NECK

DISSECTION
PRESENTOR : DR.VENKATESH.V
MODERATOR: DR.NAVEEN P.G
ANATOMY OF NECK
 The region of the body that lies between:

 The LOWER BORDER OF THE MANDIBLE &

 The SUPRASTERNAL NOTCH and the UPPER BORDER OF
CLAVICLE
FASCIAL LAYERS OF NECK
• 2 distinct fascial layers in the neck,

a)superficial cervical fascia.

b)deep cervical fascia.

• Superficial cervical fascia corresponds to subcutaneous tissue.

• Deep cervical fascia is the key element for functional and selective neck dissection
 DEEP CERVICAL FASCIA
Superficial layer(investing or anterior fascia)-

• It is attached to occipital protuberance, mastoid process, capsule of parotid gland, angle of jaw, and body of the mandible to the

symphysis, where it proceeds around opposite side in a similar manner.

• It then goes posteriorly across the spinal process of the cervical vertebrae .

• Anteriorly, it passes from the mandible to hyoid bone.

• Inferiorly, it attaches to sternum, upper edge of clavicle, acromion, and spine of scapula.

• At the inferior border, in the midline, superficial layer splits in two different layers just superior to the manubrium of sternum.
 The space between these two layers is known as the suprasternal space of burns.

 From posterior to anterior, the superficial layer splits to enclose the trapezius, the portion
of the omohyoid muscle that crosses the posterior triangle of the neck, and the
sternocleidomastoid muscle.

 In a similar way it envelops the strap muscles, before ending in the midline.

 The superficial veins of the neck lie on or within this superficial layer of the deep cervical
fascia
DEEP LAYER(PREVERTEBRAL FASCIA)

 The deep or prevertebral layer, like the superficial layer, attaches posteriorly
at the spinous process of the cervical vertebrae.

 At its upper limit, it goes to the skull base at the jugular foramen and carotid
canal, then passes across the basilar process to the opposite side.
 This fascial layer covers the muscles of the back that enter into the neck
immediately deep to the trapezius muscle (splenius and levator
scapula).

 At the upper limit of the posterior triangle, this space is almost virtual.
The spinal accessory nerve crosses the posterior triangle at this level,
along with some lymph nodes.

 At the lower end, both fascial layers further separate, the deep layer
covering the scalene muscles, where as superficial layer remains
attached to the trapezius muscle and the clavicle.
 pretracheal fascia

Infrahyoid m.
trachea esophagu
thyroid s
Internal jugular
Pretracheal layer
vein
s.c.m Common carotid
Carotid sheath a.
Vagus n.
Buccopharynge scalenus
al fascia

Investing
layer

Prevertebral
Trapezius layer
 HISTOR
Y
188
0–
Ko c
re m he r
ov i p r o
m et n g p os
n
a s ta o d a l e d
se s

Emil Theodor Kocher

Earned Nobel Prize in 1909 for his
work in thyroid and neck
surgery — the first ever awarded to a
surgeon.
1906 – George Crile
described the classic radical
neck dissection (RND)
1967 - Bocca and Pignataro
described the “functional neck dissection” (FND)
 CERVICAL LYMPHATICS

 The cervical lymphatics are divided into superficial and

deep.
 The superficial perforate the cervical fascia and drain into
the deep.
 The deep vessels and nodes are more densely associated
with fascia condensations, are most commonly found along
blood vessels, nerves and muscles.
LEVELS OF LYMPH NODES
 REGION SPECIFIC
LYMPHATIC DRAINAGE
 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 IIA & IIB
Oral cavity, nasal cavity, nasopharynx, oropharynx,, hypopharynx, larynx, parotid
gland
Level III
Oral cavity, nasopharynx, oropharynx, hypopharynx, larynx
Level IV
Hypopharynx, thyroid, cervical esophagus, larynx
Level VA & VB
Nasopharynx, oropharynx, posterior scalp/neck skin
Level VI
Thyroid gland, glottic and subglottic larynx, apex of piriform sinus, cervical
esophagus
STAGING OF THE NECK
• “N” classification – AJCC
• Consistent for all mucosal sites except the nasopharynx
• Thyroid and nasopharynx have different staging based on
tumor behavior and prognosis
• Based on extent of disease prior to first treatment
HUMAN PAPILLOMAVIRUS
ASSOCIATED (P16 +)
OROPHARYNGEAL CANCER
N Category N criteria

Nx Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 One or more ipsilateral lymph nodes, none

larger than 6 cm

N2 Contralateral or bilateral nodes , none larger

than 6 cm

N3 Lymph nodes larger than 6 cm

AJCC cancer staging manual, Eighth edition(2017)

PREOPERATIVE
PREPARATION

 Patient is advised preoperatively about risks

and possible complications of the appropriate
neck dissection.
 POSITION OF
PATIENT
 Patient is laid supine on operating table with head extended on a head ring, sand
bag placed under the shoulders and the head turned to the opposite side.
1.APRON FLAP INCISION

Incision extends between both mastoid tips, crossing the midline at the level of the
Cricoid arch. This incision allows good exposure when the neck dissection is to be combined with
total or partial laryngectomy.

2.HAYES MARTIN ICISION

This incision allows good exposure when the neck dissection is to be combined with total or
partial laryngectomy.
The double-Y incision of Martin is also popular for functional and selective neck dissection.
A well-known disadvantage of this incision is the compromise to the blood supply, especially in
the two crossings of the incision.
3.The single-Y incision avoids one of the crossings of the double-Y incision but makes the
dissection of the supraclavicular fossa difficult.

4.The Schobinger flap is also designed to protect the carotid artery by means of a large
anteriorly based skin flap. However the blood supply to the posterosuperior part of the flap
is not good and occasionally, this area becomes devitalized.

5.The Conley modification of the Schobinger flap brings the posterosuperior arm of the
incision a little further anteriorly. The vertical arm of the incision is extended more
posteriorly, toward the lateral third of the clavicle

6. Mac Fee parallel transverse incision and the H incision They both allow a good
preservation of the blood supply to the skin flaps. The Mac Fee incision has excellent
cosmetic results. However, the approach to the neck is not as good as with other incisions
 BASIC NEEDS OF AN INCISION ARE:
 1.Good exposure of the neck and primary disease.
 2. Ensure viability of the skin flaps.
Avoid acute angles
 3. Protect carotid artery even in the cases of wound infection.
 4. Facilitate reconstruction
Example, if pectoral muscle is used a lower limb should be near the
clavicle to enable flap accommodation.
 5. It should be cosmetically acceptable.
RATIONALE OF NECK
DISSECTION
It falls into 2 categories:
 Therapeutic
 Elective

 Therapeutic: When palpable operable nodes are present-N2a,2b,3metastatic

nodes with occult primary.

 Elective: When no lymph nodes are palpable-N0 nodes with high incidence of
microscopic metastasisCa pyriform fossa, supraglottis, post 1/3rd of tongue.
CLASSIFICATION
MEDINA’S CLASSIFICATION
• Comprehensive neck dissection
• Radical neck dissection
• Modified radical neck dissection
• - TYPE 1 (XI PRESERVED)
• -TYPE 2 (XI,IJV PRESERVED)
• -TYPE 3 (XI,IJV,SCM PRESERVED)
• Selective neck dissection (as mentioned above)
 Neck
Dissection

Selective Extended
Comprehensive ND
ND ND

Modified
Radiacal Supraomo Lateral Posterolateral
radical
ND hyoid ND ND ND
ND
 SPIRO’S CLASSIFICATION
Radical (4 or 5 node levels resected)
• Conventional radical neck dissection
• Modified radical neck dissection
• Extended radical neck dissection
• Modified and extended radical neck dissection

Selective (3 node levels resected)

• Supraomohyoid neck dissection
• Jugular dissection (Levels II-IV)
• Any other 3 node levels resected

Limited (no more than 2 node levels resected)

• Paratracheal node dissection
• Mediastinal node dissection
• Any other 1 or 2 node levels resected
RADICAL NECK
DISSECTION
 This involves removing the lymph node containing levels in the neck ( I-
V) with draining lymphatics & lymphatic drainage structures and all 3
non- lymphatic structures (spinal accessory nerve, sternocleidomastoid
muscle and internal jugular vein).

INDICATIONS:
 Significant advanced operable neck disease
(N2a,N2b,N3)
 Access prior to pedicled flap reconstruction.
FOUR AREAS OF SPECIAL
INTEREST 3. Upper end
4. Submandibular of internal
triangle jugular vein

2. Junction of lateral border

1. Lower end of
of clavicle with lower edge of
internal jugular vein
trapezius
 STEPS:
• RAISING OF SKIN FLAPS:
• Superiorly up to mandibular
border,
• Anteriorly to midline,
• Posteriorly to anterior border of
trapezius,
• Inferiorly to supraclavicular
region.
DISSECTION AT LOWER END
OF SCM  Sternal and clavicular ends of SCM are
identified and divided.
• WHY NECESSARY TO DIVIDE AT
LOWER END:
-Preserves blood supply of SCM
-Exposes IJV
 DISSECTION AT LOWER END OF IJV
 Once SCM is divided, carotid sheath is
visualized and exposed.
 At least 2cm length of IJV is freed and
exposed to facilitate ligation.
 1 above and 2 below point of division.
 Both ends are transfixed and vein
transected.
 Thoracic duct identified on left side at junction of IJV &
subclavian vein & preserved.
 Once IJV is ligated dissection extends to chaissaignac’s
triangle, scalene nodes found here are removed.

CHAISSAIGNAC TRIANGLE longus colli and scaleneus

anterior forms lateral border, cervical spine forms medial
border, subclavian artery forming base.
JUNCTION OF
CLAVICLE AND ANTERIOR BORDER OF TRAPEZIUS
• Having tied IJV move and begin dissection at lower end of
trapezius muscle.
• Fatty tissues in supraclavicular region are divided and care should
be taken not to pull these tissues from behind clavicle into neck.
• While fat is retracted upwards, inferior belly of omohyoid muscle is
encountered and it is either cut or ligated and it can then be
retracted upwards.
• Deeper to the omohyoid, transverse cervical artery and vein are
found as they run laterally across floor of posterior triangle and
ligated.
• Dissection is then continued further directly beneath prevertebral
fascia, phrenic nerve and brachial plexus are seen and, as long as
fascia is not breached, these structures are protected.
• Phrenic nerve descends from lateral to medial through neck over
anterior scalenus muscle and brachial plexus emerges between
medial and anterior scalenus muscles.
• Supraclavicular dissection is continued to anterior border of trapezius
muscle and here dissection proceeds in an upward direction , thus
dissecting posterior triangle of the neck .
DISSECTION OF POST
TRIANGLE
 Dissection continues upwards following anterior border of trapezius
muscle to uppermost point of triangle at mastoid tip where trapezius and
scm meet.

 By following the anterior border of trapezius, but dissecting on to

prevertebral fascia posterior triangle can be cleared.

 The anterior border of trapezius muscle constitutes lateral border of

dissection & floor of posterior triangle is formed by the prevertebral fascia
overlying deeper muscles of neck: the splenitis capitis and levator
scapulae.
 The exit point of nerve from within SCM can be predicted by rule of thumb that it is
located approximately 1 c m above Erb's point, the point where the great auricular
nerve winds from behind muscle on its route to supply the skin over parotid gland.

 Another way to identify accessory nerve, but often thought more difficult, is to locate
it at its entry point into anterior border of trapezius muscle a few centimeters above
the clavicle.

 Posterior belly of digastric muscleoften referred to as resident's friend - is cleared

& using Langenbeck retractor, it can be retracted superiorly exposing IJV and
accessory nerve.
Accessory nerve crosses jugular vein from medially to laterally as nerve enters SCM
at approximately junction of upper & middle third of muscle.
 The transverse process of atlas serves as a useful anatomical landmark.

 As muscle has been divided from its cranial insertion into skin and mastoid process, and
muscle is retracted caudally, accessory nerve can be transposed in craniolateral direction.

 Dissection plane across jugular vein lies close to vessel wall and vein is cleared and
mobilized
.
 The vein is divided after ligation and transfixion with sutures.
 Two important structures should be identified before ligating IJV: vagus and
hypoglossal nerves.

 Vagus nerve runs along with the internal and common carotid artery and its
position is verified during dissection.

 Hypoglossal nerve runs across carotid bifurcation, lingual and occipital arteries
and forms a rather convenient tunnel along which dissection can be continued.
DISSECTION OF SUBMENTAL AND
SUBMADIBULAR TRIANGLES:
• Starts in submandibular space & carried along inferior border
of mandible up to attachment of anterior belly of digastric .
• Contents of 1a are cleared.
• Dissection continued in submandibular triangle.
 CONTRAINDICATIONS

Patient unfit for major surgery.

Distant metastasis.
Significant bilateral neck disease.
Inoperable neck disease.
EXTENDED RADICAL NECK
DISSECTION
 Consists of removal of all the structures removed in a RND along with
additional lymph node groups (retropharyngeal,parapharyngeal, parotid, or
lymph nodes in level VI or VII) and non lymphatic structures such as part of
mandible, parotid gland, part of mastoid tip, prevertebral fascia and
musculature, digastric muscle, hypoglossal nerve, external carotid as well as
part of skin.

 Indicated when direct extension of the growth, primary in parotid gland,

subglottic carcinomas, carcinomas of cervical esophagus and thyroid where
level vi and vii dissection is required.
 MODIFIED RADICAL NECK DISSECTION

 Removal of I-V level nodes with preservation of one or more non

lymphatic structures.
 Indications : operable palpable neck disease not involving
accessory nerve.
- Treatment of clinically obvious lymphnode involvement
- Treatment of DTC
Skin tumors as melanomas, squamous cell carcinoma and merkel
cell carcinoma in the narrow band of scalp between both ears.
SUPRAOMOHYOID NECK
DISSECTION
• Most commonly performed SND
– En bloc removal of cervical lymph node groups I-III
– Posterior limit is the cervical plexus and posterior border of the
SCM
– Inferior limit is the omohyoid muscle overlying the IJV
FOR CANCER OF SUBSITES
Lips, buccal mucosa, upper
and lower alveolar ridges,
retromolar trigone, hard
palate, and anterior 2/3rd of
the tongue and Floor of mouth
LATERAL NECK DISSECTION
– En bloc removal of the
jugular lymph nodes including
Levels II-IV.
Indications:
– N0 neck in carcinomas of the
oropharynx, hypopharynx,
supraglottis, and larynx
EXTENDED SUPRAOMOHYOID
(ANTEROLATERAL)

 Levels I-IV removed,

 skin cancer ( SCC and
melanoma ) anterior to the
line of tragus, or in
conjunction with a
superficial parotidectomy.
 POSTEROLATERAL
 levels II- V removed plus
postauricular and suboccipital
nodes
 Skin cancers ( melanoma,
SCC, merkel cell carcinoma
that originate posterior to the
line of tragus.
ANTERIOR/CENTRAL
COMPARTMENT
 Levels VI removed
 Differentiated and medullary
thyroid carcinoma, and in
conjunction with a lateral
selective neck dissection for
tumors of hypopharynx and
subglottis.
SUPERIOR MEDIASTINUM

 For level VII

 An upper median sternotomy ( with a lateral extension at
the angle of Louis if required) is made to facilitate access
to upper mediastinum.
 For differentiated and medullary thyroid carcinoma,
subglottic and hypopharyngeal SCC, cervical esophageal
carcinoma along with an anterior compartment dissection.
 CLOSURE
Valsalva is performed.
Wound is irrigated with saline.
Hemostasis is secured.
Suction drain kept & brought through separate stab
incision.
Wound closed in 2 layers.
Gauze dressing applied.
 POSTOP CARE
• NBM till recovery from Anesthesia.
• Monitor vitals.
• Injectable antibiotics & analgesics.
• Watch for neck swelling/breathing difficulty.
• Drain removal when drainage ceases usually 24 to 48 hrs.
• Sutures removed after 7 days.
 LOCAL COMPLICATIONS:

Hemorrhage :shock
• Avulsion of IJV
• Laceration of carotid artery
• Vessels around nerve plexus
 DAMAGE TO IJV
 Damage to internal jugular vein, but also to small contributing vessels in its
proximity, can lead to alarming bleeding during which it is of utmost importance
to remain calm and instruct the assistant not to grab the bleeding vessel with
artery forceps or use diathermy as this will enlarge the hole in vessel.

 The trick in stopping bleeding is to apply pressure with finger or apply arterial
clamps and then ligate vessel.

 If a large hole occurs or the vein is torn, adequate finger pressure should be
applied and the patient should ideally be placed in trendelenburg position before
clamping and ligating vein , as the main danger of torn IJV is not blood loss but
possibility
of an air embolism
CAROTID ARTERY RUPTURE(CAROTID BLOW OUT)

Spontaneous rupture- necrosis of arterial wall- infection/

Irradiated patient/Combination procedure (development
of salivary fistula adjacent to carotid artery)

 Treatment: Surgical debridement and toilet with local

and systemic antibiotics
-Wound exploration and localizing the bleeder and
ligation.
-Ligation of carotid artery.
 CHYLOUS FISTULA:
• Thoracic duct passes behind esophagus to left side of neck & reaches angulus venosus
dorsal to IJV.

• Treatment:
Remove suction drainage
pressure bandages to area
Total parenteral nutrition

 Pneumothorax

 If disease is low in the neck the apical pleura can be damaged.

Treatment: Immediate insertion of chest tube.

WOUND INFECTION
• Contamination of surgical field at time of surgery

• Contamination because the surgery involves an in continuity RND

and primary excision, infected postoperative hematoma

• Flap necrosis and wound breakdown.

Nerve injuries

 In a standard RND the nerves which are deliberately divided are the accessory nerve, branches of
cervical plexus ( lesser occipital, greater auricular, transverse cutaneous nerve, supraclavicular
nerves and some motor branches to trapezius), descendens hypoglossi.

 Mandibular or cervical division of the Facial nerve, hypoglossal , lingual nerve, the vagus,
sympathetic trunk, phrenic nerve or brachial plexus.

 Shoulder syndrome due to division of accessory nerve – pain in joint, limitation of abduction and
drooping of affected shoulder.

Best way to prevent is to save both the accessory nerve and the separate branches from the cervical
plexus ( c4 ,c5) to the trapezius.
 REFERENCES

 Stell n maren 5th e/d

 Scott 7th e/d
 Schwatz 10 e/d
 Sabiston 20 e/d
 Cummings 5th e/d
 Farquharson’s textbook of operative general surgery
 Myers head & neck surgery operative manual
Thank you