a technique of monoblock
removal of regional cervical lymph nodes from the
lateral neck for malignant tumors involving the upper
aerodigestive tract.

Indications for a classical radical neck
dissection
1. Significant operable neck disease (N2a, N2b, N3) with
tumour bulk near to or directly involving spinal accessory
nerve and/or internal jugular vein.
2. Extensive recurrent disease after previous selective
surgery or radiotherapy.
3. Clinical signs of gross extra nodal disease.

Contraindications for a classical radical
neck dissection
1. Untreatable primary tumor or unresectable neck
disease.
2. Patient unfit for major surgery.
3. Distant metastases
4. Simultaneous bilateral neck dissection.

Surgical boundaries
 Superiorly- The inferior border of the mandible
 Anteriorly- The contralateral anterior belly of the
The hyoid bone (median ridge)
The sternohyoid muscle
 Inferiorly – The clavicle
 Posteriorly – Anterior border of the trapezius muscle
diagestric muscle

Surgical Technique
• The patient typically is in the supine position, with
the head and chest elevated to 30°.
• The neck is hyperextended and turned to the
contralateral side.

The single trifurcate incision is most commonly used for
the radical neck dissection. It can be extended to
accommodate resection of the primary tumor.

• Dissection done in subplatysmal plane with No 10
blade.
• It is important to keep platysma in skin flap as it
provides important blood supply and strength to
wound in the postoperative period.
• Removed only if invaded.
• Rake retractor or double skin hooks used to retract
platysma.

• During the dissection of upper neck, two branches of
facial nerve should be preserved.
– Marginal Mandibular Nerve
– Cervical Branch
• Both nerves curve downwards below and in front of
the angle of the mandible across the facial vessels
about one finger’s breadth below the mandible.

Marginal
mandibular
nerve
Cervical
branch
Submandibular
gland

• Easiest way save these nerves is expose the capsule of
the lower part of the submandibular gland.
• The fascia can then be elevated as a flap over the
mandible taking the nerve with it.
• Then the flap is sutured superiorly.

• Lower end of internal jugular vein
• Junction of lateral border of clavicle with lower
edge of trapezius
• Upper end of internal jugular vein
• Submandibular triangle
Major corners of consternation

Major corners of consternation

First area of special attention: The
lower end of the internal jugular
vein

• The lower end of the internal
jugular vein is approached
first by continuing dissection
along the upper border of
the clavicle from trapezius
muscle to the suprasternal
notch.

• The supraclavicular nerves and vessels (such as the
external jugular vein) are divided as well as the
sternocleidomastiod muscle.

• The internal jugular vein lies between the sternal and
clavicular heads of the sternocleidomastiod muscle and
dividing the muscle fibres just above the clavicle reveals the
vein.

• This can be done by using blunt-tipped scissors, isolating
the muscle by pushing the scissors under the
sternocleidomastiod muscle and then keeping the
scissors in place to protect the underlying vein, the
muscle can be cut.

• After dividing the sternocledomastoid muscle, the
blueness of the internal jugular vein can be seen as
the vein lies within the carotid sheath.

• The carotid sheath is opened and the internal jugular
vein is exposed for at least a few centimeters in order
to allow for adequate access for ligation.
• The position of the vagus nerve is verified before
ligation of the internal jugular vein.
• Three ligating sutures, are placed around the vein,
upper end of the vein and lower end of the vein.

• Tansfixation suture on lower end is known as
HOUSEMAN’s SUTURE (since, if it fails in the early
hours of the morning following surgery, it is the
houseman who knows about it first)
• The bleeding injured vessel should be identified and
occluded temporarily with pressure or arterial
clamps and the defect repaired using 6.0 Ethilon.

• Adequate finger pressure and trendelenburg position
of the patient should be maintained before clamping
and ligating the vein.

• When performing a neck
dissection on the left side
of the neck, one should be
alert between the IJV,
subclavian vein and the
clavicle because of the
thoracic duct.
Thoracic
duct
Subclavian
vein

• After ligation of the vein, the carotid artery and
vegus nerve are carefully retracted medially allowing
for dissection of the IJV and its associated lymph
node.

• Once the IJV has been tied the dissection extends
laterally towards Chaissaignac’s triangle.
• Its defined as the triangle between where the longus
colli and scalenus anterior attach to the tubercle of
C6 (Chaissaignac’s or carotid tubercle) with the
subclavian artery as the base.

Longus Colli
Scalenus
Anterior
Tubercle Of C6
Clavicle

• Here are found scalene node which should be
removed.
• Main jugular lymph duct that terminates here on the
left side with the thoracic duct.
• If the duct damaged, noticeable by extra clear fluid
welling up into the dissection area, the source should
be found and transfixed.

Second area of special attention:
Junction of clavicle and anterior
border of trapezius

• Divide the lower end of
sternocleidomastoid muscle.
• Identified the IJV.
• Ligation and dissection of the
lower end of the IJV and
dissection from the carotid
sheath.

• Deeper to the omohyoid, the
transverse cervical artery and
vein are found as they run
laterally across the floor of the
posterior triangle and ligated.
• Both the artery and particularly
the vein have small branches
across the anterior border of
trapezius muscle. Omohyoid Transverse
Cervical
artery
Trapezius
muscle

• Dissection is then continued further, either sharp or
blunt with a swab, on to the underlying level of the
prevertebral fascia overlying the scalene muscle.

• Directly under prevertebral
fascia , the phrenic nerve and
the brachical plexus are seen.
• As long as the fascia is not
breached, these structures
are protected.

• Chaissaignac's triangle cleared off disease now.
• Once the supraclavicular dissection has been completed
towards the anterior border of trapezius, the operation
continues in an upwards direction to dissect the posterior
triangle.

Dissection of the posterior triangular
• The dissection continues upwards following the
anterior border of the trapezius muscle to the
uppermost point of the triangle at the mastoid tip
where the trapezius and sternocleidomastoid meet.

• The anterior border of the trapezius muscle
represents the lateral border of the dissection.
• Floor of the posterior triangle is formed by the
prevertebral fascia overlying the deeper muscles of
the neck- the splenius capitis (cranially), medial,
anterior and posterior scalenus muscles and the
levator scapulae.

• It is important before dissecting the posterior triangle
that the SAN is identified.
• There are a number of ways to identify the nerve,
based on its anatomical trajectory and surgical
landmarks.

• It exits the lateral border of the SCM at the junction
of its upper third with the lower two-thirds.
• This is known as Erb's point and can be identified 1
cm above the point where the Greater Auricular
Nerve winds around the muscle on its way to supply
the parotid fascia.

Erb's pointGreater Auricular Nerve

• Once identified, the nerve may be mobilized.
• The dissected tissue now hinges on the mastoid and
skin insertions of the sternocleidomastoid muscle;
these are dissected as well as the lower lobe of
parotid gland at the level of the angle of the
mandible.

Third area of special attention: The
upper end of the internal jugular
vein

• Divided the upper end of the sternocleidomastoid
muscle in the third area.
• Retract the posterior belly of digastric muscle
upwards.
• Posterior belly of digastric muscle as known as
resident’s friend – is cleared and using a Langenback
retractor, it can be retracted superiorly exposing IJV
and accessory nerve.

• It is not usually necessary to remove the posterior
belly of the digastric muscle unless wider access into
level II is required.
• Before tying any ligatures, the Vagus and
Hypoglossal Nerves should be identified and
preserved.

• The Hypoglossal Tunnel is a particularly useful
landmark when tumour is stuck near the carotid
bifurcation.
• The Occipital Artery crosses the Posterior Part of the
Internal Jugular Vein and this should also be ligated
now to prevent further troublesome bleeding.

Upper end of the internal jugular vein identified and
ligation done

• Dissection across the carotid bifurcation may cause
bradycardia and changes in blood pressure due to
triggering of the carotid sinus lying within the
bifurcation.
• Once the IJV has been ligated and dissected at the
upper end, the surgical specimen is mobilized by
working both from a cranial and caudial direction.
• Dissection continues anteriorly along the border of the
mandible.

Fourth area of special attention: the
submandibular triangle

• The contents of the triangle, including lymph nodes
and fatty tissue must be removed leaving behind
clean muscles that form the boundaries.
• Dissection of the submandibular triangle is usually
begun in the midline, by dividing the fatty tissue on
to the dissection plane of the anterior belly of the
contralateral digastric muscle.

Submandibular salivary gland
Lingual nerve
Nerve to mylohyoid
Digastric muscle
(posterior belly)
Hypoglossal nerve
Facial artery

• The anterior part of the submandibular gland is
identified and is dissected to the posterior border of
the mylohyoid muscle.
• The upper border of the submandibular gland is
freed by tying and dividing the vessels, including the
facial artery, that cross the lower border of the
mandible

• The mylohyoid muscle is retracted in a forward
direction to reveal the submandibular duct and, at
this point, the lingual nerve is pulled down in a
curve.
• The latter is freed by dividing the fascia around the
submandibular ganglion.

• The lingual nerve is identified, and two artery
forceps are placed below it to divide the branch to
the submandibular ganglion.
• The submandibular duct is tied and divided and
during both of these procedure, the hypoglossal
nerve is kept under direct vision to avoid any
damage.

Closure
• Two large drains are placed through the posterior
flap and securely tied.
• Drains should never cross the carotid sheath, be cut
to the correct length and kept well away from any
microvascular anastomosis.

• Finally, make a check for any chylous leak, any
bleeding from the veins accompanying the
hypoglossal nerve .
• The wound is closed in two layers with an absorbable
Vicryl stitch to the platysmal layer and the skin then
closed using either interrupted or continuous sutures
of Ethilon.

Modified Radical Neck Dissection

What is modified RND
• Removal of lymphatic tissues in levels I to V with
preservation of one or more non-lymphatic
structures.
– Type III: Preservation of SCM, IJV, SAN
– Type II: Preservation of IJV, SAN
– Type I: Preservation of SAN
• MRND is analogous to the “functional neck
dissection” described by Bocca.

Rationale
• Modifications of the classic RND aim to reduce
postsurgical neck pain and shoulder dysfunction
encountered when the spinal accessory is resected
without compromising adequate oncologic treatment.
• Sacrifice of the SCM and IJV is less debilitating.

• SCM preservation - improves cosmetic appearance
and protects the carotid artery if adjuvant
radiotherapy is employed.
• Preserving the IJV becomes more significant in
patients requiring bilateral neck dissections.

MRND Indications
Type I – Removal of Level
I to V + IJV + SCM but
preservation of Spinal
Accessory Nerve
1. Operable palpable neck
disease (usually N1, N2a,
N2b) not involving SAN.
2. Occasionally for N0 neck

Type II - Removal of
Level I to V + SCM only
Same as for Type I particularly
for a second side operation
when there is need for
microvascular anastomosis.
Type III – Removal of
only Level I to V lymph
nodes
1. N0 neck
2. Differentiated thyroid cancer
MRND Indications

Preserving spinal accessory nerve
• If the accessory nerve is to be preserved , extra care
should be taken when the skin flap of the posterior
triangle is developed, as the nerve runs at a superficial
level and is therefore close to the plane of dissection.

• The accessory nerve supplies the innervation of the
trapezius muscle.

• Once the spinal accessory nerve has been
completely exposed, the tissue lying superior and
posterior to the nerve must be dissected from the
splenius capitis and levator scapulae muscles.
• The tissue is pulled in an anteroinferior direction
toward the spinal accessory nerve.

• It must be emphasized that the lymph nodes that are
now being removed are located between the spinal
accessory nerve and the internal jugular vein.
• This region corresponds to the ill-defined boundary
between level II and the upper part of level V.

• The occipital artery are identified, ligated and
divided at this stage.
• Once the dissected tissue reaches the level of the
spinal accessory nerve, it must be passed under the
nerve to be removed in continuity with the main part
of the specimen.
• Osvaldo Suarez referred to this step of the operation
as ‘‘the spinal accessory maneuver’’

Sparing of the sternocleidomastoid
muscle
• Preservation of the sternocleidomastoid muscle
requires mobilization of the deep inserting fascia
from the anterior border of the sternocleidomastoid
muscle and dissection of the muscle from the fascia
below allowing for upward retraction of the muscle
using loops or retractors.

• The dissection itself is continued under the
sternocleidomastoid muscle in the same way as one
would proceed as in a radical neck dissection.

• Prior to approaching the fascia of the
sternocleidomastoid muscle, the external jugular
vein must be ligated and divided.
• Usually, three sections of the external jugular vein
are required in functional and selective neck
dissection.

Sparing of the internal jugular vein
• Preservation of the internal jugular vein requires
careful dissection along the surface of the vein.

• As in radical neck dissection, the vein is located
preferably first in the lower neck, after having
completed the dissection across the clavicle from
trapezius to suprasternal notch.
• The supraclavicular nerves and vessels (such as the
external jugular vein) are divided as well as the
sternocleidomastoid muscle.
• The sternocleidomastoid lies directly over the
internal jugular vein.

• Selective Neck Dissection consists of preservation of
one or more lymph node groups and all three
nonlymphatic structures.

Selective Neck
Dissection
Levels
dissected
Main Indications
Supraomohyoid
(SOHND)
I – III N0 SCC oral cavity
Extended
supraomohyoid
I – IV 1. Skin Ca (SCC,
Melanoma) anterior
to line of tragus.
2. Performed in
Conjunction to
superficial
parotidectomy

Selective Neck
Dissection
Levels dissected Main Indications
Lateral II – IV T2-T4,N0 SCC larynx,
Oropharynx and
Hypophaynx
Posterolateral II – V plus Post.
Auricular
Skin Ca (SCC, Melanoma)
posterior to line of tragus

Anterior /
Central
VI Differentiated Thyroid
Ca,Subglottic,
Hypopharyngeal SCC
Superior
Mediastinal
VII Differentiated and
Medullary Thyroid Ca
,Subglottic, Laryngeal,
Hypopharyngeal SCC 3.
Cervical Oesophageal Ca

Supraomohyoid Type (Level I-III)
• The supraomohyoid neck dissection (SOHND) is the
most commonly performed selective neck dissection
for the treatment of the N0 neck.
• It involves the en bloc removal of cervical lymph
node groups I-III.

Lymph Node levels
dissected
I-lll
Also excised
Submandibular
gland

Indications
• SOHND is indicated in patients with primary tumors
arising from the oral cavity without clinical or
radiologic evidence of cervical metastasis but who
have a high probability of occult lymphatic disease.
• The oral cavity includes the area between the
vermillion border of the lips and the junction of the
of the hard and soft palate superiorly and the
circumvallate papillae of the tongue inferiorly.

• Subsites in the oral cavity include
– The lips
– Buccal mucosa
– Upper and lower alveolar ridges
– Retromolar trigone
– Hard palate
– Anterior two thirds of the tongue
– Floor of mouth.

• Bilateral SOHND is indicated in patients who have
carcinomas of the anterior tongue or oral tongue and
floor of mouth that approach or cross the midline.
• SOHND is indicated along with parotidectomy in
patients with squamous cell carcinoma.

• There has been a significant increase in concern
towards improving aesthetic and functional
outcomes without compromising the oncologic
effectiveness in head and neck surgery.

• Up till now, there is only limited evidence available
on endoscopic and robotic neck dissection via a
retroauricular approach.

Advantages of Retroauricular approach
• Provided sufficient working space for the robotic arm
• Less invasive
• Completely hidden scar
• Benefits in functional aspects such as drainage of
lymphedema

Disadvantages of retroauricular
approach
• Auricular nerve paresthesia
• Auricular deformity
• Cervical postrhytidectomy contracture

Endoscopic neck dissection
• Endoscopic neck dissection is a new set of surgical
procedures aiming at removing a varied number of
lymph nodes and lymph node bearing tissues of the
neck through small incisions with endoscopic
instruments and techniques.

Debate and controversy continue to exist in the
following areas:
1. Treatment of level IV in patients with N0 necks and
carcinoma of the oral tongue
2. Supraomohyoid neck dissection: diagnostic or
therapeutic?

Controversies
3. Management of carotid artery with involvement in
cervical metastases
4. Salivary gland- preserved or excised ?

• The complex anatomy makes neck dissection a tricky
procedure to perform.

neck dissection part 2

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