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SELECTIVE NECK DISSECTION
- 1. SELECTIVE NECK DISSECTION DR. AYESHA FAYYAZ TR ENT SZH 17TH MAY 2018
- 2. LAYOUT • Anatomy Of Neck • Lymphatic Drainage • Ln staging • Classification Of Neck Dissection • Indications • Contraindications • Preoperative Preparation • Positioning • Incisions • Steps • Complications
- 3. ANATOMY
- 4. LYMPHATIC DRAINAGE A: Submental B: Submandibular C: Upper Deep Cervical D: Middle Deep Cervical E: Lower Deep Cervical F: Posterior Triangle G: Paralaryngeal H: Paratracheal I: Parotid J: Suboccipital
- 6. LN & DRAINAGE LEVEL CLASS LN DRAINAGE LEVEL I IA Submental Anterior floor of the mouth IB Submandibular Floor of mouth, tongue & buccal cavity LEVEL II Jugulodigastric Palatine tonsil, oral cavity, nasopharynx, oropharynx, hypopharynx & larynx LEVEL III Middle jugular nodes Mid hypopharynx & upper thyroid gland LEVEL IV Lower jugular nodes (prescalene) Larynx & Hypopharynx LEVEL V VA Along spinal accessory Nasopharynx VB Along thyrocerviacal Thyroid gland LEVEL VI Paratracheal, Perithyroidal & Delphian LEVEL VII Superior mediastinal
- 7. SURGICAL ANATOMY OF LN ( FOR THYROID) Central compartment: • Bounded by submandibular glands, brachiocephalic veins n carotid arteries. • C1a: Right level VI & VII • C1b: Left level VI & VII Lateral compartment: • Bounded by carotid sheath, trapezius, subclavian veins & hypoglossal nerve • C2: Right level I,II, III & IV • C3: Left level I,II, III & IV C4 • Ant & Post Mediastinal LN
- 9. LN STAGING
- 11. CLASSIFICATION OF NECK DISSECTION • Radical neck dissection: Level (I-V) , IJV , SCM , spinal accessory nerve • Modified radical neck dissection: One of non lymphatic is preserved • Selective neck dissection: One or more LN groups & non lymphatic • Extended radical neck dissection: Additional LN groups or non lymphatic
- 12. SELECTIVE NECK DISSECTION • Cervical lymphadenectomy with preservation of one or more lymph node groups • Five common subtypes: • Supraomohyoid • Extended supraomohyoid • Posterolateral • Lateral • Anterior
- 13. SND: SUPRAOMOHYOID • Most commonly performed SND • Definition En bloc removal of cervical lymph node groups I-III • Posterior limit : Cervical plexus and posterior border of the SCM • Inferior limit : Omohyoid muscle overlying the IJV
- 14. STRUCTURES REMOVED DISSECTION STRUCTURES Supraomohyoid I-lll Submandibular gland Extended supraomohyoid (anterolateral) I-lV Submandibular gland Lateral ll-lV Posterolateral II-V (IIB) Anterior or central Vl (Perithyroid, Delphian,Tracheo-oesophageal & anteriosuperior mediastinum)
- 15. • Supraomohyoid • Extended supraomohyoid (anterolateral) • Lateral • Posterolateral • Anterior or central
- 16. INDICATIONS SND LN INDICATIONS Supraomohyoid I-III T1–T4 N0 SCC oral cavity Extended supraomohyoid (anterolateral) I–IV SCC & melanoma ant to tragal line conjunction with a superficial parotidectomy Lateral II–IV T2–T4: N0 SCC larynx, oropharynx & hypopharynx Posterolateral II–V + POSTAURICULAR SCC & melanoma post to tragal line Anterior or central VI Differentiated thyroid carcinoma Subglottic & hypopharyngeal SCC Superior mediastinum VII Dif & MTC Subglottic laryngeal & hypopharyngeal SCC Cervical oesophageal carcinoma
- 17. INDICATIONS OF BILATERAL SOHND • Anterior tongue • Oral tongue • Floor of mouth that approach the midline • SOHND + parotidectomy • Cutaneous SCC/Melanoma of the cheek
- 18. CONTRAINDICATIONS • Primary tumors are untreatable • Unfit for major surgery • Inoperable neck disease; • Distant metastases
- 19. PREOPERATIVE PREPARATION • Pre- Anesthesia evaluation • Shave • Counseling about risks & complications • Pre-op Antibiotic
- 20. POSITIONING • Supine • Head turned to the opposite side • Hyperextended • Head ring • Upper end of table raised to 30° • Painting & Draping
- 21. INCISOINS • Schobinger • Horizontal T • McFee • Lateral utility • Utility • Visor • Extended thyroid • H incision
- 22. SND (I–III) & (I–IV) Subplatysmal flaps Leave external jugular & greater auricular nerve on SCM Expose anterior belly of digastric muscle Elevate mylohyoid muscle Divide duct, vessels
- 23. CONT.. Identify posterior belly of digastric muscle Follow posterior digastric muscle to SCM Unwrap SCM Cut deep fascia to omohyoid muscleIdentify, ligate branches of internal jugular vein Elevate, clamp, ligate lymphatic pedicle
- 24. IF LEVEL IIB IS TO BE DISSECTED If level IV also has to be dissected → dissection is extended inferiorly to include this lymph node level fatty contents of the submental & submandibular triangles are cleared Followed to C/L anterior digastric belly Skeletonized omohyoid followed to the hyoid inferior belly of omohyoid left (inferior limit) accessory nerve gently lifted off Fibrofatty under splenius capitis & levator scapulae mobilized
- 25. SND (POSTEROLATERAL + ANTERIOR DISSECTION) skin flap elevation till trapezius mobilization of the scm Early identification of accessory nerve Levels Va & Vb are cleared with anterior retraction of the sternomastoid specimen to be delivered anteriorly
- 27. HEMOSTASIS, CLOSURE & POSTOPERATIVE CARE • Hemostasis ( ligatures, electrocautery) • Irrigation of wound • One or two drains are placed • Subcutis with vicryl • Cutis with staples or ethilon sutures • Suction checked • No dressing is needed
- 28. ORIENTATING SPECIMEN • High quality clinical information • Pinned on to a cork or polystyrene blocks, with coloured pins OR • Separate the node groups, mark the superior margin of each group with a suture & place each group in a separately labeled container
- 29. COMPLICATIONS • Intra Op • Post Operative • Delayed Complications
- 30. INTRA OPERATIVE • Inadequate Planning • Inadvertent Injury To Local Blood Vessels And Nerves • Marginal Mandibular N. • Spinal Accessory N. • Cervical Plexus • Brachial Plexus • Thoracic Duct Injury
- 31. POST OPERATIVE • Haemorrhage • Lymph leak • Facial oedema • Wound infection
- 32. DELAYED • Dysphagia ( CN V,IX, X, XI) • Shoulder weakness • Trismus
- 33. THANK YOU!
Editor's Notes
- Submental, submandbular, muscular, carotid, occipital n subclavian Submandibular: Occipita: spinal accessory , cervical plexus Subclavian: brachial plexus, subclavian vein,pleura n sibson pleural fascia
- Submandibular: preglandular, prevascular, retrovascular, retroglandular, intraglandular & deep nodes
- 80% of lymph nodes in the neck are closely associated with the internal jugular vein Level 2 is further subdivided in a(ant) n b(post) by an imaginary line drawn by spinal accessory nerve
- 1= central= 6 +7 2 & 3= lateral= 1+2+3+4 4= ant & post mediastinal
- T1= <2cm t2=2-4cm t3= .4cm + regional invasion/ cord fixation t4a
- dissections of one or two levels, called superselective neck dissection (SSND) Still not included in classification of american association of head n neck surgery
- laryngeal primaries & contralateral N0 necks are ideal scenarios for preservation of sublevel Iib Rate of occult metastasis in clinically negative neck 20-30%
- A sandbag, or a towel, pillow or inflatable rubber bag, is placed under the shoulders in order to obtain the desired surgical position of the neck Decreases the amount of blood loss during surgery & further extends the neck Draping done mostly with 2 horizonatl n 2 vertical sheets n having mastoid, earlobule, sternal notch visible
- HORIZONTAL T ALSO CALLED HETTER INCISION
- Care should be taken not to injure the greater auricular nerve as most of the sensory branches from the cervical plexus can be preserved for selective neck dissections not involving level V
- omohyoid muscle is left in place, but does not constitute the inferior border of the dissection
- II–V, POSTAURICULAR & SUBOCCIPITAL/
- Keeping in mid that drains should not cross anastomotic sites or carotids