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PRESENTED BY
Dr RAHUL TIWARI
2nd
Yr. MDS
Dept. of Oral and Maxillofacial Surgery
NECK DISSECTION
09/19/16 09:25 AM RT/7/NE...
Contents• Introduction
• What is neck dissection ?
• Cervical lymphatic – its drainage
• The rationale of neck dissection
...
Introduction
• Surgery is the oldest and the most reliable
form of treatment for oral malignancy.
• what is the need for t...
What is neck dissection?
• The term "neck dissection" refers to the
removal of lymphnodes and lymphnode
bearing tissues of...
How does tumor spread ?
• Spread of disease of oral cavity to neck --
palpable lymphadenopathy.
• Systemic homogenous spre...
Division of neck levels by sublevels
•
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 6
The regional lymph node groups draining a
specific primary site as first echelon lymph nodes
09/19/16 09:25 AM RT/7/NECK D...
Cervical lymphatics
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Risk for nodal metastasis
• Various factors
– Site
– Size
– T stage
– Location of primary tumour
– Histomorphologic charac...
Risk of nodal metastases increases in relation to
location of the primary tumor
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 ...
Work-up and staging
TNM ( TUMOR –NODE – METASTASIS)
SYSTEM
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TNM STAGING
• First reported by Pierre Denoix in the 1940s.
• The International Union against cancer (UICC) and
AJCC event...
A study of correlation of tumor thickness with
risk of occult nodal metastasis –Spiro et al*
*Spiro RH,Huvos AG, Wong GY ,...
T staging for tumors of the lip and oral
cavity – AJCC 2002
• TX – Primary tumor cannot be assessed
• T0 – No evidence of ...
AJCC/UICC (2002) Staging system for cervical lymph
nodes
NX – cannot be assessed, N3a – greater than 6cm , N3b-extn into
s...
Stage grouping for all head and neck sites except the
nasopharynx and thyroid AJCC (2002)
AJCC cancer staging manual, 6th
...
Patterns of cervical lymphatic metastasis
• lymphatic flow in the neck - consistent pattern -
upper neck and then to the l...
History of neck dissections
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 18
Dr George Crile (1864-1943)
In 1906 paper
“Exicision of cancer of the
head and neck ”
Gold standard procedure :
“Radical N...
Dr. Hayes Martin (1892-1977)
In 1951 paper
“Neck Dissection”
“Routine prophylactic RND was
impracticle”
09/19/16 09:25 AM ...
Historical perspective on neck
dissection
• RND should not be used for N0 neck, a
philosophy that is largely observed in 2...
Historical perspective on neck dissection
• 1880 – Kocher –proposed removal of nodal metastasis
• 1906 – George crile –RND...
Classifications of neck
dissections
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 23
Concepts behind classification of neck dissection
• Based on 4 concepts
– RND is the standard basic procedure - against
wh...
1. Radical neck dissection (RND)
2. Modified radical neck dissection (MRND)
3. Selective neck dissection (SND)
• Supraomoh...
MEDINA CLASSIFICATION(1989)
• Comprehensive neck dissection
1. Radical neck dissection (RND)
2. Modified radical neck diss...
Spiro’s classification
– Radical (4 or 5 nodes levels resected)
• Conventional RND
• MRND
• Extended RND
– Selective (3 no...
AAO-HNS CLASSIFICATION*
1991 Classification 2001 Classification
* Neck dissection classification update-Revisions proposed...
Rationale of RND
• Understanding the anatomy of lymphatics of head and neck and
why we remove them
• Understanging the con...
Surgical Anatomy
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 30
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 31
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 32
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 33
Surgical Anatomy
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 34
Surgical Anatomy
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 35
Radical neck dissection predominantly from behind forward
makes use of the anatomical fact that the IJV does not have
post...
The main arteries of the neck and face
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 37
Incisions
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 38
Anatomy of the vascularization of neck
skin
• Kambic and Sirca 1967 stated that arterial
supply is in a vertical direction...
Studies on the anatomy of the
vascularization of neck skin
• Robertson et al 1985
“Arterial supply of the skin of the neck...
Studies on the anatomy of the
vascularization of neck skin
• Ariyan 1986 - anastomosis remain intact during
neck dissectio...
The vasculature can be summarized into
• upper neck region - anterior to the angle of
mandible - branches of facial and su...
Incisions
• Incisions classified into
– Vertical
– Horizontal
• The incisions used for neck dissections are
– Tri-radiate ...
Incisions for neck dissections
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 44
Basic needs of an incision are
• Good exposure of the neck and primary disease
• Ensure viability of the skin flaps. Avoid...
Differences between incisions
Transverse incision Vertical incision
Have cosmetic advantage as
they follow natural skin
fo...
Tri-radiate incision and its
modifications
• Advantages
– Incision provides good
exposure to surgical site.
• Disadvantage...
Modification of Tri-radiate incision
• Schobinger (1957)
• Cramer & Culf (1969)
• Conley (1970)
09/19/16 09:25 AM RT/7/NEC...
Schobinger (1957)
‘vertical limb instead of
being straight should be
curved posteriorly ’
09/19/16 09:25 AM RT/7/NECK DISS...
Conley (1970)
• Suggested a
posteriorly curving
vertical incision rather
than a horizontal
incision
09/19/16 09:25 AM RT/7...
Hayes Martin Incision
• It is a paired ‘Y’ incision.
• Here the submandibular
component is met by a
vertical limb which be...
McFee Incision
• It avoids a vertical limb.
• Two horizontal incisions
are used one in
submandibular region
and other in t...
Advantages Disadvantages
Excellent cosmetic result (McFee 1960,
McNeil 1978)
Exposure is not good (Hetter 1972)
There is n...
Apron flaps
• Described by Latyschevsky and
Freund 1960.
• Only a horizontal incision from
mastoid to mentum gently curvin...
Hockey stick incision
• Lahey et al (1940) described.
• Modified for RND by Eckert
& Byars 1952.
• It has a longitudinal a...
Radical neck dissection
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 56
Radical neck dissection
• Current indications for classical radical neck dissection.
– N3 disease
– Multiple gross metasta...
Operative steps in the functional neck
dissection
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 58
Incision
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 59
Dissection of the posterior triangle begins at the
anterior border of trapezius
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 ...
Dissection of the posterior triangle medially leads to exposure
of brachial plexus, phrenic nerve and cutaneous roots of t...
Specimen reflected posteriorly and anterior flap elevated to
expose the sternal head of SCMM
09/19/16 09:25 AM RT/7/NECK D...
Sternocleidomastoid muscle is detached from the sternum and
clavicle and retracted cephalad to expose the carotid sheath
0...
Internal jugular vein is ligated and divided after common
carotid and vagus nerve is exposed and retracted medially
09/19/...
Dissection proceeds cephalad along the carotid sheath up the
skull base
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The upper skin flap is now elevated preseving the mandibular
branch of the facial nerve
09/19/16 09:25 AM RT/7/NECK DISSEC...
Surgical field following RND
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Two suction drains inserted
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 68
Contra indications for RND
• Uncontrollable cancer of the primary site
• Evidence of distant metastasis
• Fixed nodes unch...
Supraomohyoid neck dissection
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 70
Indications for supraomohyoid neck
dissection
• Cancers of oral cavity that are N0 clinically
• Discreet N1 lesions can al...
Jugular neck dissection
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Posterolateral neck dissection
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 73
Extended radical neck dissection
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 74
Complications of RND
• Intra operative problems
• Post operative problems
• Late complications
09/19/16 09:25 AM RT/7/NECK...
Intra-operative problems
• Injury to prenic nerve
• Injury to vagus nerve
• Brachial plexus injury
• Common carotid injury...
Post operative problems
• Haemorrhage
• Lymph leak
• Dysphagia
• Carotid blow out
• Facial edema
09/19/16 09:25 AM RT/7/NE...
Complications of ligating bilateral internal
jugular vein simultaneously
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Late complications
• Shoulder droop
• Shoulder pain
• Brachial neuralgia
• Neuroma
• Strictures
09/19/16 09:25 AM RT/7/NEC...
Five-year survival rates in patients undergoing
classical radical neck dissection and modified radical
neck dissection pre...
Indications for postoperative radiation
therapy to the neck
1. Gross residual disease following neck dissection
2. Multipl...
Future of neck dissections
• Sentinel lymph node biopsy
• Endoscopic neck dissections
09/19/16 09:25 AM RT/7/NECK DISSECTI...
Sentinal lymph node biopsy
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conclusion
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 84
Knowing the surgical anatomy is
very important
before starting any...
References
• Charles W. Cummings, John M. Fredrickson, Lee A. Harker,
Charles J. Krause, David E. Schurller. Neck Dissecti...
• P. Hermanek, R. V. P. Hutter, L. H. Sobin & Ch
Wittekind. TNM atlas. Illustrated guide to the TNM /
pTNM classification ...
THANK YOU
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 87
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7. neck dissection(87) Dr. RAHUL TIWARI

NECK DISSECTIONS

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7. neck dissection(87) Dr. RAHUL TIWARI

  1. 1. PRESENTED BY Dr RAHUL TIWARI 2nd Yr. MDS Dept. of Oral and Maxillofacial Surgery NECK DISSECTION 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 1
  2. 2. Contents• Introduction • What is neck dissection ? • Cervical lymphatic – its drainage • The rationale of neck dissection • Studies on patterns of cervical lymphatic drainage • Levels of lymph nodes, sublevels - their implications • Clinical assessment and staging • History of neck dissection • Classification • Surgical anatomy • Types of incisions and procedures • Complications • Future 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 2
  3. 3. Introduction • Surgery is the oldest and the most reliable form of treatment for oral malignancy. • what is the need for the neck to be treated in oral malignancy ???? 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 3
  4. 4. What is neck dissection? • The term "neck dissection" refers to the removal of lymphnodes and lymphnode bearing tissues of neck from the inferior border of the mandible to the clavicle ,as a treatment of head and neck malignancy 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 4
  5. 5. How does tumor spread ? • Spread of disease of oral cavity to neck -- palpable lymphadenopathy. • Systemic homogenous spread rarely occurs in the lymphatics of the neck. • early eradication of local and regional disease can prevent future systemic metastasis. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 5
  6. 6. Division of neck levels by sublevels • 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 6
  7. 7. The regional lymph node groups draining a specific primary site as first echelon lymph nodes 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 7
  8. 8. Cervical lymphatics 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 8
  9. 9. Risk for nodal metastasis • Various factors – Site – Size – T stage – Location of primary tumour – Histomorphologic characteristics of primary tumor 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 9
  10. 10. Risk of nodal metastases increases in relation to location of the primary tumor 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 10
  11. 11. Work-up and staging TNM ( TUMOR –NODE – METASTASIS) SYSTEM 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 11
  12. 12. TNM STAGING • First reported by Pierre Denoix in the 1940s. • The International Union against cancer (UICC) and AJCC eventually adapted the system • It is important to realize that the TNM staging system is simply an anatomic staging system • TNM Staging describes tumor burden in only two dimensions 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 12
  13. 13. A study of correlation of tumor thickness with risk of occult nodal metastasis –Spiro et al* *Spiro RH,Huvos AG, Wong GY ,Spiro JD, Strong EW .Predictive value of tumor thickness in SCC confined to the tongue and floor of the mouth Am J Surg 1986; 152: 345-350 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 13
  14. 14. T staging for tumors of the lip and oral cavity – AJCC 2002 • TX – Primary tumor cannot be assessed • T0 – No evidence of primary tumor • Tis – carcinoma in situ • T1 – Tumor 2 cm or less in greatest dimension • T2 – Tumor >2cm but not >4cm in greatest dimension • T3 – Tumor >4cm in greatest dimension • T4a – Lip – Tumor invades through cortical bone, inferior alveolar nerve, floor of the mouth, or skin of face (i.e, chin or nose). – Oral – Tumor invades through cortical bone, into deep (extrinsic) – Cavity – Muscle of tongue (genioglossus, hyoglossu, palatoglossus, and styloglossus), maxillary sinus, or skin of face. • T4b – Tumor involves masticator space, pterygoid plates, or skull base and/or encases internal carotid artery.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 14
  15. 15. AJCC/UICC (2002) Staging system for cervical lymph nodes NX – cannot be assessed, N3a – greater than 6cm , N3b-extn into supraclavicular fossa 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 15
  16. 16. Stage grouping for all head and neck sites except the nasopharynx and thyroid AJCC (2002) AJCC cancer staging manual, 6th Edition, 2002.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 16
  17. 17. Patterns of cervical lymphatic metastasis • lymphatic flow in the neck - consistent pattern - upper neck and then to the lower neck. • This orderly lymphatic flow has been demonstrated by the work of Fisch and Sigel* *Cervical lymphatic system as visualized by lymphography  Annals of Otology, Rhinology and Laryngology 73: 869-872. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 17
  18. 18. History of neck dissections 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 18
  19. 19. Dr George Crile (1864-1943) In 1906 paper “Exicision of cancer of the head and neck ” Gold standard procedure : “Radical Neck dissection” 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 19
  20. 20. Dr. Hayes Martin (1892-1977) In 1951 paper “Neck Dissection” “Routine prophylactic RND was impracticle” 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 20
  21. 21. Historical perspective on neck dissection • RND should not be used for N0 neck, a philosophy that is largely observed in 2006. • Nahum et al described a syndrome of pain following RND – “Shoulder Syndrome”*. *Nahum AM, Mullally W, Marmor L : A Syndrome resulting from radical neck dissection. Arch otolaryngol 74 : 82,1961 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 21
  22. 22. Historical perspective on neck dissection • 1880 – Kocher –proposed removal of nodal metastasis • 1906 – George crile –RND • 1933 & 1941 – Blair and Martin popularised RND • 1953 – Pietrantoni - recommended sparing SND • 1967-- Bocca and Pignataro described FND • 1975- Bocca established oncologic safety compared to RND • 1980- Ballantyne –concept of selective neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 22
  23. 23. Classifications of neck dissections 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 23
  24. 24. Concepts behind classification of neck dissection • Based on 4 concepts – RND is the standard basic procedure - against which all other modifications are compared - preservation of any non - lymphatic structures are referred as MRND - that preserves one or more groups or levels of LN`s is referred to as a SND - removal of additional LN groups or non lymphatic structures relative to the RND – Extended neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 24
  25. 25. 1. Radical neck dissection (RND) 2. Modified radical neck dissection (MRND) 3. Selective neck dissection (SND) • Supraomohyoid type • Lateral type • Posterolateral type • Anterior compartment type 4. Extended radical neck dissection Academy's classification 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 25
  26. 26. MEDINA CLASSIFICATION(1989) • Comprehensive neck dissection 1. Radical neck dissection (RND) 2. Modified radical neck dissection (MRND) • MRND I – Preserves spinal accessory nerve. • MRND II – Spinal accessory and sternocleidomastoid muscle but sacrifices internal jugular vein. • MRND III – Requires preservation of SAN, sternocleidomastoid muscle and internal jugular vein • Selective neck dissection (SND) • Supraomohyoid neck dissection – I, II, III • Jugular neck dissection – II, III, IV • Anterior triangle neck dissection – I, II, III, IV • Central compartment neck dissection – VI • Posterolateral neck dissection – II, III, IV 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 26
  27. 27. Spiro’s classification – Radical (4 or 5 nodes levels resected) • Conventional RND • MRND • Extended RND – Selective (3 node levels resected) • SOHND • Jugular dissection (level II-IV) • Any other 3 levels – Limited (no more than 2 node levels resected) • Para tracheal node dissection • Mediastinal node dissection • Any other 1 or 2 node levels resected 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 27
  28. 28. AAO-HNS CLASSIFICATION* 1991 Classification 2001 Classification * Neck dissection classification update-Revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 28
  29. 29. Rationale of RND • Understanding the anatomy of lymphatics of head and neck and why we remove them • Understanging the concepts of lymphnode metastasis • Understanding the concepts of neck incisions • Why we remove IJV ? • Why we Remove the submandibular gland ? • Why we remove the sternocleidomastoid muscle? • Why we remove the spinal accessory nerve and when do we save it ? • The concept behind the ligation of carotid artery and internal jugular vein 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 29
  30. 30. Surgical Anatomy 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 30
  31. 31. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 31
  32. 32. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 32
  33. 33. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 33
  34. 34. Surgical Anatomy 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 34
  35. 35. Surgical Anatomy 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 35
  36. 36. Radical neck dissection predominantly from behind forward makes use of the anatomical fact that the IJV does not have posterior branches 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 36
  37. 37. The main arteries of the neck and face 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 37
  38. 38. Incisions 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 38
  39. 39. Anatomy of the vascularization of neck skin • Kambic and Sirca 1967 stated that arterial supply is in a vertical direction. • descending branches: facial and occipital artery • ascending branches: transverse cervical and supraclavicular arterial branches . 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 39
  40. 40. Studies on the anatomy of the vascularization of neck skin • Robertson et al 1985 “Arterial supply of the skin of the neck is multifaceted ” • four arterial branches pass from the platysma muscle through to the top of the skin’s surface. • platysma cutaneous arteries supplying skin are in anastomosis with each other. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 40
  41. 41. Studies on the anatomy of the vascularization of neck skin • Ariyan 1986 - anastomosis remain intact during neck dissection while the platysma is dissected from the skin. • Hetter 1972, Freeland and Rogers 1975 alternative development of arterial supply even if facial, occipital and transverse cervical are ligated. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 41
  42. 42. The vasculature can be summarized into • upper neck region - anterior to the angle of mandible - branches of facial and submental arteries. • upper lateral neck - the area between ramus of mandible and the sternocleidomastoid muscle- Occipital and external auricular branches of external carotid . • Lower half of neck - The transverse cervical artery and suprascapular artery • Large platysma-cutaneous branches and branches of superior thyroid supplying the front middle portion of the neck.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 42
  43. 43. Incisions • Incisions classified into – Vertical – Horizontal • The incisions used for neck dissections are – Tri-radiate incision and its modification – Hayes martin double ‘Y’ incision – McFee incision 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 43
  44. 44. Incisions for neck dissections 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 44
  45. 45. Basic needs of an incision are • Good exposure of the neck and primary disease • Ensure viability of the skin flaps. Avoid acute angles • Protect carotid artery even in the cases of wound infection • Facilitate reconstruction • Adapt to the condition of patient esp after radiotherapy • It should be cosmetically acceptable 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 45
  46. 46. Differences between incisions Transverse incision Vertical incision Have cosmetic advantage as they follow natural skin folds of the skin Disadvantages because they intersect to the natural skin folds of the skin and the vascular supply of the neck Recovery of scar tissue in these folds are rapid and successful They tend to contract along their long axis – leads to deformity and restricted action. Easy to modify 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 46
  47. 47. Tri-radiate incision and its modifications • Advantages – Incision provides good exposure to surgical site. • Disadvantages – Flap necrosis is high due to disruption of vasculature of skin flaps – Occurrence of flap separation at the trifurcation site. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 47
  48. 48. Modification of Tri-radiate incision • Schobinger (1957) • Cramer & Culf (1969) • Conley (1970) 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 48
  49. 49. Schobinger (1957) ‘vertical limb instead of being straight should be curved posteriorly ’ 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 49
  50. 50. Conley (1970) • Suggested a posteriorly curving vertical incision rather than a horizontal incision 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 50
  51. 51. Hayes Martin Incision • It is a paired ‘Y’ incision. • Here the submandibular component is met by a vertical limb which below becomes continuous with an inverted ‘Y’ in the suprascapular region. • This flap most often gets cyanosed. • Flap necrosis and carotid exposure is more in this type of incision. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 51
  52. 52. McFee Incision • It avoids a vertical limb. • Two horizontal incisions are used one in submandibular region and other in the suprascapular region. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 52
  53. 53. Advantages Disadvantages Excellent cosmetic result (McFee 1960, McNeil 1978) Exposure is not good (Hetter 1972) There is no lessening of vascularity in the centre of the flap (Ariyan 1986) It is not suitable for bilateral simultaneous neck dissection (Chandler and Ponzoli 1969) There is no angle intersection in incision (McFee 1960) Operating period is long (McFee 1960) Post operative wound recovery is rapid (McFee) Posterior triangle dissection is difficult (Maran et al 1989, White et al 1993) Suitable in necks receiving radiotherapy and in peripheral vascular disease (Maran et al 1989) Difficulty may arise while working under the bridge flap Recovery of flap excellent due to wide bipedicled flaps (Stella & Brown 1970, Daniel & McFee 1987) In short neck it might be difficult to distinguish between the front tip of the incision from that of the tracheostomy. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 53
  54. 54. Apron flaps • Described by Latyschevsky and Freund 1960. • Only a horizontal incision from mastoid to mentum gently curving inferiorly upto upper border of the thyroid cartilage is used. • Advantages – Carotid artery is well protected – Protects the descending arterial recovery • Disadvantages – It will damage the ascending arterial and venous recovery – Venous congestion and oedema might develop at the bottom corner 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 54
  55. 55. Hockey stick incision • Lahey et al (1940) described. • Modified for RND by Eckert & Byars 1952. • It has a longitudinal and transverse incision • B/L hockey stick incision allows the deglovement of the whole neck. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 55
  56. 56. Radical neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 56
  57. 57. Radical neck dissection • Current indications for classical radical neck dissection. – N3 disease – Multiple gross metastases involving multiple levels. – Recurrent metastatic disease in a previously irradiated neck. – Grossly apparent extranodal spread with invasion of the spinal accessory nerve and /or internal jugular vein at the base of the skull – Involvement of accessory chain lymph nodes by metastatic disease. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 57
  58. 58. Operative steps in the functional neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 58
  59. 59. Incision 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 59
  60. 60. Dissection of the posterior triangle begins at the anterior border of trapezius 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 60
  61. 61. Dissection of the posterior triangle medially leads to exposure of brachial plexus, phrenic nerve and cutaneous roots of the cervical plexus 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 61
  62. 62. Specimen reflected posteriorly and anterior flap elevated to expose the sternal head of SCMM 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 62
  63. 63. Sternocleidomastoid muscle is detached from the sternum and clavicle and retracted cephalad to expose the carotid sheath 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 63
  64. 64. Internal jugular vein is ligated and divided after common carotid and vagus nerve is exposed and retracted medially 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 64
  65. 65. Dissection proceeds cephalad along the carotid sheath up the skull base 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 65
  66. 66. The upper skin flap is now elevated preseving the mandibular branch of the facial nerve 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 66
  67. 67. Surgical field following RND 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 67
  68. 68. Two suction drains inserted 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 68
  69. 69. Contra indications for RND • Uncontrollable cancer of the primary site • Evidence of distant metastasis • Fixed nodes unchanged by radiotherapy or chemotherapy • Life expectancy of less than 3 months 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 69
  70. 70. Supraomohyoid neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 70
  71. 71. Indications for supraomohyoid neck dissection • Cancers of oral cavity that are N0 clinically • Discreet N1 lesions can also be treated 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 71
  72. 72. Jugular neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 72
  73. 73. Posterolateral neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 73
  74. 74. Extended radical neck dissection 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 74
  75. 75. Complications of RND • Intra operative problems • Post operative problems • Late complications 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 75
  76. 76. Intra-operative problems • Injury to prenic nerve • Injury to vagus nerve • Brachial plexus injury • Common carotid injury • Internal carotid injury • Hypoglossal nerve injury • Lingual nerve injury 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 76
  77. 77. Post operative problems • Haemorrhage • Lymph leak • Dysphagia • Carotid blow out • Facial edema 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 77
  78. 78. Complications of ligating bilateral internal jugular vein simultaneously 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 78
  79. 79. Late complications • Shoulder droop • Shoulder pain • Brachial neuralgia • Neuroma • Strictures 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 79
  80. 80. Five-year survival rates in patients undergoing classical radical neck dissection and modified radical neck dissection preserving the spinal accessory nerve 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 80
  81. 81. Indications for postoperative radiation therapy to the neck 1. Gross residual disease following neck dissection 2. Multiple positive lymph nodes in the neck 3. Extracapsular extension by metastatic diseae 4. Perivascular or perineural invasion by tumor 5. Other ominous findings such as tumor emboli in lymphatics, cranial nerve invasion, or extension of disease to the base of the skull. 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 81
  82. 82. Future of neck dissections • Sentinel lymph node biopsy • Endoscopic neck dissections 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 82
  83. 83. Sentinal lymph node biopsy 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 83
  84. 84. conclusion 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 84 Knowing the surgical anatomy is very important before starting any surgical procedure.
  85. 85. References • Charles W. Cummings, John M. Fredrickson, Lee A. Harker, Charles J. Krause, David E. Schurller. Neck Dissection. Otolaryngology- Head and neck surgery. Vol. II, 2nd edition. 1993: 1649-1672. • Ian A. McGregor, Frances M. McGregor. Neck dissection. Cancer of the face and mouth – Pathology and management for surgeons. Churchill Livingstone.1986: 282- 320. • Ian T. Jackson. Inrtra oral tumour and cervical lymphadenectomy. Grabb & Smith’s Plastic Surgery. Sherrel J. Aston, Robert W. Beasley, Charles H. M. Thorne. 5th edition. Lippincott- Raven . 1997 : 439 –452. • L. H. Sobin & Ch Wittekind. TNM Classification of malignant tumours. 5th edition. UICC, A John Wiley & Sons Inc. Publication. 1997.. Surg. 1999: 28 : 197 – 202.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 85
  86. 86. • P. Hermanek, R. V. P. Hutter, L. H. Sobin & Ch Wittekind. TNM atlas. Illustrated guide to the TNM / pTNM classification of malignant tumours. 4th edition. Springer. 1997. • Aydin Acar, Gürsel Dursun, Ömer Aydin,Yücel Akbaş. J incision in neck dissections. The journal of Laryngology and otology. 1998: 112: 55 - 60. • Susumu Omura, Hiroki Bukawa, Ryoichi Kawabe, Shinjiro Aoki, Kiyohide Fujita. Comparision between hockey stick and reverse hockey stick incision: gently curved single linear neck incisions for oral cancer. Int. J. Oral Maxillofac 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 86
  87. 87. THANK YOU 09/19/16 09:25 AM RT/7/NECK DISSECTION/87 87

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