This document provides information on metastasis and lymph node anatomy and surgical procedures related to the neck. It discusses the pathways of metastasis, including lymphatic and hematogenous spread. It describes the triangles and fascial layers of the neck important for surgery. Four types of regional lymphadenectomy procedures are outlined, including their indications and boundaries. Potential complications of radical neck surgery are also summarized.

1. TAHA AHMADI
2021

2. METASTASIS
•
•
•
1 - LYMPHOGENOUS;
2 - HEMATOGENOUS;
3 - IMPLANTATION

3. METASTASES
• INTRAORGAN
• REGIONAL
• DISTANT

4. IMMUNOLOGY OF METASTASIS
•
CELLULAR HUMORAL
• T-LYMPHOCYTES (KILLER CELLS) CONNECT WITH TUMOR CELLS AND PROMOTE THEIR REJECTION.
ANOTHER GROUP OF T-LYMPHOCYTES (SUPPRESSORS) STIMULATE THE MULTIPLICATION OF B-
LYMPHOCYTES, WHICH PRODUCE ANTI-TUMOR ANTIBODIES AND, THEREFORE, PROVIDE SPECIFIC
ANTITUMOR IMMUNITY.

5. HEMATOGENOUS METASTASIS
• MECHANICAL BARRIER IMMUNOLOGICAL
LYMPH NODES
•

6. TOPOGRAPHY OF NECK LYMPHONES.
• KOZLOVA 80 130
• CHIN SUBMANDIBULAR RETROPHARYNGEAL
SUPERFICIAL DEEP CERVICAL
• ALL LYMPH NODES CAN BE INTO THE FOLLOWING METASTATIC ZONES:
- UPPER
- MIDDLE
- LOWER

7. SURGICAL ANATOMY OF THE NECK APPLICABLE TO RADICAL
OPERATIONS ON A REGIONAL LYMPHATIC EQUIPMENT
• ANTERIOR POSTERIOR ANTERIOR
EDGE OF THE TRAPEZIUS MUSCLE
RIGHT LEFT
3
• 1. THE MEDIAL TRIANGLE OF THE NECK IS BOUNDED BY THE MIDLINE OF THE NECK, THE LOWER
EDGE OF THE MANDIBLE AND THE ANTERIOR EDGE OF THE STERNOCLEIDOMASTOID MUSCLE.
WITHIN IT ARE: PAIRED SUBMANDIBULAR TRIANGLE, UNPAIRED CHIN TRIANGLE, SLEEPY TRIANGLE.
• 2. THE LATERAL TRIANGLE OF THE NECK IS FORMED BY THE POSTERIOR EDGE OF THE
STERNOCLEIDOMASTOID MUSCLE, THE ANTERIOR EDGE OF THE TRAPEZIUS MUSCLE, AND THE
UPPER EDGE OF THE CLAVICLE. DIVIDED INTO 2 TRIANGLES: UPPER AND LOWER (CORRESPONDS TO
THE SUPRACLAVICULAR FOSSA).
• 3. THE AREA OF THE STERNOCLEIDOMASTOID MUSCLE CORRESPONDS TO THE BOUNDARIES OF
THIS MUSCLE.

8. FASCIA OF THE NECK (ACCORDING TO
V.N.SHEVKUNENKO).
• 1 FASCIA - SUPERFICIAL FASCIA OF THE NECK, PART OF THE GENERAL SUPERFICIAL FASCIA OF THE BODY. ON THE
NECK, FORMS A SHEATH FOR THE SUBCUTANEOUS MUSCLE.
• 2 SUPERFICIAL LAYER OF THE OWN FASCIA OF THE NECK. FORMS A RECEPTACLE FOR THE STERNOCLEIDOMASTOID
AND TRAPEZIUS MUSCLES AND THE SUBMANDIBULAR SALIVARY GLAND. ATTACHED TO THE LOWER EDGE OF THE
LOWER JAW, CLAVICLE, DELIMITS THE FRONT AND BACK SURFACES OF THE NECK.
• 3 A DEEP LEAF OF THE OWN FASCIA OF THE NECK. COVERS THE MUSCLES BELOW THE HYOID BONE. ON THE MIDLINE
OF THE NECK, 2 AND 3 LEAVES GROW TOGETHER, FORMING A WHITE NECK LINE.
• 4 LEAF - COVERS THE ORGANS OF THE NECK (LARYNX, PHARYNX, ESOPHAGUS, TRACHEA, THYROID GLAND). THE
VISCERAL LEAF OF THIS FASCIA COVERS THE ORGANS OF THE NECK FROM THE OUTSIDE, THE PARIETAL FROM THE
INSIDE, AT THE SAME TIME FORMING THE VAGINA OF THE NEUROVASCULAR BUNDLE OF THE NECK.
• 5 LEAF - PREVERTEBRAL FASCIA. FORMS THE SHEATH OF THE SCALENE MUSCLES AND THE TRUNK OF THE
SYMPATHETIC NERVE.

9. DIAGNOSTICS OF REGIONAL METASTASES
• - PALPATION;
• - MORPHOLOGICAL EXAMINATION;
• - RADIONUCLIDE METHOD;
• - ULTRASOUND;
• - LYMPHOGRAPHY.

10. CHARACTERISTIC OF REGIONAL METASTASING
• N0 - NO SIGNS OF METASTATIC LESIONS OF REGIONAL LYMPH NODES.
• N1 - METASTASES IN ONE LYMPH NODE ON THE AFFECTED SIDE UP TO 3 CM OR LESS IN THE
LARGEST DIMENSION.
• N2A - METASTASES IN ONE LYMPH NODE ON THE AFFECTED SIDE UP TO 6 CM IN THE LARGEST
DIMENSION.
• N2B - METASTASES IN SEVERAL LYMPH NODES ON THE AFFECTED SIDE UP TO 6 CM IN THE
LARGEST DIMENSION.
• N2С - METASTASES IN LYMPH NODES ON BOTH SIDES OR ON THE OPPOSITE SIDE UP TO 6 CM IN
GREATEST DIMENSION.
• N3 - LYMPH NODE METASTASIS MORE THAN 6 CM IN GREATEST DIMENSION.

11. CHARACTERISTIC OF REMOTE METASTASING
• M0 - NO SIGNS OF DISTANT METASTASES.
• M1 - THERE ARE DISTANT METASTASES

12. TREATMENT OF REGIONAL METASTASIS
• CURRENTLY, THERE ARE NO UNIFIED APPROACHES TO THE CHOICE OF A METHOD
FOR THE TREATMENT OF REGIONAL METASTASES IN PATIENTS WITH MALIGNANT
NEOPLASMS OF THE MAXILLOFACIAL REGION. ONE OF THE REASONS FOR THIS
SITUATION IS THE DIFFICULTY OF DIAGNOSING METASTASES.
• THERE ARE SUPPORTERS OF RADIATION, SURGICAL AND COMBINED METHODS OF
TREATMENT

13. • MOST SUPPORTERS OF THE COMBINED TREATMENT OF REGIONAL METASTASES
SUGGEST REMOTE GAMMA THERAPY BEFORE SURGERY, INCLUDING THE PRIMARY
FOCUS IN THE IRRADIATION ZONE, AND AFTER A 3-4 WEEK BREAK NECESSARY
FOR THE RADIATION EPIDERMIS TO SUBSIDE, PERFORM LYMPHADENECTOMY IN AN
APPROPRIATE VOLUME. SOME AUTHORS MANAGED TO OBTAIN POSITIVE RESULTS
IN 90% OF PATIENTS.
• THE PROPOSAL TO USE CHEMOTHERAPY IN COMBINATION WITH LOCAL
HYPERTHERMIA HAS NOT GIVEN PROMISING RESULTS. COMPLETE REMISSION OF
METASTASES WAS ACHIEVED ONLY IN 1.3% OF PATIENTS.
• THE MAIN METHOD OF TREATMENT OF REGIONAL METASTASES OF MALIGNANT
TUMORS OF THE MAXILLOFACIAL REGION IS CURRENTLY SURGICAL.

14. 4 TYPES OF REGIONAL LYMPHADENECTOMY
• 1.OPERATION VANAHA.
• 2.UPPER CERVICAL EXCISION.
• 3.FASCIAL-SHEATH EXCISION.
• 4. OPERATION OF KRAILLE.

15. INDICATIONS AND CONTRAINDICATIONS FOR
OPERATIONS ON THE REGIONAL LYMPHATIC NECK
APPARATUS.
• IF THE LOCALIZATION OF THE PRIMARY TUMOR IS SUCH THAT THE AREA OF THE LESION DIRECTLY
BORDERS ON THE NECK (PAROTID SALIVARY GLAND, LOWER JAW, FLOOR OF THE MOUTH, TONGUE,
SUBMANDIBULAR SALIVARY GLAND) AND THE PATIENT'S CONDITION ALLOWS, THEN THE
LYMPHATIC APPARATUS IS REMOVED IN THE BLOCK WITH THE PRIMARY FOCUS AT THE SAME TIME.
SEPARATE REMOVAL OF THE PRIMARY FOCUS AND THE REGIONAL LYMPHATIC APPARATUS IS
PERFORMED IN SUCH LOCALIZATIONS AS THE LIP, UPPER JAW, SOFT PALATE.
• A NECESSARY CONDITION FOR PERFORMING RADICAL LYMPHADENECTOMY IS THE CURE OF THE
PRIMARY FOCUS.
• TO REMOVE "IMPACTED" LYMPH NODES DUE TO THE RISK OF COMPLICATIONS SUCH AS BLEEDING
FROM THE COMMON OR INTERNAL CAROTID ARTERIES, TO WHICH SUCH NODES ARE OFTEN FIXED,
AS WELL AS THE HIGH FREQUENCY OF RELAPSES.
• IN THE PRESENCE OF DISTANT METASTASES, REGIONAL LYMPHADENECTOMY DOES NOT PROVIDE A
CURE AND THEREFORE IS MEANINGLESS

16. OPERATION VANAHA
• INDICATIONS
• THE BOUNDARIES OF THE OPERATING FIELD
• THE VOLUME OF REMOVED TISSUES

17. SUPERIOR CERVICAL EXCISION (HSE).
• INDICATIONS
• THE BOUNDARIES OF THE OPERATING FIELD
• THE VOLUME OF REMOVED TISSUES
• IN CONTRAST TO THE VANACH OPERATION, HSE MANAGES TO REMOVE BIFURCATED LYMPH NODES,
INTO WHICH MALIGNANT TUMORS OF THE MAXILLOFACIAL REGION VERY OFTEN METASTASIZE.

18. FASCIAL-SHEATH EXCISION (FFE).
• INDICATIONS
• THE BOUNDARIES OF THE OPERATING FIELD:
• THE VOLUME OF TISSUES REMOVED:

19. THE KRAILLE OPERATION
• INDICATIONS
• THE BOUNDARIES OF THE OPERATING FIELD
• THE VOLUME OF REMOVED TISSUES:

20. GENERAL RULES FOR PERFORMING JREGIONAL
LYMPHADENECTOMY:
• FOR ALL 4 TYPES OF LYMPHADENECTOMY, THE SUBCUTANEOUS MUSCLE OF THE NECK IS INCLUDED
IN THE BLOCK OF REMOVED TISSUES TO REMOVE SUPERFICIAL LYMPH NODES;
• WHEN HSE, FFE, CRAILLE OPERATIONS, THE LOWER POLE OF THE PAROTID SALIVARY GLAND IS
INCLUDED IN THE BLOCK OF REMOVED TISSUES TO FACILITATE ACCESS TO THE UPPER GROUP OF
DEEP CERVICAL LYMPH NODES;
• PERFORMANCE OF ALL TYPES OF LYMPHADENECTOMY PROVIDES FOR THE REMOVAL OF
NECESSARY TISSUES IN A SINGLE BLOCK (BLOCK PRINCIPLE), AND NOT FOR THE EXFOLIATION OF
INDIVIDUAL METASTATIC LYMPH NODES, IN ORDER TO AVOID ABLASTIC DISORDERS;

21. • REMOVAL OF THE TISSUE BLOCK SHOULD BE PERFORMED WITHIN THE BOUNDARIES OF THE
CORRESPONDING FASCIAL SHEATHS (SEE ABOVE), WHICH IS ALSO ONE OF THE PRINCIPLES OF
ABLASTY;
• THE ALLOCATION OF A TISSUE BLOCK ALWAYS GOES FROM BOTTOM TO TOP (FROM THE LOWER
BORDER OF THE FASCIAL SHEATH TO THE UPPER). THE REASON IS THAT THE LYMPH NODES
CLOSEST TO THE PRIMARY TUMOR ARE USUALLY THE FIRST TO BE AFFECTED BY METASTASES. THIS
PRINCE SP ALLOWS TO SOME EXTENT TO REDUCE THE RISK OF SEEDING THE WOUND ON THE
NECK WITH TUMOR CELLS;
• IF A SIMULTANEOUS OPERATION IS PLANNED ON THE PRIMARY TUMOR FOCUS AND THE REGIONAL
LYMPH DRAINAGE PATHWAYS, THEN FOR A SIMILAR REASON, THE SURGICAL INTERVENTION BEGINS
WITH LYMPHADENECTOMY. ONLY AT THE FINAL STAGE OF THE OPERATION, THE PRIMARY TUMOR
IS INCLUDED IN THE TISSUE BLOCK;
• IN ORDER TO AVOID IMPLANTATION METASTASIS DURING THE OPERATION, IT IS NECESSARY TO
CAREFULLY LIGATE THE VESSELS, BECAUSE TUMOR CELLS, WHICH MAY BE IN THEIR LUMEN, ENTER
THE WOUND AND SERVE AS A SOURCE OF TUMOR GROWTH;
• ALL LYMPHADENECTOMIES ARE PERFORMED UNDER ENDOTRACHEAL ANESTHESIA.

22. COMPLICATIONS DURING RADICAL OPERATIONS ON
THE WAYS OF RHEONARY METASTASING
• ALL COMPLICATIONS ARE DIVIDED INTO 2 GROUPS
1. COMPLICATIONS ARISING DURING THE OPERATION.
2. COMPLICATIONS ARISING IN THE POSTOPERATIVE PERIOD. IN EACH GROUP,
COMPLICATIONS OF GENERAL AND LOCAL

23. COMPLICATIONS OF THE 1ST GROUP:
a) DAMAGE TO THE NERVE TRUNKS, MORE OFTEN THE MARGINAL BRANCH OF THE FACIAL NERVE, AS
WELL AS THE HYPOGLOSSAL, LINGUAL, VAGUS NERVES. AS A RESULT, HOARSENESS AND TACHYCARDIA
OCCUR. DAMAGE TO THE PHRENIC NERVE LEADS TO PARALYSIS OF THE CORRESPONDING HALF OF THE
DIAPHRAGM AND, AS A CONSEQUENCE, THE OCCURRENCE OF PNEUMONIA;
b) DAMAGE TO THE THORACIC LYMPHATIC DUCT WHEN PERFORMING LYMPHADENECTOMY ON THE LEFT.
THIS IS FRAUGHT WITH PROLONGED LYMPHORRHEA, THE ADDITION OF SECONDARY INFLAMMATION
TO THE COURSE OF THE WOUND PROCESS, BECAUSE THE LYMPH FLOWING INTO THE WOUND IS
INFECTED. TO PREVENT THIS COMPLICATION, IT IS RECOMMENDED DURING LYMPHADENECTOMY TO
SUTURE NOT ONLY THE BLOOD VESSELS, BUT ALSO THE AREAS OF FATTY TISSUE REMAINING IN THE
WOUND, IN WHICH THE LYMPHATIC VESSELS ARE LOCATED;

24. MEDIASTINAL EMPHYSEMA WITH THE SUBSEQUENT DEVELOPMENT OF PNEUMOTHORAX
AIR EMBOLISM WITH DAMAGE TO LARGE VEINS. TO AVOID THIS, IT IS NECESSARY TO CROSS THE
VENOUS TRUNKS BETWEEN THE TWO CLAMPS AND THEN CAREFULLY LIGATE THEM;
MASSIVE BLEEDING. THE MOST DANGEROUS IS BLEEDING FROM THE INTERNAL AND COMMON
CAROTID ARTERIES. PREVENTION - THE IMPOSITION OF A PROVISIONAL LIGATURE. TO REPLENISH
BLOOD LOSS DURING THE OPERATION, A SINGLE-GROUP BLOOD TRANSFUSION (250-500 ML) IS
NECESSARY.

25. COMPLICATIONS OF THE 2ND GROUP:
a) BREATHING DISORDER (LARYNGOSPASM, LARYNGEAL EDEMA);
a) PNEUMONIA (ASPIRATION);
a) SECONDARY BLEEDING AS A RESULT OF UNRELIABLE VASCULAR LIGATION DURING
SURGERY, INSUFFICIENT HEMOSTASIS, MELTING OF THE VESSEL WALL OR BLOOD
CLOT DUE TO WOUND INFECTION.

26. THANK YOU