Neck Dissections - types, various modifications, incisions, steps and latest developments in the field, complications during and after the surgery.

1. Presented by : Dr Meghali Diwaker
Guided by : Dr G.K Thapliyal
NECK DISSECTION
Various modifications, incisions in
RND

2. Surgical procedure in which
the fibrofatty contents of the
neck are removed for the
treatment of cervical
lymphatic metastases
Neck dissection

3. Lymph node levels

4. Neck
Dissection
Comprehensive
ND
Radical ND
Modified
radical ND
Selective ND
Supraomohyoi
d ND
Lateral ND
Anterolatera
l ND
Extended
ND
Classification

5. Radical neck dissection
All lymph nodes in Levels I
- V including spinal
accessory nerve (SAN),
SCM, and IJV

6. Excision of same lymph
node bearing regions
as RND with
preservation of one or
more nonlymphatic
structures (SAN, SCM,
IJV)
Modified Radical neck dissection

7. MRND Type I
Preservation of SAN
MRND Type II
Preservation of SAN
and IJV
MRND Type III
Preservation of SAN,
IJV, and SCM

8. SUPRAOMOHYOID
NECK DISSECTION
LATERAL NECK
DISSECTION
Selective neck dissection

9. Any dissection which includes removal of
one or more additional lymph node groups
and/or non-lymphatic structures.
Extended neck dissection

10. Neck boundaries

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

12. • 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.
Patient positioning

13. • Good exposure of the neck and primary disease
• Ensure viability of the skin flaps. Avoid acute angles
• Protect carotid artery even in the cases of wound infection
• Facilitate reconstruction
• Adapt to the condition of patient esp after radiotherapy
• It should be cosmetically acceptable
Basic needs of an incision are

14. • Incisions classified into
– Vertical
– Horizontal
Incisions
Transverse incision Vertical incision
Have cosmetic advantage as
they follow natural skin
folds of the skin
Disadvantages because they
intersect to the natural skin
folds of the skin and the
vascular supply of the neck
Recovery of scar tissue in
these folds are rapid and
successful
They tend to contract along
their long axis – leads to
deformity and restricted
action
Easy to modify

15. • Advantages
– Incision provides good exposure to surgical
site.
• Disadvantages
– Flap necrosis is high due to disruption of
vasculature of skin flaps
– Occurrence of flap separation at the
trifurcation site.
• Variations of classical Y incision – gluck,
schobinger, conley, martin incision.
• Other alternatives : utility incision, hockey
incision, apron flap, Mcfee incision
Tri-radiate incision

16. Apron incision
A horizontal incision from mastoid to
mentum gently curving inferiorly upto upper
border of the thyroid cartilage is used.
• Advantages
– Carotid artery is well protected
– Protects the descending arterial recovery
• Disadvantages
– It will damage the ascending arterial and
venous recovery
– Venous congestion and oedema might
develop at the bottom corner

17. Half Apron incision
• It has a longitudinal and transverse
incision
• B/L hockey stick incision allows the
deglovement of the whole neck.

18. It is a paired ‘Y’ incision.
• Here the submandibular
component is met by a vertical
limb which below becomes
continuous with an inverted ‘Y’ in
the suprascapular region.
• This flap most often gets
cyanosed.
• Flap necrosis and carotid
exposure is more in this type of
incision.
Hayes Martin incision

19. Schobingerincision Modified Schobinger incision
Vertical limb instead of being straight should be
curved posteriorly

20. • It avoids a vertical limb.
• Two horizontal incisions are used one in submandibular region and other in the suprascapular region.
McFee incision
Advantages Disadvantages
Excellent cosmetic result Exposure is not good
There is no lessening of
vascularity in
the centre of the flap
It is not suitable for bilateral
simultaneous neck dissection
There is no angle intersection
in incision
Operating period is long
Post operative wound recovery
is rapid
Difficulty may arise while
working
under the bridge flap
Recovery of flap excellent due
to wide
bipedicled flaps
In short neck it might be
difficult

21. • Incision – blade no.10 through skin down to the
platysma fibers.
• Platysma muscle ensures appropriate blood supply to
the skin flap and also increases the strength of the
wound in the postoperative period.
• Removed only if invaded.
• Rake retractor or double skin hooks used to retract
platysma.
Generic steps for all neck dissections

22. • 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.
Generic steps for all neck dissections

25. • 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.
Generic steps for all neck dissections

26. 4 areas of special
attention during neck
dissection
1. Lower end of IJV
2. Junction of lateral border of
clavicle with lower edge of
trapezius
3. Upper end of IJV
4. Submandibular triangle

27. Indications for a classical radical neck dissection
1. Significant operable neck disease 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.
RADICAL NECK DISSECTION

28. 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.
RADICAL NECK DISSECTION

29. • 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.
First area of special attention : the lower end of the IJV

30. • The supraclavicular nerves and
vessels 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.

31. • 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.
Dharamshila Narayana Hospital

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

33. • The carotid sheath is opened and
the IJV 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.

34. • 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. Dharamshila Narayana Hospital

35. 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.
After ligation of the vein, the
carotid artery and vagus nerve are
carefully retracted medially
allowing for dissection of the IJV
and its associated lymph node.

36. • Once the IJV has been tied the
dissection extends laterally towards
Chaissaignac’s triangle.
• It’s 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.
• 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.

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

38. • 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.
• 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.

39. • 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.
• 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.

40. • 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.
Dissection of the posterior triangle

41. • 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.

43. • 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.
• 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.

46. • 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.
Third area of special attention: The upper end of the internal
jugular vein

47. • Before tying any ligatures, the Vagus and Hypoglossal Nerves should be
identified and preserved.

48. The Occipital Artery crosses the
Posterior Part of the Internal
Jugular Vein and this should also
be ligated now to prevent
further troublesome bleeding.

49. • 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.
• Dissection continues
anteriorly along the border
of the mandible.

50. • 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.
Fourth area of special attention: the
submandibular triangle

51. • 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

52. • 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.

53. • 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.

54. • 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.
Closure

55. • 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.
Modified radical neck dissection

56. 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.
Preserving spinal accessory nerve

57. • 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.
Sparing of the sternocleidomastoid
muscle

58. • 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.

59. • 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.
Sparing of the IJV

60. • Selective Neck Dissection consists of preservation of one or more
lymph node groups and all three nonlymphatic structures.
SELECTIVE NECK DISSECTION
Selective Neck
Dissection
Levels
dissected
Main Indications
Supraomohyoid
(SOHND)
I – III SCC oral cavity
Extended
supraomohyoid
I – IV 1. Skin Ca (SCC,
Melanoma) anterior
to line of tragus.
2. Performed in
Conjunction to
superficial
parotidectomy

61. Selective Neck
Dissection
Levels
dissected
Main Indications
Lateral II – IV 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

62. • 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 hard and soft palate superiorly and the
circumvallate papillae of the tongue inferiorly.
• 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.
INDICATIONS OF SUPRAOMOHYOID TYPE

63. COMPLICATIONS

64. • Hemorrhage
• Pneumothorax
• Carotid sinus reflux
• Air embolism
• Nerve damage
INTRAOPERATIVE COMPLICATIONS

65. • Hematoma
• Wound infection
• Skin flap loss
• Salivary fistula
• Electrolyte disturbances
• Carotid artery rupture
POSTOPERATIVE COMPLICATIONS

66. • Treat by opening and elevating the neck flaps to evacuate the hematoma.
• Irrigate the surgical field with isotonic sodium chloride solution, and, if any source of bleeding is found,
ligate, suture, or electrocauterize to achieve hemostasis.
• If the hematoma is recognized and treated early, no adverse consequences ensue.
• However, if found late, airway compromise, infection, or flap necrosis can occur.
HEMATOMA
• Use suction drains to avoid accumulation of blood under the skin flap and to prevent hematoma
formation.
• Sudden bleeding indicates that an untied vessel has opened or that a ligature has slipped from the
vessel.

67. • Salivary contamination from the oral cavity is possible, causing
bacterial invasion and wound infection.
• Other factors are malnutrition, chemotherapy, anemia, diabetes
mellitus, and advanced tumor mass.
WOUND INFECTION
• If wound infection develops, open the flap, evacuate and culture the pus, and irrigate the
wound.
• Administer antibiotics.
• Carefully debride necrotic tissue.
• Local care with frequent dressing changes, salivary fistula control, and wound irrigation is
critical.

68. • Skin flap necrosis causes design errors, elevation, poor handling, or improper
postoperative care.
• Preexisting scars, prior radiation therapy, hematoma, infection, and poor nutrition
can contribute to skin flap loss.
• Carefully and progressively trim necrotic tissue and frequently change wound
dressings.
• Skin necrosis, infection, and accumulation of pus adjacent to the carotid wall alert
the surgeon to a potential carotid artery rupture.
SKIN FLAP LOSS

69. • Carotid artery rupture is rare after supraomohyoid neck dissection.
• Incidence of this complication ranges from 3-7%. The precipitating factors of carotid artery rupture
are as follows:
• Radiation therapy
• Infection and salivary fistula
• Suction catheters that cause erosion of the vessel wall
• Exposure by dehiscence of the suture line or necrosis of the dermis
• Rupture occurs in patients who underwent neck surgery with exposure of the carotid artery
and one or more of the precipitating factors listed above.
• Initial bleeding indicates that serious complications can be avoided with elective ligation of
the offending artery.
CAROTID ARTERY RUPTURE

70. Immediate treatment for carotid artery rupture
includes the following measures:
• Apply direct and firm pressure to the affected area.
• Suctioning, good illumination, and adequate instrumentation are imperative.
• With a large-bore catheter, cannulize a peripheral vein in each arm for immediate administration of
fluids
• The airway should be adequate and stable.
• If the patient does not undergo a tracheotomy, orotracheal intubation may be necessary.
• Blood is typed and cross-matched for 4-6 units of blood.
• Move the patient to the operating room.
• If bleeding cannot be controlled with pressure, clamp the common carotid artery as an emergency
procedure.

71. Definitive treatment for carotid artery rupture
includes the following measures:
• Ligate the carotid artery.
• Adequate exposure (both proximally and distally) to the source of bleeding and
contaminated or infected areas helps prevent a second rupture.
• Accomplish ligation with 1-0 silk suture. Reinforce this suture, distally and
proximally, with 2-0 silk suture. Then, bury the ligated stump in surrounding
healthy tissue.

72. RECENT ADVANCES

73. ROBOT ASSISTED NECK DISSECTION

75. THANK YOU