Neck Dissections:

Classifications, Indications, & Techniques

INTRODUCTION

Neck dissection is performed for the surgical control of metastatic neck disease in patients with squamous cell carcinomas of the upper aerodigestive tract, salivary gland tumors, and skin cancer of the head and neck (including melanomas).

Neck dissection is also indicated for the surgical control of metastatic carcinoma to the neck when the nasopharynx and thyroid are the primary sites.

Evolution of the neck dissection

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

Evolution of the neck dissection

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

Evolution of the neck dissection

1991 Official Report of the Academys Committee for Head and Neck Surgery and Oncology standardized neck dissection terminology

Surgical Anatomy

Fascial layers of the neck

Superficial cervical fascia

Deep cervical fascia Superficial layer (investing layer)

SCM, strap muscles, trapezius

Middle or Visceral Layer (pretracheal fascia)

Thyroid Trachea Esophagus

Deep layer (prevertebral fascia)

Vertebral muscles Phrenic nerve Cervical & Brachial Plexus

MUSCLES
Platysma SCM Omohyoid Trapezius Digastric

Platysma

MUSCLES

Surgical considerations Increases blood supply to skin flaps Absent in the midline of the neck Fibers run in an opposite direction to the SCM

SCM

Surgical considerations Overlies IJV, Has to be retracted laterally to exposes LN related to IJV

MUSCLES

Omohyoid muscle

Surgical considerations Landmark demarcating level III from IV Inferior belly lies superficial to The brachial plexus Phrenic nerve Transverse cervical vessels Superior belly lies superficial to IJV

Trapezius

Surgical considerations Posterior limit of Level V neck dissection Denervation results in shoulder drop and winged scapula

MUSCLES

Digastric

Surgical considerations Posterior belly is superficial to: ECA Hypoglossal nerve ICA IJV Anterior belly Landmark for identification of mylohyoid m. for dissection of the submandibular triangle

NERVES

Marginal Mandibular Nerve

Should be preserved in neck dissections Most commonly injured while dissection at level Ib Found: 1cm anterior and inferior to angle of mandible Deep to fascia of the submandibular gland (superficial layer of deep cervical fascia) Superficial to adventitia of the facial vein

NERVES
Spinal Accessory Nerve

Penetrates the deep surface of the SCM

Exits posterior surface of SCM deep to Erbs point Traverses the posterior triangle ensheathed by the superficial cervical fascia and lies on the levator scapulae Enters the trapezius approx. 5 cm above the clavicle

Spinal Accessory Nerve

CN XI Relationship with the IJV

NERVES
Phrenic Nerve

Sole nerve supply to the diaphragm

Supplied by nerve roots C3-5

Runs obliquely toward midline on the anterior surface of anterior scalene Covered by prevertebral fascia
Lies posterior and lateral to the carotid sheath

NERVES
Hypoglossal nerve

Lies deep to the IJV, ICA, CN IX, X, and XI Curves 90 degrees and passes between the IJV and ICA Surrounded by venous plexus (ranine veins) Iatrogenic injury

Most common site - floor of the submandibular triangle, just deep to the duct Ranine veins

Thoracic duct

Conveys lymph from the entire body back to the blood

Exceptions: Right side of head and neck, Rt. U Ext, right lung right heart and portion of the liver Begins at the cisterna chyli
Enters posterior mediastinum between the azygous vein and thoracic aorta Courses to the left into the neck anterior to the vertebral column. Enters the junction of the left subclavian and the IJV

Thoracic duct

Staging of the Neck nodes

Staging of the neck nodes

N classification AJCC (1997) Consistent for all mucosal sites except the nasopharynx. Nasopharynx and Thyroid have different staging based on tumor behavior and prognosis. Based on extent of disease prior to first treatment.

Staging of the neck nodes

-Nx- Can not be assessed -N1- Single, ipsilateral, <3cm

-N0- No lymph node metastasis -N2- Single, ipsilateral 3-6 cm or multiple <6 cm *N2a- single, ipsilateral 3-6 cm *N2b- multiple, ipsilateral none >6 cm *N2c- contra lateral/ bilateral, none >6 cm

-N3- > 6cm

Lymph Node Levels/Nodal Regions

Lymph Node Subzones

Lymph node levels/Nodal regions

Level I: Submental & Submandibular. Levels II, III, IV: nodes associated with IJV within fibroadipose tissue (posterior border of SCM and lateral border of sternohyoid). Level II: Upper third jugular chain, Jugulodigastric, and upper posterior cervical nodes.

Boundaries - hyoid bone (clinical landmark) or carotid bifurcation (surgical landmark)

Lymph node levels/Nodal regions

Level III: Middle jugular nodes

Boundaries - Inferior border of level II to cricothyroid notch (clinical landmark) or omohyoid muscle (surgical landmark).

Level IV: Lower jugular nodes.

Boundaries -inferior border of level III to clavicle.

Lymph node levels/Nodal regions

Level V: Posterior triangle of neck Boundaries - posterior border of SCM, clavicle, and anterior border of trapezius.

Level VI: Anterior compartment structures. Boundaries - Hyoid, supra sternal notch, medial border of carotid sheath) Level VII: Ant. mediastinal

Classification of Neck Dissections

Classification of Neck Dissections

Academys classification

1) Radical neck dissection (RND) 2) Modified radical neck dissection (MRND) 3) Selective neck dissection (SND) Supra-omohyoid type Lateral type Posterolateral type Anterior compartment type 4) Extended radical neck dissection

Classification of Neck Dissections

Academys classification

Based on 4 concepts. 1) RND is the standard basic procedure for cervical lymphadenectomy against which all other modifications are compared.

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

Classification of Neck Dissections

Academys classification

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.

Classification of Neck Dissections

Medina classification (1989)

Radical neck dissection.. Modified radical neck dissection. Type I (XI preserved) Type II (XI, IJV preserved) Type III (XI, IJV, and SCM preserved)

Selective neck dissection.

Radical Neck Dissection

Definition

-All lymph nodes in Levels I-V including Spinal-accessory nerve (SAN), SCM, and IJV are removed.

EXTENT OF RADICAL NECK DISSECTION

The margins dissection are

of

the

Inferiorly- the clavicle Superiorly- the mandible Posteriorly- the anterior border of the trapezius Anteriorly- the lateral border of the sternohyoid muscle.

Radical Neck Dissection

Indications

Extensive cervical involvement or matted lymph nodes with gross extracapsular spread and invasion into the SAN, IJV, or SCM.

Modified Radical Neck Dissection (MRND)

Definition

Excision of same lymph node bearing regions as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV) Spared structure specifically named. MRND is analogous to the functional neck dissection described by Bocca.

MRND- Rationale
Lymphatics of neck- contained in fibroadipose tissue within the aponeurotic partions c are separate from SCM and IJV. Aponeurotic coverings can be stripped from these structure to preserve these. SAC n. runs thro nodal bearing tissue of neck, can only be preserved if LNs are not closly related to it.

EXTENT OF MODIFIED RADICAL NECK DISSECTION

Modified Radical Neck Dissection

Three types

MRND TYPE I: Preservation of SAN

MRND TYPE II : Preservation of SAN and IJV

MRND TYPE III: Preservation of SAN, IJV, and SCM ( Functional neck dissection).

Selective Neck Dissections

Definition
Cervical lymphadenectomy with preservation of one or more lymph node groups RATIONALE: SND is designed to remove cervical lymph nodes at risk of involvement by metastatic cancer, which is based on site of primary cancer. The basic anatomic studies have demonstrated that lymphatic drainage of mucosal sites of head and neck follow relatively constant and predictable routes.

Selective Neck Dissections

Four common subtypes: :
Supraomohyoid neck dissection (SO) Posterolateral neck dissection (PL)
Lateral neck dissection (L) Anterior neck dissection (A)

SND: Supraomohyoid type

Most commonly performed SND Definition En-bloc removal of cervical lymph node groups I-III Posterior limit is the post. border of the SCM Inferior limit is the omohyoid muscle overlying the IJV Indications Oral cavity carcinoma with N0 neck

Extended supraomohyoid N D

In case of carcinoma of lateral border of tongue involvement of level IV L. N. is common, so level IV dissection should be done in such case.

SND: Lateral Type

Definition En bloc removal of the jugular lymph nodes including Levels II-IV

Indications N0 neck in carcinomas of the oropharynx, hypopharynx, supraglottis, and larynx.

SND: Posterolateral Type

Definition En bloc excision of lymph nodes in Levels II to V.

Indications Cutaneous malignancies Melanoma Squamous cell Ca Ca Thyroid Merkel cell carcinoma Soft tissue sarcomas of the scalp and neck.

SND: Anterior Compartment

Definition En bloc removal of lymph structures Level VI Peri thyroidal nodes Pre tracheal nodes Pre cricoid nodes (Delphian) Para tracheal nodes along recurrent nerves. Limits of the dissection are the hyoid bone, suprasternal notch and carotid sheaths

Indications Selected cases of thyroid carcinoma Parathyroid carcinoma Subglottic carcinoma Laryngeal carcinoma with subglottic extension CA of the cervical esophagus

Extended Neck Dissection

Definition Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic structures. Usually performed with N+ necks in MRND or RND when metastases invade structures usually Preserved Indications Carotid artery invasion - dissection of mediastinal nodes and central compartment for subglottic involvement, and - removal of retropharyngeal lymph nodes for tumors originating in the pharyngeal walls.

ANAESTHESIA AND POSITION

ANAESTHESIA General Anaesthesia with ETT.

POSITION-Place the patient in the supine position with a shoulder roll extending the neck. Elevate the upper half of the operating table to a 30 angle.

INCISIONS

Can be performed through a number of incisions The decision to use a certain incision will be based on a number of factors which include:
Personal

preference Previous radiotherapy Number of levels required to assess Site of the primary tumor if that is being resected

INCISIONS
Half Apron Incision

Apron Incision

INCISIONS
Double-Y Incision

Conley Incision

INCISIONS
MacFee Incision

H Incision

INCISIONS
Modified Schobinger Incision

Y Incision

OPERATIVE PROCEDURE

OPERATIVE PROCEDURE

The skin is prepared in the standard manner and the skin incision marked out using a marking pen

OPERATIVE PROCEDURE

Make the skin incision through the platysma and elevate the flap in the subplatysmal plane

OPERATIVE PROCEDURE

Identify and preserve the marginal mandibular nerve at the superior aspect of the flap. Remove submental fatty tissue and displace it inferiorly

OPERATIVE PROCEDURE

Removal of Submental and pregladular Submandibular nodes

Removal of submandibular glands with duct and associated lymph nodes

OPERATIVE PROCEDURE

Expose the sternocleidomastoid muscle and incise it above the clavicle. Identify the anterior and posterior belly of the omohyoid with transection of the omohyoid posteriorly

OPERATIVE PROCEDURE

Identify the internal jugular vein and vagus nerve in the lower aspect of the neck before ligation of the internal jugular vein. Further identify the carotid artery and the vagus nerve.

OPERATIVE PROCEDURE

Open the supraclavicular fatty tissue using blunt dissection, either with a finger or hemostat, with identification of the phrenic nerve and brachial plexus Dissect from inferior to superior. Continue the dissection along the anterior border of the trapezius. Preserve the phrenic nerve and brachial plexus.

OPERATIVE PROCEDURE

Separate the surgical specimen from the carotid and vagus, proceeding superiorly, with identification of the hypoglossal nerve

OPERATIVE PROCEDURE

Cut the sternocleidomastoid muscle superiorly Identify the internal jugular vein superiorly, medial to the posterior belly of the digastric muscle. Dissect and ligate

OPERATIVE PROCEDURE

OPERATIVE PROCEDURE

Irrigate with isotonic sodium chloride solution. Maintain hemostasis

OPERATIVE PROCEDURE

Insert drains (0.125-in Hemovac or JacksonPratt); usually, use 2 for each side of the neck. Close the wounds in layers with 3-0 Vicryl through the platysmal flaps and skin with staples or 4-0 nylon.

Postoperative details:

Maintain head elevation at a 30 angle. Ensure that the Hemovacs or drains are functioning properly. Ensure that drains are maintained on continuous suction until they drain less than 20-25 mL in 24 hours.

Monitor for fever, bleeding, or hematoma formation in the postoperative period.

Avoid atelectasis. Move the patient out of bed the day after surgery with assistance. Encourage deep breathing and early ambulation with assistance. Monitor for possible fistula if the oral or upper digestive tract was opened, particularly during the third or fourth postoperative day.

Intraoperative Complications
Hemorrhage Carotid sinus reflux Pneumothorax Air embolus Nerve damage Chylous fistula

Postoperative Complications
Hematoma Wound infection Skin flap loss Salivary fistula Facial edema Carotid artery rupture

THANKS