NECK DISSECTION

ASNOMINANDA
Study Literatur

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PENDAHULUAN
Cervical lymphadenectomy to the systematic removal of lymph nodes with their surrounding fibrofatty tissue from the various compartments of the neck Primer : - rongga mulut

- faring - laring

Faktor-faktor yang mempengaruhi penyebaran Ca ke KGB reg. :

- histologi - klasifikasi Tumor / stadium - lokasi primer Sejarah : - Koeher (1880) - George Crile - Blair dan Martin - Suarez dan Bocca (1960s)
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AM-H&N-Study Literatur

PENDAHULUAN
Terminology : Group KGB :

- AAO-HNS (1988)
- Level I : the submental dan the submandibular group - Level II : the upper jugular lymph nodes - Level III : the middle jugular lymph node group - Level IV : the lower jugular lymph node group - Level V : the posterior triangle group - Level VI : the anterior neck compartment - Cab. descenden dari a. facial, submental dan occip.

Vascular supply : - Menghindari komplikasi

dan cab. ascenden dari a. cervical transversa dan a. suprascapula - Suplay darah yg adekuat ke skin flap Fascia leher : - superficial - middle (visceral fascia ) - deep (prevertebral fascia)
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CLASSIFICATION
1. Radical neck dissection

(AAO-HNS)

2. Modified radical neck dissection (type I, II and III) 3. Selective neck dissection - Supraomohyoid type - Lateral type - Posterolateral type - Anterior compartment type 4. Extended radical neck dissection

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RADICAL NECK DISSECTION

Definisi
Mengangkat semua group kgb leher mulai dari mandibula (superior) s/d klavikula (inferior) termasuk levels I s/d V, N. accessory spinal, V. jugular interna, dan M. Sternokleidomastoideus

Indikasi
Metastase kgb yg luas atau perluasan yang melebihi kapsul dari nodus atau nodus meliputi N. accessory spinal dan V. jugular interna. Juga pada masa tumor metastatik yang besar atau nodus multipel tidak beraturan di bagian atas dari leher.
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Tehnik Posisi : Supine , leher

ekstensi optimal

Incisi :

Tidak termasuk : nodus postauricular dan suboccipital, periparotid

kecuali nodus di ekor glandula parotid, nodus perifacial dan buccinator,

nodus retropharyngeal dan nodus paratracheal.

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A, hockey stick; B, inverted hockey stick C, Mc Fee; D, modified Schobinger (Babcock dan Conley); E, Apron atau bilateral hockey stick; F, Latyschevsky dan Freud; G, Crile; H, Martin
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RADICAL NECK DISSECTION

Flap elevation
superiorly dan inferiorly

Diseksi ruang leher atas :

- Excision of level I lymph nodes - allows visualization of the lingual nerve, submandibular duct, and hypoglossal nerve. - The submandibular duct is isolated, divided, and ligated - The submandibular ganglion next should be clamped and divided - complete excision of all contents of the submandibular triangle within its muscular boundaries, and not just the submandibular gland, is required - Neck drains are inserted and brought through separate .....
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Diseksi segitiga posterior :

exposed batas anterior dari musk. trapezius s/d batas posterior dari musk. sternokleidomastoideus dan di inferior mla dari klavikula

Lantai otot dari segitiga posterior

Diseksi segitiga anterior :

dielevasi ke medial, sarung karotis exposed, ligasi v. jugular internal, thoracic duct, common carotid artery, carotid bifurcation, and v. thyroid media & superior dan v. retromandibular
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MODIFIED RADICAL NECK DISSECTION

Definisi
as the en bloc removal of lymph node bearing tissue from one side of the neck (levels I to V) - The dissection extends from the inferior border of the mandible above to the clavicle below and from the lateral border of the strap muscles medially to the anterior border of the trapezius muscle laterally

Klasifiikasi
Type I, in which only one structure, the spinal accessory nerve, is preserved. Type II, the spinal accessory nerve and the internal jugular vein, are preserved. Type III, the spinal accessory nerve, the internal jugular vein, and the stenocleidomastoideus muscle are preserved.

Indikasi
Major : to remove
probable or grossly pathologic visible lymph node disease that is not directly infiltrating or fixed to the nonlymphatic structures

Tehnik : Unlike the radical neck dissection, the next step is to identify
the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle
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SELECTIVE NECK DISSECTION

Definisi
..... performed for patients who are at risk for early lymph node metastases. The procedure consists of en bloc removal of one or more lymph node groups at risk for harboring metastatic cancer, an assessment which is based on the location of the primary tumor

Alasan
It was based on removing lymph node groups that were at highest risk for patients with N0 nodal disease. ....... if nodal disease is encountered during the execution of the selective neck dissection, the field of dissection may be extended to remove all levels of potential lymph node involvement

Pembagian
- Supraomohyoid
type (levels I-III)

- Lateral type
(levels II - IV)

- Posterolateral type - Anterior compartment type

frequently to neck nodes in levels I, II, and III, whereas carcinomas of the pharynx, hypopharynx, and larynx involve mainly the nodes in levels II, III, and IV
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Penting : They concluded that tumors of the oral cavity metastasize most

Supraomohyoid type (levels I to III)

Definisi & Alasan
- for patients with oral cavity cancer who are at risk for harboring occult nodal disease - removal of levels I through III (level IV for those with tongue cancer)

SELECTIVE NECK DISSECTION

Tehnik incisi
- modified apron
- bilateral apron incision - bilateral hockey stick carefully injuring : mandibular branch of the facial nerve, the external jugular vein and branches of the greater auricular nerve - not to cut across the sensory branches of the cervical plexus9 - A drain is placed

- Elective contralateral : * for patients with primary lesions involving the floor of mouth, ventral surface or midline involvement of the tongue, no definite indications for postoperative radiotherapy
- Contralateral therapeutic : * for patients with clinically N2c disease

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Lateral type (levels II to IV)

Definisi & Alasan
- to remove nodal disease
associated with carcinomas originating in the pharynx,

SELECTIVE NECK DISSECTION

Tehnik incisi
identify the spinal accessory nerve adequate exposure of levels II to IV hockey stick incision

hypopharynx, and larynx

- selective removal of levels II to IV

bilateral hockey stick incision

the fibrofatty contents of the anterior triangle are removed en bloc
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- neck dissection usually is

performed on both sides

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SELECTIVE NECK DISSECTION

Posterolateral type
Tehnik incisi

Definisi & Alasan

- to eradicate nodal metastases associated with cutaneous malignancies and softtissue sarcomas - located in the posterior scalp, nuchal ridge, occiput, or posterior upper neck
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exposure along the nuchal ridge to the occiput and the posterior triangle and exposure of the upper, middle, and lower jugular lymph nodes a lazy S pattern or the combination of the

hockey stick pattern with a horizontal extension

from its upper aspect along the nuchal ridge placed in the lateral decubitus position The posterior auricular and suboccipital nodes are removed the posterior triangle is cleared in a fashion
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Anterior compartment type

Definisi & Alasan
- to eradicate nodal metastases from the anterior compartment of the neck - cancers originating in the thyroid gland, hypopharynx, cervical trachea, cervical esophagus, and laryngeal tumors extending below the level of the glottis - removal of the perithyroidal nodes, pretracheal and paratracheal nodes along its cervical portion, precricoid (Delphian) nodes, and nodes located along each recurrent laryngeal nerve
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SELECTIVE NECK DISSECTION

Tehnik incisi

possibly one or more sternal heads this procedure is done first, if . The carotid artery, the superior thyroid artery, the thyroid gland, the parathyroid glands, the recurrent laryngeal nerve, dissection is carried superiorly as far as the hyoid bone and inferiorly as far as the suprasternal notch total thyroidectomy is performed splitting the sternum or removing the manubrium and one or more clavicular heads
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Extended neck dissection

Definisi & Alasan
- extended to remove either lymph node groups or vascular, neural, or muscular structures - Tumors of the base of the tongue, tonsil, soft palate, and retromolar trigone also may spread to these lymph nodes when they involve the lateral or posterior walls of the oropharynx. - Adequate removal of a metastatic tumor in the neck may dictate the need to extend a neck dissection to resect structures such as the hypoglossal nerve, the levator scapulae muscle, or the carotid artery - Controversy still exists about the advisability of resecting the common or the internal carotid artery - Moore and Baker, for example, observed a mortality rate of 30% and a cerebral complication rate of 45% among patients who underwent carotid ligation.
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SELECTIVE NECK DISSECTION

RESULTS OF NECK DISSECTION

Radical neck dissection
- 3% to 7% of patients will have disease recur in the ipsilateral neck - 44% recurrence rate for macroscopic extracapsular spread versus 25% for microscopic - 5% in patients with positive nodes in one level versus 71% in patients with positive nodes in multiple levels
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Modified radical neck dissection

patients with clinically N0 disease, the rate of recurrence varies between 4% to 7% used therapeutically for patients with clinically positive disease, the recurrence rate between 0% to 20%.

Selective neck dissection

For supraomohyoid : recurrence rate 5.8%, positive nodes

: 10 15 %

For lateral neck dissection 3.9% (7,3%)

Postoperative radiotherapy is recommended
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SEQUELAE OF NECK DISSECTION

Radical neck dissection
- removal of the spinal accessory nerve - 44% recurrence rate for macroscopic extracapsular spread versus 25% for microscopic - 5% in patients with positive nodes in one level versus 71% in patients with positive nodes in multiple levels

Modified radical neck dissection

patients with clinically N0 disease, the rate of recurrence varies between 4% to 7% used therapeutically for patients with clinically positive disease, the recurrence rate between 0% to 20%.

Selective neck dissection

For supraomohyoid : recurrence rate 5.8%, positive nodes

: 10 15 %

For lateral neck dissection 3.9% (7,3%)

Postoperative radiotherapy is recommended
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COMPLICATIONS OF NECK DISSECTION

Air leaks
Circulation of air through a wound drain prevented by using an adhesive used to immobilize the skin graft nyl drape immediately after surgery controlled by ligation or infiltration hematoma is detected early, milking the drains if this is not accomplished immediately, return to the OR wound infection !! Spiro and Strong found that 14 patients (1.9%) early surgical exploration before the tissues exposed are managed conservatively with closed wound drainage, pressure dressings, and low-fat nutritional support mechanical problem of venous drainage who had previous radiation to the head and neck prevented by preserving at least one external jugular vein Ligation of the IJV leads to increased intracranial pressure
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Bleeding

Chylous fistula

Facial/cerebral edema

COMPLICATIONS OF NECK DISSECTION

Visual loss after bilateral neck dissection is a rare but catastrophic complication

Blindness

In one report, histologic examination revealed intraorbital optic nerve infarction, suggesting intraoperative hypotension and severe venous distension as possible etiologic factors. lethal complication after surgery occur in the presence of malnutrition, diabetes, infection, and previous radiotherapy, which impair healing capacity and compromise vascular supply use of perioperative antibiotics to stop the bleeding and repair the area of rupture

Carotid artery rupture

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S U M M A R Y
Neck dissection is an operative procedure designed to remove metastases involving the regional cervical lymph nodes

The gold standard procedure is the radical neck dissection

Modifications of the radical neck dissection procedure subsequently have evolved, designed to reduce morbidity by sparing nonlymphatic structures Selective neck dissection is an operative procedure to treat early nodal disease by removing only the lymph node groups at greatest risk for harboring metastases

The AAO-HNS have endorsed a classification system for neck dissection procedures and a standard nomenclature for the terminology of the lymph node groups based on the level system
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A L G O R I T H M
ORAL CAVITY PRIMARY OROPHARYNX PRIMARY LARYNGOPHARYNX PRIMARY

No palpable nodes High risk for occult nodes*

Palpable nodes

No palpable nodes

Palpable nodes

SND (levels I III) Bilateral SND for midline/floor of mouth primary

Ipsilateral/bilateral MRND (levels I-V)

Bilateral SND (levels II-IV)

Ipsilateral MRND contralateral SND (levels II-IV)

* T1-T4 oral tongue; T2-4 other site; perineural/lymphatic invasion Bilateral neck dissection for N disease 2c RND if gross tumor invasion of nonlymphatetic structures Ipsilateral neck dissection for oropharyngeal primaries if postoperative radiotherapy is planned SND for N disease only Sumber : Cummings 0 19 20-Juli -2001 AM-H&N-Study Literatur