NECK DISSECTION

AKANA MOHAN PHANEENDRA Final M.B.B.S part-2 8th SEMESTER

26th JULY , 2016

Academy’s committee for head & neck surgery & oncology.

• Radical neck dissection (RND) is the standard basic procedure for cervical lymphadenopathy against which all other modifications are compared

• Modifications of RNDpreservation of any non-lymphatic structuresmodified radical neck dissection (MRND)

• Any neck dissection that preserves one or more groups or levels of lymphnodes Selective neck dissection (SND)

• Extended radical neck dissection (ERND)removal of additional lymphnode groups or non lymphatic structures relative to the RND.

TYPES OF NECK DISSECTION

• Classic radical neck dissection (RND)• Modified radical neck dissection (MRND)• Selective neck dissection (SND)– Supra omohyoid block– Postero lateral neck dissection– Lateral neck dissection– Anterior (central) dissection

• Commando operation• Bilateral neck dissection• Extended radical dissection (ERND)

Classical radical neck dissection• Resection of: Fascia Fat Gland : Sub-mandibular , Lower part of

parotid Muscle :Sternomastoid , Omohyoid Vein : Internal & External jugular Nerve: Spinal accesory Lymph nodes(Level 1 to 5) En-block(Crile’s operation)

Mc fee incision• Also called “Fischel T or modified Crile’s incision”• Only incision with bony landmarks.• It has two components namely:• SUBMANDIBULAR COMPONENT : 1st limb begins over mastoid ,goes down

to hyoid, again superiorly to submental area.

• SUPRACLAVICULAR COMPONENT : 2nd limb – 2cm above clavicle , laterally

from anterior border of trapezius to mid line.

Mc fee incision• ADVANTAGES:• Good blood supply from

medial & lateral aspects• Flap necrosis chances

are rare• Central bipedicled flap

has good vascularity & covers most length carotid vessels & protect carotid artery, easy to repair

• DISADVANTAGES:• Difficult to perform in

short neck patients

• Dissection under central bipedicled flap is tedious with intensive retration required by assistant for proper exposure

Crile’s incision• ADVANTAGES:• Easy to perform• Maximum exposure to

repair field

• DISADVANTAGES:• Trifurcation point is prone

for delayed healing• Vertical limb of this

incision overlies carotid artery.compromised healing results in exposure of carotid vessels

• Unsightly scar later forms contracture band

Other incisions for RND / MRND

• SCHOBINGER• CONLEY / SCHECHTER• HOCKEY STICK• HAYES MARTIN• TRIRADIATE• APRON • FISCHEL T-J / CIRCLES

MODIFIED RADICAL NECKDISSECTION(MRND)

• Also called Conservative Functional Block Dissection

• Well-differentiated & less aggressive tumor(like PAPILLARY CARCINOMA OF THYROID with lymph node secondaries)

• Structures preserved : Spinal accessory nerve (SAN) Sternocleido mastoid muscle (SCM) Internal jugular vein (IJV)

• MRND type-1 : only Spinal accessory nerve is preserved(only N)

• MRND type-2 : Accessory nerve & Sternocleido mastoid(NM-preserved)

• MRND type-3 : Accessory nerve , Stenocleidomastoid muscle , Internal jugular vein (NMV-Preserved) functional neck dissection

SELECTIVE NECK DISSECTION: • SUPRA OMOHYOID BLOCK :Fat , Fascia , Lymph nodes ,

Muscles , Sub-Mandibular Salivary Gland + OMO-HYOID MUSCLE

• Well-differentiated tumor & involvement of few sub-mandibular lymph nodes(levels-1,2,3)

• LATERAL NECK DISSECTION(ANTERO-LATERAL \ ALND \ JUGULAR) :

LEVELS 2 , 3 , 4 are removed Bilaterally Laryngeal and pharyngeal primaries with clinically

negative nodes

• POSTERO-LATERAL DISSECTION: LEVELS- 2 , 3 , 4 , 5 are removed for cutaneous

malignancies , with sub occipital nodes

• ANTERIOR(CENTRAL) DISSECTION :Level 6 (pre-tracheal , para-tracheal) are removed

COMMANDO OPERATION (Combined mandibular dissection & neck dissection)• Wide excision of primary tumor with hemi-

mandibulectomy and neck block dissection (en-block removal)

• Composite resection of primary tumor , mandible & radical neck dissection (RND)

• Ex: carcinoma of tongue or floor of mouth

BILATERAL NECK DISSECTION

• IJV is preserved on one side• Always the side where preserved operated first• Ligating one IJV increases ICP by 3 fold• Both IJV ligation increases ICP by 5 fold• ICP gradually falls over 8-10 days

EXTENDED RADICAL DISSECTION

• Removal of one or more additional group of lymphatics or removal of non lymphatic structures with RND

COMPLICATIONS OF BLOCK DISSECTION

• HEMORRHAGE • INFECTION• LYMPHATIC OOZE• CAROTID BLOW OUT• SEROMA & FLAP NECROSIS• FROZEN SHOULDER IS COMMON• RARELY PNEUMOTHORAX & CHYLOUS FISTULA• DROOPING OF SHOULDER DUE TO PARALYSIS OF

TRAPEZIUS IN RADICAL NECK DISSECTION