NECK DISSECTION HEAD & NECK ONCOLOGY

1. NECK DISSECTION : OPERATIVE
TECHNIQUES
DR.ALANGKAR SAHA
M.D.S. ; FELLOW IN HEAD & NECK ONCOLOGY (CNCI,KOLKATA)
CLINICAL TUTOR /DEMONSTRATOR
DEPT. OF DENTAL & DEPT. OF PLASTIC SURGERY
IPGMER-SSKM HOSPITAL (GOVT. OF W.B.)

2. • Systematic removal of lymph nodes, along with their
surrounding fibrofatty tissue, from various compartments of
neck.
• Aim : to remove neck lymph nodes into which cancer cells
may have migrated.
• Metastases may originate from cancers of oral cavity,
nasopharynx, oropharynx, hypopharynx, and larynx, as well as
the thyroid, parotid and posterior scalp.

3. EVOLUTION
• 1880 – Kocher proposed removing nodal metastases.
• 1906 – George Crile described the classic radical neck dissection (RND).
• 1933 and 1941 – Blair and Martin popularized the RND.
• 1953 – Pietrantoni recommended sparing the spinal accessory nerves.
• 1967 - Bocca and Pignataro described the “functional neck dissection”
(FND).
• 1975 – Bocca established oncologic safety of the FND compared to the
RND.
• 1989, 1991, and 1994 – Medina, Robbins, and Byers respectively
proposed classifications of neck dissections.

4. LYMPH NODES OF HEAD & NECK
Conventionally divided into two systems :-
• Superficial lymph node system
• Deep lymph node system

5. Deeper fascial structures of the head and
neck drain either directly into the deep
cervical nodes or through the superficial
system.
• A. Junctional nodes
• B. Internal jugular nodes
• C. Spinal accessory nodes
• D. Supraclavicular nodes
• E. Nuchal nodes
• F. Deep medial visceral nodes

6. LEVELS OF NECK NODES
7 levels of neck nodes according to Memorial Sloan
Kettering Group
• Level I – Submental & Submandibular
• Level II – Upper Jugular
• Level III – Middle Jugular
• Level IV – Lower Jugular
• Level V – Posterior triangle
• Level VI – Anterior/ Central compartment
• Level VII – Superior Mediastinal

7. DIVISION OF NECK LYMPH NODES BY LEVEL
& SUB-LEVEL

8. DRAINING AREAS

9. “N” CLASSIFICATION – AJCC 8TH EDITION
Nx – Regional lymph nodes cannot be assessed
N0 – No regional lymph node metastasis
N1 – Metastasis in a single I/L LN, 3cm or less in greatest dimension without
extranodal extension
N2 – N2a : Metastasis in a single I/L LN, 3-6cm without extranodal extension
N2b : Metastasis in multiple I/L LNs, none more than 6cm without extranodal
extension
N2c : Metastasis in B/L or C/L LNs, none more than 6cm without extranodal
extension
N3 - N3a : Metastasis in a LN > 6cm without extranodal extension
N3b : Metastasis in a single or multiple LNs with clinical extranodal extension

10. ASSESSMENT OF CERVICAL LYMPH NODES
• First Clinical
• Computed tomography
• Magnetic resonance imaging
• Ultrasound
• Ultrasound guided fine needle aspiration cytology
• Radionuclide scanning - PET
• Sentinel node biopsy

11. SENTINEL NODE BIOPSY
• Sentinel lymph node is defined as a lymph
node to which a tumor first metastasizes.
• SLNB if negative for metastases, lymph node
dissection is not necessary.
• Use in oral cancer – Controversial
• One of the main problem of SLNB of oral
cancer is skip metastasis in which the
disease by passes level 1 and 2 nodes and
goes directly to level 3-4.

12. CLASSIFICATION

13. CONTRAINDICATIONS FOR NECK DISSECTION
• Unresectable disease – invasion into carotid artery/ brachial plexus/
prevertebral fascia/ skull base involvement.
• Patient unfit for major surgery
• Primary tumour that is uncontrollable
• Distant metastasis

14. PREOPERATIVE CONSIDERATIONS
Patient should be prepared as like any major operation
• Complete oncological work up.
• Planning of the neck incision, particularly if the primary tumor is undergoing resection
simultaneously.
Anesthesia :-
• General endotracheal anesthesia.
• Tracheostomy

15. POSITION OF THE PATIENT DURING SURGERY
• Supine position with head end
elevated to 30 degree
• Neck is hyper-extended with the use
of a shoulder roll, and rotated to the
opposite side.

16. INCISIONS
Factors to be considered :-
• Skin flap viability
• Adequate exposure of the surgical field with protection of the major vessels.
• Consider the localization of the primary tumour.
• Consider to facilitate reconstructive surgery, if needed.
• To include previous surgical fields (scars, incision for biopsy etc).
• To produce an acceptable cosmetic results.
• The incisions used in the neck dissection are generally classified into - Vertical
and Horizontal.
• The combined incisions are also performed.

18. RADICAL NECK DISSECTION
Enblock removal of all I/L LN groups extending from the inferior
border of mandible to the clavicle, from the lateral border of
sternohyoid muscle, hyoid bone and C/L anterior belly of digastric
muscle medially to the anterior border of trapezius along with SAN,
IJV and SCM.
Structures removed
• LN Level I – V
• SCM
• Spinal Accessory N
• IJV
• Tail of parotid
• Submandibular gland
• Omohyoid
Structures preserved
• Carotid Artery
• Brachial plexus
• Phrenic & Vagus nerves
• Cervical sympathetic chain
• Marginal Mandibular,
Lingual,Hypoglossal nerves

19. INDICATIONS
• 1. Significant operable neck disease (N2a,N2b,N3) with tumour
bulk near to or directly involving SAN/SCM/IJV.
• 2. Extensive recurrent disease after a previous Selective dissection
or radiotherapy.
• 3. Clinical signs of gross extranodal disease (N3b).
Simultaneous bilateral RND is contraindicated, to preserve one IJV.

20. EXTENDED RADICAL NECK DISSECTION
• RND + Removal of any adjacent structures due to tumour
involvement or LN metastasis into additional lymph node
groups.
• E.g. : Retropharyngeal LN, Nodes in the Parotid gland, Level
VI, VII, Hypoglossal N, Muscles, Skin of neck etc.

21. MODIFIED RADICAL NECK DISSECTION
• Excision of all LNs routinely removed by the RND with
preservation of 1 or more non-lymphatic structures –
SAN/IJV/SCM.
• The structure preserved should be specifically named. Eg :-
MRND with preservation of SAN.

22. INDICATIONS FOR MRND
• Type I – Bulky nodal disease with extracapsular spread
involving SCM and IJV, where SAN is free of disease.
• Type II – Bulky nodal disease with SCM involvement but
sparing the IJV and SAN.
• Type III – Metastatic disease with limited extracapsular
spread and IJV, SAN and SCM can all be dissected free.

23. SELECTIVE NECK DISSECTION
• Preservation of 1 or more of the LN groups that are routinely removed in
the RND in addition to the non-lymphatic structures.
• Commonly used for a clinically N0 neck in which the LN levels at the
highest risk of containing micrometastasis are dissected.
• For N1, N2 – if post-operative irradiation is planned.
• During surgery, if positive LNs are found, especially at multiple levels, it
may be necessary to convert the dissection to a MRND.
• LN groups to be dissected are determined by the patterns of metastatic
spread for specific tumour locations.

24. • Nasal cavity, PNS – IB,II-III
• Nasopharynx – II, III, V
• Oral cavity – I-III/IV
• Oropharynx – II-IV
• Hypopharynx - II-IV, VI
• Larynx - II-IV, VI
• Thyroid – IV, VI, VII
• Parotid – Pre-auricular, Peri- & Intra parotid, II, III, VA

25. SUPRAOMOHYOID DISSECTION
• Levels I – III
• Indications :-
* For oral cavity cancers.
* For facial skin malignancies in a line anterior to the tragus.
* B/L neck dissection in midline lesions of the floor of mouth
or ventral tongue.
Extended Supraomohyoid dissection :-
• Levels I – IV
• For anterolateral part of tongue cancers.

26. LATERAL DISSECTION
Levels II – IV
For oropharyngeal, hypopharyngeal and laryngeal
tumors.
B/L dissection – Ca hypopharynx, supraglottic.
Levels II – V
For tumors of scalp and neck ( posterior to tragus)
Including suboccipital and postauricular nodes
POSTEROLATERAL DISSECTION

27. ANTERIOR OR CENTRAL DISSECTION
Levels VI – VII
• For Differentiated thyroid cancers, Laryngeal carcinoma with
subglottic extension, Ca of cervical esophagus.

28. Super selective ND
• Limited to 1 or 2 contiguous neck levels.
• Done in :–
• * Elective treatment of No neck.
• * Salvage treatment for persistent LNs after CTRT
Elective ND
• Performed to remove LN groups in patients who have clinically No disease which
have an increased risk of harbouring occult disease.
Therapeutic ND
• Done if metastatic cervical lymphadenopathy is clinically evident.

31. SALVAGE NECK DISSECTION
• Neck dissection in a neck that has been previously treated with RT, CT,
Surgery or a combination of these three modalities.
• Can be planned or unplanned
Planned ND :- Performed 6 to 8 weeks after the completion of CTRT when the
probability of residual disease in the neck is high.
• Technically more challenging due to the presence of scarring and fibrosis.
• Increased rate of post surgical complications.

32. MINIMALLY INVASIVE NECK DISSECTION
Using endoscopes and laparoscopic instruments
Advantages :-
• No scar in the neck
• Accelerated wound healing
• Enable to start post-op adjuvant treatment within 10 days
Disadvantages :-
• Only for NO neck
• Primary tumour not able to approach
• Limited manipulation with rigid endoscopes

33. ROBOTIC NECK DISSECTION
• Total thyroidectomy with central neck
dissection
• Modified lateral neck dissection
• Can be done by retro auricular approach
Advantages:–
• Precise surgical dissection
• 3D and 10 times magnified vision
• Absence of tremors
• Superior cosmetic outcome
Disadvantages :-
• More expensive

34. COMPLICATIONS OF NECK DISSECTION
Intra-operative
• Hemorrhage from major vessels
• Nerve injury
• Chyle leak
• Bradycardia
• Pneumothorax
Post-operative
• Delayed bleeding
• Seroma/ Hematoma
• Facial/ Cerebral edema
• Wound infection
• Wound dehiscence
• Flap necrosis
• Chylous fistula

35. TAKE HOME :-
• Correct patient position
• Appropriate neck incision planning & marking along Langer line.
• Subplatysmal raising of flap.
• Marginal mandibular nerve identification & preservation.
• Facial artery & vein identification & ligation or preparation for anastomosis.
• Exposing digastric muscles.
• Exposing lateral neck between IJV & SCM.
• Identification of SAN.
• Dissection of tissue over the prevertebral fascia preserving Pherinic N.
• Chyle duct /lymphatic duct identification.

36. SPECIAL THANKS :-
• DR. SAIDUL ISLAM
• DR. ANIRUDDHA DAM
• DR. ABDUS SALAM
• DR. JAYANTA CHATTERJEE
• DR. SWAGATO CHOWDHURY
• MY PATIENTS
• MY PARIENTS
STILL LEARNING ….

37. THANK YOU ALL…