1. Neck dissection Dr. Mansoor Khan MBBS, FCPS-I, Resident Surgeon

2. Introduction Status of the cervical lymph nodes important prognostic factor in SCCA of theupper aerodigestive tract

3. Introduction Cure rates drop in half when there is regional lymph node involvement

4. 1880 – Kocher proposed removing nodal metastases Emil Theodor Kocher Earned Nobel Prize in 1909 for his work in thyroid and neck surgery — the first ever awarded to a surgeon.

5. 1906 – George Crile described the classic radical neck dissection (RND)

6. 1967 - Bocca and Pignataro described the “functional neck dissection” (FND)

7. • 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

9. Level - I

10. Level - II

11. Level - III

12. Level - IV

13. Level - V

14. Level - VI

15. Subzones of Levels I-V

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

18. Lymph node staging No regional lymph node metastases Single ipsilateral lymph node, < 3 cm Single ipsilateral lymph node 3 to 6 cm Multiple ipsilateral lymph nodes < 6 cm Bilateral or contralateral nodes < 6cm Metastases > 6 cm

19. “ Surgical approach” Incisions

20. A p r o n I n c i s i o n

21. H a l f A p r o n I n c i s i o n

22. C o n l e y I n c i s i o n

23. D o u b l e – Y I n c i s i o n

24. Y - I n c i s i o n

25. H - I n c i s i o n

26. M a c F e e I n c i s i o n

27. M o d i f i e d S c h o b i n g e r I n c i s i o n

28. S c h o b i n g e r I n c i s i o n

29. Academy’s classification Radical neck dissection (RND) Modified radical neck dissection (MRND) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type Extended radical neck dissection

30. Extent of Radical Neck Dissection Indications Extensive cervical involvement or matted lymph nodes with gross extracapsular spread and invasion into the SAN, IJV, or SCM Radical Neck Dissection All lymph nodes in Levels I-V including spinal accessory nerve (SAN), SCM, and IJV

31. Modified Radical Neck Excision of same lymph node bearing regions as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV) analogous to the “functional neck

32. MRND Type I Preservation of SAN

33. MRND Type II Preservation of SAN and IJV

34. MRND Type III Preservation of SAN, IJV, and SCM ( “Functional neck dissection”)

35. Selective Neck Dissections Cervical lymphadenectomy with preservation of one or more lymph node groups (Supraomohyoid neck dissection, Posterolateral neck dissection , Lateral neck dissection, Anterior neck dissection) Supraomohyoid neck dissection

36. Selective Neck Dissections Lateral neck dissection

37. Extended Neck Dissection Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic structures.

38. Radical Neck Dissection