Neck dissection for Head and neck surgeons, otolaryngologists, general surgeons, Surgical residents, medical students

1. Neck dissection Dr. Rajesh Pandey

2. Introduction
• It is a procedure to remove lymph nodes and surrounding
fibro fatty tissues from neck to eradicate metastasis to
cervical lymph nodes in cancer of aerodigestive tract.
• Status of the cervical lymph nodes is the single most
important prognostic factor in head and neck tumors.
• Cure rates drop into half when there is regional lymph node
involvement

3. Emil Theodor Kocher
Earned Nobel Prize in 1909 for
his work in thyroid and neck
surgery — the first ever
awarded to a surgeon.

4. 1906 – George Crile
described the classic radical
neck dissection (RND)

5. 1967 - Bocca and Pignataro
described the “functional
neck dissection” (FND)

6. Subgroups of lymph nodes
• Ia Submental
• Ib Submandibular
• IIa Upper jugular (Anterior to XI)
• IIb Upper jugular (Posterior to XI)
• III Middle jugular
• IVa Lower jugular (Clavicular)
• IVb Lower jugular (Sternal)
• Va Posterior triangle (XI)
• Vb Posterior triangle (Transverse
cervical)
• VI Central compartment

8. Level I
• Submental triangle (Ia)
– Anterior digastric
– Hyoid
– Mylohyoid
• Submandibular triangle
(Ib)
– Anterior and posterior
digastric
– Mandible.

9. Level IA
Floor of mouth, anterior oral tongue, anterior
mandibular alveolar ridge, lower lip
Level IB
Oral cavity, anterior nasal cavity, soft
tissue of midface, submandibular gland

10. Level II
• Upper Jugular Nodes
• Anterior  Lateral border of
sternohyoid, posterior
digastric and stylohyoid
• Posterior  Posterior border
of SCM
• Skull base
• Hyoid bone (clinical landmark)
• Carotid bifurcation (surgical
landmark)

11. • Level IIa anterior to XI
• Level IIb posterior to XI
– Submuscular recess
– Oropharynx > oral cavity
and laryngeal mets

12. Level IIA & IIB
Oral cavity, nasal cavity, nasopharynx, oropharynx,, hypopharynx, larynx,
parotid gland

13. Level III
• Middle jugular nodes
– Anterior  Lateral border of
sternohyoid
– Posterior  Posterior border of
SCM
– Inferior border of level II
– Cricoid cartilage lower border
(clinical landmark)
– Omohyoid muscle (surgical
landmark)
• Junction with IJV
Level III
 Middle jugular nodes
• Anterior  Lateral border of
sternohyoid
• Posterior  Posterior border of
SCM
• Inferior border of level II
• Cricoid cartilage lower border
(clinical landmark)
• Omohyoid muscle (surgical
landmark)
 Junction with IJV

14. Level III
Oral cavity, nasopharynx, oropharynx, hypopharynx, larynx

15. Level IV
• Lower jugular nodes
– Anterior  Lateral border of
sternohyoid
– Posterior  Posterior border of
SCM
– Cricoid cartilage lower border
(clinical landmark)
– Omohyoid muscle (surgical
landmark)
• Junction with IJV
– Clavicle

16. Level IV
Hypopharynx, thyroid, cervical esophagus, larynx

17. Level V
• Posterior triangle of neck
– Posterior border of SCM
– Clavicle
– Anterior border of trapezius
– Va Spinal accessory nodes
– Vb  Transverse cervical artery
nodes
• Radiologic landmark
– Inferior border of Cricoid
– Supraclavicular nodes

18. Level VA & VB
Nasopharynx, oropharynx, posterior scalp/neck skin

19. Level VI
Anterior Compartment Structures
Boundaries
• Above by Hyoid bone
• Below by Suprasternal notch
• On either side by medial border
of Carotid sheath
Lymph Nodes
– Perithyroidal
– Pretracheal
– Precricoid Nodes (Delphian)
– Paratracheal nodes along
recurrent laryngeal nerves

20. Level VI
Thyroid gland, glottic and subglottic larynx, apex of
piriform sinus, cervical esophagus

21. Staging of the
neck
“N” classification – AJCC (1997)
Consistent for all mucosal sites except the nasopharynx
Thyroid and nasopharynx
have different staging based on tumor behavior and
prognosis

22. Staging
• Nx: Regional lymph nodes cannot be assessed.
• N0: No regional lymph node metastases.
• N1: Single ipsilateral lymph node, < 3 cm

23. Staging
• N2a: Single ipsilateral lymph node 3 to 6 cm
• N2b: Multiple ipsilateral lymph nodes < 6 cm
• N2c: Bilateral or contralateral nodes < 6cm
• N3: Metastases > 6 cm

24. Staging
• Nasopharyngeal Carcinoma
– N1 – Unilateral < 6cm
– N2 – Bilateral < 6 cm
– N3a > 6 cm
– N3b – Extension to
supraclavicular fossa
• Thyroid
– N1 – Regional node mets
• N1a - Ipsilateral
• N1b - Bilateral, midline,
contralateral cervical or
mediastinal LN

25. Classification
Neck
Dissection
Comprehensive ND
Radiacal
ND
Modified
radical ND
Selective
ND
Supraomo
hyoid ND
Lateral ND
Anteriolat
eral ND
Extended
ND

26. RND
Structure removed
• LN level I – V
• SCM
• Spinal accessory n.
• IJV
• Tail of parotid
• Submandibular gland
• Omohyoid

27. Structures to be preserved
 Carotid artery
 Brachial Plexus
 Phrenic & vagus nerve
 cervical sympathetic chain
 marginal mandibular, lingual and
hypoglossal nerves

28. Modified Radical Neck
Excision of same lymph node bearing regions as RND with
preservation of one or more nonlymphatic structures (SAN,
SCM, IJV)

29. MRND Type I
Preservation of SAN

30. MRND Type II
Preservation of SAN and IJV

31. MRND Type III
Preservation of SAN, IJV, and SCM
( “Functional neck dissection”)
By Bocca

32. Selective Neck dissection:
Any type of cervical lymphadenectomy with preservation of one
or more lymph node groups
Four subtype:
• Supraomohyoid neck dissection
• Postero-lateral neck dissection
• Lateral neck dissection
• Anterior neck dissection

33. Supraomohyoid neck dissection:
• Removal of lymph nodes in regions I –III
• The posterior limit is the cutaneous branches of the cervical
plexus and posterior border of SCM
• The inferior limit is the superior belly of the omohyoid where it
cross IJN

34. Selective Neck Dissections
Lateral neck dissection– En bloc removal of the jugular lymph nodes
including Levels II-IV.

35. • Definition
– En bloc excision of lymph bearing tissues in Levels II-IV and additional
node groups – suboccipital and postauricular.
• Indications
-Cutaneous malignancies
-Melanoma
-Squamous cell carcinoma
-Merkel cell carcinoma
- Soft tissue sarcomas of the scalp and neck

36. • Definition
– En bloc removal of lymph structures in Level VI
Perithyroidal nodes
Pretracheal nodes
Precricoid nodes (Delphian)
Paratracheal nodes along recurrent nerves
– Limits of the dissection are the hyoid bone, suprasternal notch and carotid
sheaths

37. • Definition
– Removal of one or more
additional lymphatic groups and/or
non-lymphatic structures relatively
to a radical neck dissection.eg-level
VII, Retro-pharyngeal lymphnode,
hypoglosal nerve, carotid artery.
Indication
• Carotid artery invasion
–Other examples:
• Resection of the hypoglossal
nerve resection or digastric
muscle
• dissection of mediastinal nodes
and central compartment for
subglottic involvement, and
• removal of retropharyngeal
lymph nodes for tumors
originating in the pharyngeal
walls

38. Indication of RND
• 1. Significant operable neck disease (N2a,N2b,
N3) with tumour bulk near or directly involve
spinal accessory nerve and/or internal jugular
vein/SCM.
• 2.Extensive recurrent disease after previous
surgery or radiotherapy.
• 3.Clinical sign of gross extranodal disease

39. Indication of MRND
– MRND Type I:
1. Clinically obvious neck
lymph nodes metastasis
and SAN not involved by
tumor
1. Intraoperative decision
just like preservation of
the facial nerve in parotid
surgery
• MRND Type II:
1. Rarely planned
2. Intra-operative decision for
tumor found adherent to SCM
but away from SAN & IJV
• MRND Type III:
– Depend on the autopsy
reports
1. Lymph nodes were in
the fibrofatty and do
not share the same
adventitia with blood
vessels
2. They are not found
within the aponeurosis
or glandular capsule of
the submandibular
“Functional neck
dissection”

40. • MRND Type III:
– For treatment of N0 neck nodes
– Indicated for N1 mobile nodes and not greater than 2.5 – 3.0 cm
• Contra-indicated in the presence of node fixation
• Result is difficult to interpret because of the use of radiation
therapy

41. • Selective/elective neck dissection:
– For treatment of N0 neck nodes
– For N+ nodes when combined with radiotherapy
• Adjuvant radiotherapy for patient with 2 – 4 positive
nodes or extra-capsular spread
– Upgrade intra-operatively following positive frozen section

42. Indication of SND
• SOH TYPE
• Is indicated for oral cancer.
• T1-T4 with clinical No neck
• .indicted for contra-lateral neck in midline
lession of the floor of the mouth or
ventral tongue.
• Other indication-extension of parotid
surgery, facial skin malignancy anterior to
the tragus
• In case antero-lateral part of the tongue
level I-IV also be considered.
ANTERIOR COMPARTMENT
• Selected Cases of Thyroid Carcinoma
• Parathyroid Carcinoma
• Subglottic Carcinoma
• CA of Cervical Oesophagus
LATERAL TYPE
N0 Neck in carcinomas of
• Oropharynx
• Hypopharynx
• Supraglottis
• Glottic Larynx
POSTERO-LATERAL TYPE
Cutaneous malignancies
• Melanoma
• SCC
• Merkell cell Carcinoma
- Soft tissue sarcomas of scalp and neck

43. • Indication and the type of ND, specially for N0, is controversial
• The following surgical outline was suggested:
– SCC oral cavity anterior to circumvalate papilla
• Supraomohyoid
– SCC Oropharynx, larynx and hypopharynx
• level I- IV or level II-V
– SCC with N+ nodes
• RND
– SCC with 2-4 positive nodes or extracapsular spread
• RND and adjuvant therapy
Shah Cancer July 1;109-113: 1990

44. N+ disease needs
Comprehensive neck dissection

45. Contra-indication
• 1.Untreatable primary tumour or unresectable neck
disease(i.e-encasement of brachial plexus, internal carotid
artery, prevertebral fascia.
• 2.Patient unfit for major surgery
• 3.Simaltaneous bilateral neck dissection
• 4. Distant metatases

46. PREOPERATIVE PREPARATION
1. Ensure all documentation, preoperative procedures,
and orders are complete.
2. Check the surgical consent form and others for
completeness.
3. Document allergies.
4. Document height and weight.
5. History and Physical.
6. Baseline vital signs.
7. Ensure results of all laboratory and diagnostic tests
are on the chart. Document and report any abnormal
results.Report special needs and concerns.

47. 1.Good exposure of the neck and primary disease.
2. Ensure viability of the skin flaps. Avoid acute angles
3. Protect carotid artery even in the cases of wound infection
4.Considered preoperative factor—previous radio or chemotherapy
.
5. When draping the surgical field the following ipsilateral landmarks
should be visible
6.Mastoid tip., Ear lobule, Body of the mandible, midline of the chin,
supra-sternal notch, clavicle and region of trapizius muscle
insertion

48. “Surgical approach”
Incisions

49. A p r o n I n c i s i o n
INCISION TYPES
Freeland and Rogers (1975) suggest
that the incisions that are most likely
to safeguard the blood supply to the
skin flaps are the superiorly based
apron like.
• incision from mastoid to mentum
designed by Latyschevsky and
Freund (1960) for combined neck
dissection with intraoral
procedures
• Apronlike incision described by
Freund (1967) to be used when a
neck dissection is performed in
conjunction with a laryngectomy

50. H a l f A p r o n I n c i s i o n

51. C o n l e y I n c i s i o n

52. Y-Incision

53. D o u b l e – Y I n c i s i o n

54. H - I n c i s i o n

55. M a c F e e I n c i s i o n
• 1st limb begins over mastoid
process goes down to hyoid
bone then up again to the
point of chin.
• 2nd limb lies 2cm above the
clavicle.It start laterally at
ant border of tepezius and
and medially at the midline

56. S c h o b i n g e r I n c i s i o n

57. M o d i f i e d S c h o b i n g e r
I n c i s i o n

58. 0ther incision
J incision Lateral Utility incision Lahey’s

59. Steps of Radical
Neck Dissection

60. Good Incision
• 1.Good exposure of the neck and
primary disease.
• 2. Ensure viability of the skin
flaps. Avoid acute angles
• 3. Protect carotid artery even in
the cases of wound infection.
• 4. Facilitate reconstruction
Example, if pectoral muscle is
used a lower limb should be near
the clavicle to enable flap
accommodation.
• 5. It should be cosmetically
acceptable.

61. 4 area of special attention
• Lower end of IJV
• Junction of lateral border of clavicle with lower edge of
trapezius
• Upper end of IJV
• Submandibular triangle

62. Critical steps in RND-lower neck
• Divide the lower end of the SCM muscle in the first area.
• Isolate and ligate the Internal jugular vein
• Look for and avoid damage to the thoracic duct and branches of the
jugular lymphatic duct in chaissaignac ‘s triangle
• Remove scalene nodes
• Devide and retract OM ms upwards.
• Mobilize the fat pad overlying prevertebral fascia
• Identify and preserve brachial plexus
• Identify and preseve the phrenic nerve
• Deal with 2nd area

63. Critical steps in RND-upper neck
• Divide the upper end of SCM in 3rd area
• Retract the post belly of digastric muscle upward
• Identify and ligate IJV
• Identify and preserve hypoglossal n.

64. 1st area-lower end IJV
• Lower end of IJV is approached 1st by continuing dissection along upper boder of
clavicle from trapezius to suprasternal notch
• Supra clavicular n and vessel divided
• IJV lies between sternal and clavicular head of SCM .Divide ms fibre reveal vein
• Carotid sheath opened , IJV exposed few cm ligate with 3 suture( vicry 0-0) and
transfixed at lower end taking care vagus n.
• Left side dissection thoracic duct passes medial to IJV then post finally curve
around it and enter the jn of IJV and subclavian v.
• Rt side similar but smaller duct ( accessory duct) encouter
• Once IJV tied dissection extends laterally upward towards chaissaignac triangle(
b/w scalenus ant attach to tubercle of c6 , subclavian Ar base)
• Remove scalene nodes .
• Main jugular lymph duct that terminate on left side with thoracic duct risk if
damage . Found source and transfixed

65. 2nd area – Jn of Clavicle and Ant. border of Trapezius
• Begin dissection at lower end of trapezius.
• The fatty tissue in supraclavicular region are divided.
• While the fat is retracted upwards, the inferior belly of omohyoid muscle is
encountered.
• It is either cut or ligated and then it can be retracted upwards.
• Deeper to omohyoid, transverse cervical artery and vein found , run laterally
across floor of post triangle is ligated which may be a source of bleeding during
dissection of posterior triangle.
• Dissection continued till prevertebral fascia—Phrenic nerve and brachial plexus
protectrd.
• Phrenic n. descends from lateral to medial through the neck over the ant
scalenus ms and brachial plexus emerges from between medial and ant scalenus
ms.
• Supraclavicular dissection is continued to ant border of trepizius and dissection
continue in upward direction to dissect post triangle.

66. Dissection of posterior triangle
• Following the ant border of trapezius but dissecting on the prevertebral fascia
the post triangle is cleared. Prevertebral fascia left intact.
• Acessory n. is identified before dissection of post. triangle . Nerve run in the
floor of post triangle.
• Methods of identification of acessory n.
 It exists the lat border of SCM at Jn of upper 1/3 and lower 2/3 and
then has sinuos course before arriving at lower ant border of trepizius
to supply this ms.
 At the exist from sternomastoid , 1cm above Erb’s point where nerve
winds around the ms on its way to supply the parotid fascia.
 Dissect up ant border of trapizius in post triangle until nerve is
encounter ( confused with with branches of B. plexus.
 Drow line lat from laryngeal prominence through post triangle, n
crosses that line as it run from erb’s point to the lower post corner of
post triangle.

67. Dissection of posterior triangle
• Attempt to preserve shoulder ( preserve C3 , C4 n) even if acessory n
divided.
• Dissection continue up to mastoid tip
• SCM ms at upper end divided under tension by pulling down
• The level of transection is at angle of jaw include lower pole of parotid.

68. 3rd Area-Upper end of IJV
• Using langenbech retractor under post belly of digatric ms (resident’s
friends), upper end of IJV identified
• Its position may be located by palpating transverse process of C2
• Vein is mobilise using lehey forcep , nonabsorbable suture 2 above and 1
below to point of division along with transfixing suture.
• Before tying any ligature ,vagus and hypoglossal n identified and preserved
• Vagus n run along ICA and CCA. Hypoglossal n run across carotid
bifurcation.
• Remember- all branches of IJV arise from antero-medial surface ligated

69. 4th area- submandibular triangle
• Dissection begin in the midline
• Fat is divided in submental area , display ant belly of DG ms.
• Ant. Part of submandibular gland is then idintified and dissected to the
post border of mylohyoid
• Upper border of submandibular gland freed by dividing and tying the
vessel including the facial artery
• Mylohyoid ms retracted in forward direction to reveal the submandibular
duct. At this point lingual n. is is pulled down in a curve.
• Lingual gives small but const branch to SM ganglion, divided
• SM duct is tied and divided , taking hypoglossal n in direct vision
• Specimen is removed following transfixion and division of facial artery as
it winds over post border of DG ms at post-inf border boder of SM gland.

70. summary
Subplatismal flap elevation with external
jugular vein and greater auricular nerve
overlying the SCM
Transecting the sternal head of
the SCM

71. The supraclavicular nerves
Exposing the IJV by incising the
carotid sheath

75. Anteriorly based flap elevated to
expose the omohyoid and SCM

77. The lesser occipital nerve (C2) can
be confused with the XIn
Free the XIn and divide its
branches to SCM

78. Spinal Accessory Nerve
• CN XI – Relationship with the IJV

79. XIn passing through the IJV

80. Posterior flap fully elevated to the
trapezius muscle
The XIn is located 1-2cm behind
the greater auricular nerve

82. Posterior flap fully elevated to the
trapezius muscle
The XIn is located 1-2cm behind
the greater auricular nerve

86. Clossure
• The neck is irrigated with water
• 2 suction drain(12 fz) is inserted.drai should never cross
carotid sheath.
• Anaesthetist ask to perform a valsalva manoeuvre to check
chylous leak and bleeding.
• The neck is closed in layers with continuous vicryl to platysma
and sutures/staples to skin
• The drain is maintained on continuous suction e.g. low
pressure wall suction, until the drainage volume is <50ml
/24hrs

87. COMPLICATIONS
• Air embolus
• HAEMORRAGE
• Carotid blowout
• Carotid sinus syndrome
• Pneumothorax
• Chyle leak & Chylus fistula
• Increased intracranial pressure
• Wry Neck (Torticollis Coli)
• Shoulder dysfunction
• Cerebral oedema