Neck DissectionDr Yasha Gupta

LADY HARDINGE MEDICAL COLLEGE

Neck Boundaries1 = Mandible2 = Zygomatic Process Of The Temporal Bone3 = External Auditory Canal4 = Mastoid5 = Superior Nuchal Line6 = External Occipital Protuberance7 = Manubrium Sterni8 = Clavicle9 = Acromioclavicular Joint10 = Spinous Process Of Seventh Cervical Vertebra

The Surgical AnatomyPlatysma muscle:

Wide muscular sheet embedded in superficial fasciaOrigin InsertionAction Skin flap

The Surgical AnatomySternocleidomastoid Muscle:

Differentiated from the platysma by the direction of its fibresCrossed by the IJV and the great auricular nerveOrigin InsertionNerve supplyAction boundary of posterior triangle & nodes level II - IV

Change to picture with labels sterno mastpoid

The Surgical AnatomyTrapezius muscle:

Origin InsertionNerve supplyAction

The Surgical AnatomyDigastric Muscle

Posterior belly, intermediate tendon, anterior bellyOriginNerve supplyThe external and internal carotid artery, 12th & 11th cranial nerves

and the IJV lie medial

The Surgical AnatomyOmohyoid Muscle:

Superior & inferior bellies, intermediate tendonOriginNerve supply Action Surgical landmark for nodal levels III and IVThe inferior belly is superficial to the brachial plexus, phrenic nerve and transverse cervical vesselsThe superior belly is superficial to the IJV

Blood Supply of Head & Neck

Arteries of Head & Neck

• Common Carotid Artery

• External Carotid Artery

• Internal Carotid Artery

• Subclavian Artery

Common Carotid ArteriesRight Common Carotid Artery:

Arises from brachiocephalic artery

(Behind right sternoclavicular joint)

Left Common Carotid Artery:

Arises from Arch of Aorta

Runs upwards in the neck from sternoclavicular

joint to upper border of thyroid cartilage

Common Carotid Arteries

Relations of Common Carotid ArteryAnterolaterally:

Sternocleidomastoid Sternohyoid Sternothyroid Superior belly of omohyoid

Posteriorly: Prevertebral muscles

Medially: Larynx Pharynx

Laterally: Internal jugular vein

Branches of Common Carotid Artery

External Carotid Artery

Internal Carotid Artery

Common Carotid Arteries

Branches of External Carotid Artery Superior thyroid artery

Ascending pharyngeal artery

Lingual artery

Facial artery

Occipital artery

Posterior auricular artery

Superficial temporal artery

Maxillary artery

Internal Carotid Artery

Begins at the level of upper border of thyroid

cartilage

No branches in the neck

Through carotid canal enters into cranial cavity

Supplies brain, eyes, forehead and part of the nose

Subclavian Artery

Right Subclavian Artery:

Arises from brachiocephalic artery

(Behind right sternoclavicular joint)

At outer border of 1st rib it becomes Axillary Artery

Left Subclavian Artery:

Arsis from Arch of Aorta in the thorax

Runs upwards to the root of the neck & arches

laterally

At outer border of 1st rib it becomes Axillary Artery

Jugular Vein

INTERNAL JUGULAR VEIN

ANTERIOR JUGULAR VEIN

EXTERNAL JUGULAR VEIN

External jugular Vein Formed behind the angle of jaw by the union of

Posterior branch of retromandibular vein with

posterior auricular vein.

It drains into subclavian vein

Tributaries:

Posterior external jugular

Transverse cervical

Suprascapular

Anterior jugular

Internal jugular Vein

Receives blood from brain, face and neck.

Continuation of sigmoid sinus and leave the skull from jugular foramen.

Ends by joining subclavian vein to form brachiocephalic vein.

• Tributaries: Facial vein Pharyngeal vein Lingual vein Superior thyroid vein Middle thyroid vein

The Surgical AnatomySpinal Accessory nerve: SAN

Emerge from the jugular foramen medial to the digastric and stylohyoid muscles and lateral and posterior to IJV

It passes obliquely downward and backward to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erb’s point

The Surgical AnatomyThoracic duct:

• Conveys lymph from the entire body back to the blood

• Begins at the cisterna chyli

• Enters posterior mediastinum between azygous vein & thoracic aorta

• Courses to left into neck anterior to the vertebral artery and vein

• Enters the junction of the left subclavian vein and the IJV

Triangles Of The Neck

29

Stylohyoid

Mandible

Digastric

Digastric triangleSubmental triangleCarotid triangleMuscular triangle

Omohyoid

ANT

ERIO

R TR

IANG

LE

Sternocleidomastoid Trapezius

Occipital triangleSupraclavicular triangle

POSTERIOR

TRIANGLE

Anterior TriangleBoundaries

Sub-mental triangle

Digastric triangle

Carotid triangle

Muscular triangle

Posterior TriangleBoundaries

Contents

Lymph Node Levels/Nodal Regions

Developed by Memorial Sloan-Kettering Cancer Center

Ease and uniformity in describing regional nodal involvement

AAOHNS Classification Of Cervical Lymph Nodes

LEVEL I – Submental / Submandibular Lymph NodesLEVEL II – Upper Jugular Lymph NodesLEVEL III – Middle Jugular Lymph NodesLEVEL IV– Lower Jugular Lymph NodesLEVEL V – Posterior Triangle Lymph NodesLEVEL VI –Anterior Compartment Lymph Nodes LEVEL VII- Superior Mediastinal Lymph Nodes

VIVI

Metastatic Nodal DiseaseLevel I – lip, anterior tongue, anterior floor of mouth, buccal

mucosa

Level II, III – tonsil, base of tongue (scalp, external auditory canal)

Level IV – hypopharynx & larynx

Level V – nasopharyngeal malignacy

Level VI – thyroid, subglottic

Clinical Staging Joint UICC/AJCC classification (2009)

Not only for presence of lymph node but also size, number & laterality

Applies for all head & neck tumour except nasopharynx, thyroid

Only clinical classification

Staging Of The Neck

NX: Regional lymph nodes cannot be Assessed

N0: No regional lymph node metastasis

N1: Metastasis in a single ipsilateral lymph node, < 3cm

N2a: Metastasis in a single ipsilateral lymph node 3 to 6 cm

Staging of the NeckN2b: 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

Nasopharyngeal CarcinomaN1 – Unilateral < 6cmN2 – Bilateral < 6 cmN3a > 6 cmN3b – Extension to supraclavicular fossa

ThyroidN1 – Regional node

N1a - IpsilateralN1b - Bilateral, midline, contralateral cervical or

mediastinal LN

Types Of Neck DissectionRadical neck dissection

Modified radical dissection

Selective neck dissection

Extended radical neck dissection

Classification of NeckDissections

Academy’s classification

– Based on 4 concepts

1. RND is the standard basic procedure for cervical lymphadenectomy against which all other modifications

2. Modifications of the RND which include preservation of any non- lymphatic structures are referred to as modified radical neck dissection (MRND)

Classification of NeckDissections

3) Any neck dissection that preserves one or more groups or levels of lymph nodes is referred to as a selective neck dissection (SND)

4) An extended neck dissection refers to the removal of additional lymph node groups or non-lymphatic structures relative to the RND

Skin IncisionVascularisation of flaps

Exposure

Protection of major vessels

Localization of primary tumour

Consider previous radiotherapy & reconstruction

Cosmesis

Previous surgical field

Blood Supply Of Cervical Neck Skin

Blood enters from above, below and either

side with a resultant watershed in the

middle of the neck. Incisions can be

planned to utilize this so as to maximize

blood supply to each of the neck flaps.

Radical Neck DissectionLymph nodes level I – V

Non-lymphatic structuresAccessory nerve Internal jugular veinSternocleidomastoid muscle

Indications Significant operable neck disease (N2a,N2b,N3) with spinal

accessory or IJV involvement

Extensive recurrent disease after previous selective surgery

Contraindication Untreatable primary tumour or unresectable neck disease

Patient unfit

Distant metastasis

Simultaneous bilateral dissection

Surgical BoundariesSuperior- angle of mandible

Anterior- contralateral anterior belly of digastric

Inferior- clavicle

Posterior- anterior border of trapezius

With traction and countertraction, the skin is incised in one movement with a No. 10 blade through the platysma muscle

In the posterior part of the neck, the fibers of the sternomastoid muscle are inserted directly into the skin which makes the dissection and identification of the appropriate plane more difficult.

Marginal mandibular nerve

Cervical branch of facial nerve

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 .

The marginal mandibular nerve then runs Immediately superior to the submandibular gland while the cervical branch runs lateral and inferior to this gland . Both of the nerves then curve upwards again

2 approaches can be used

Hayes martin (upward approach)

Downward approach

Hayes Martin ApproachSternocliedomastoid is divided just above sterno clavicular attachment

Internal jugular vein identified

Carotid sheath is opened to expose internal jugular vein & ligated

The dissection extends laterally to approach chaissaignac's triangle.

Divide and retract the omohyoid muscle upwards.

Mobilize the fat pad overlying the prevertebral fascia.

Identify and preserve the brachial plexus and phrenic nerve.

Dissection Of The Posterior Triangle

Dissection continues up the anterior border of trapezius to the mastoid tip

First accessory nerve is identified

Branches from cervical plexus C3,4 are saved

Accessory nerve dissected away from muscle

Upper end of sternocleidomastoid is cut under tension & digastric is retracted to show IJV

Division of upper end of IJV

Identify and preserve the hypoglossal nerve.

Specimen is mobilized both top and bottom

Top section is completed by finding and ligating the posterior branch of the posterior facial vein.

The dissection of the posterior triangle is completed by lifting the specimen & dissect between the contents of the posterior triangle and prevertebral fascia.

Dissection of the Submandibular Triangle

The fat is divided in the submental area and anterior belly of digastric is identified.

The anterior part of the submandibular gland is then identified and is dissected to the posterior border of the mylohyoid muscle.

The upper border of the submandibular gland is freed by dividing and tying the Vessels

The lingual nerve is identified, branch to the submandibular ganglion is divided

The submandibular duct is tied and divided

Facial artery is divided and specimen is removed

Above Downward Approach Incision given and flaps are raised

Clearance of posterior triangle

Incision along anterior border of trapezius and SCM s divided

Posterior belly of digastric is identified

Clearance proceed downwards

Accessory nerve, inferior belly of omohyoid, transverse cervical vessels, brachial plexus covered with fascia identified

Supraclavicular dissection

Fat is divided to locate inferior belly of omohyoid

Omohyoid is divided and dissection is continued upto the level of prevertebral fascia

External jugular vein is divided

SCM is divided at it’s lower end

IJV is dissected and divided

Clearance is continued from posterior triangle to midline

Clearance is done close to artery and nerve

Tributaries of IJV are carefully divided

Submandibular triangle clearance

Modified Neck DissectionMedina classification (1989)

Modified radical neck dissection

– Type I (XI preserved)

– Type II (XI, IJV preserved)

– Type III (XI, IJV, and SCM preserved)

MRND Type I

Indications Operable palpable neck disease ( N1, N2a, N2b) not

involving the accessory nerve

N0 neck (occasionally)

MRND Type II

MRND Type III

IndicationsTreatment of No neck disease

Treatment of undifferentiated thyroid cancer

Skin tumours eg. Melanoma, SCC

Approaches for MRNDAnterior approach (Ballantyne)

Posterior approach (Bocca)

Selective Neck DissectionAny type of cervical lymphadenectomy with preservation of one

or more lymph node groups

Four subtype:Supraomohyoid neck dissectionPosterolateral neck dissectionLateral neck dissectionAnterior neck dissection

Removal of lymph nodes in regions I –III

The posterior limit

The inferior limit

SCC oral cavity (T1-T4) with N0

Single palpable LN in level I or II (controversial) with Ca oral cavity, lip

Posterolateral Neck Dissection

Removal of levels II-V

Skin cancer posterior to tragus

Lateral neck dissection

Remove lymph nodes in levels II – IV

Ca larynx, orophaynx, hypopharynx T2-4 N0

Anterior Neck Dissection

Removal of LN surrounding the visceral structure in the anterior aspect of the neck, level VI

Superior limitInferior limitLaterallyDifferentiated and medullar Ca

of thyroid with thyroidectomy

Extended Radical Neck DissectionRemoval of additional lymphatic structure other than RND

Retrophayngeal LNLevel VII LNHypoglossal nerveCarotid arterySkin of neck

Complications General

Local

General ComplicationsAnaesthetic complications

Post operative atelectasis with basal collapse

Pneumonia

Ischaemic heart diaease

Urinary retention

Deep vein thrombosis

Local ComplicationsHemorrhage

Wound infection

Carotid artery rupture

Nerve injuries

Chylous fistula

Pneumothorax

Cerebral edema

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