Head and Neck Dissection

History of Head and Neck Dissection

1888- Jawdynski – first to describe RND.
Jawdynski- polish surgeon was 1st to describe LN dissection procedure later known as RND but his publication went unnoticed due to his native language. He Also ligated carotid artery due to mass tumour invasion

1906- george washington crile – gave systematic enbloc dissection of LN in Head and neck carcinoma. He was first to give the detail description in english language

1951- hayes martin from memorial hospital newyork popularised the rnd with a stepwise description of the technique

1963-Osvaldo suarez described FND in spanish so went unnoticed. He demonstrated LN to be within well defined fascial compartments and therefore introduced possiblity of performing cervical LN dissection while preserving certain structures.

1967 – Bocca and Suarez– published article in English on technique of “functional neck dissection” (FND).

1989, 1991 and 1994 – Medina, Robbins, and Byers respectively proposed classifications of neck dissections.

Head and Neck Dissection – Classification^​1,2​

Academy’s 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.

Medina classification (1989)

– Comprehensive neck dissection.

• 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

The TEN commandments For Neck Dissections^​2​

• 1.Not operate by clock!!
• 2.Position correctly and make right incision
• 3.Raise the flaps adequately and find the “holy planes”, ramus mandibularis
• 4.Not look for aberrations as anatomy in the head and neck “generally” predictable
• 5.Search for the anatomical “lighthouses”—Erbs’ point, phrenic nerve, mmohyoid, facial vein etc.
• 6.Identify internal and external carotid vessels, hypoglossal nerve
• 7.Always find “facio-jugular lymph node”
• 8.Find the digastric to reach level I (b) and I (a)
• 9.Aim to preserve extra-lymphatic structures [SAN, IJV, SCM] but not at the cost of oncological safety
• 10.Shall preserve at least one side IJV.

Radical Neck Dissection

Definition– All lymph nodes in Levels I-V including spinal accessory nerve (SAN), SCM, and IJV.

Nodes not included:- preauricular, postauricular, occipital regions & nodes in parotid, retropharyngeal, lateral pharyngeal, prelaryngeal & paratracheal nodes.

Indications for RND:

1. -Significant operable neck disease (N2a, N2b, N3) with tumour bulk near to or directly involving spinal accesssory nerve and or internal jugular vein.
2. -Extensive recurrent disease after previous selective surgery or RT.
3. -Clinical signs of gross extranodal disease.

Contraindications for RND :

1. If Primary tumour is unresectable- encasement of tumor in internal carotid artery , brachial pleuxes, prevertebral fascia.
2. In B/L dis – one IJV should be preserved.
3. Patient who is unfit for major surgery.
4. Patient whose primary tumor is untreatable.
5. Patient with extensive bilateral neck disease.
6. Patients with distant metastasis.

Preoperative Preparation :

1. Anaesthetic evaluation
2. Parts preparation
3. Patient and relatives should be explained about risk and complication – consent
4. Tracheostomy consent (Tracheostomy required when primary tumour is dissected in contunity with neck especially in cases where mandible is split for acess. Also elective tracheostomy in pts with B/L neck dissections)
5. Antibiotic regime for 24 hours (Antibiotic covering- gm +, gm –ve, anaerobic bacteria based on local sensitivities are mandatory for clean surgery).

Position

Supine, intubated, Head turned to opposite side and hyperextended, resting on head ring Sandbag /towel placed under shoulder to obtain desired position. Upper end of operating table elevated to approx 30 degree, Disinfectant solution applied, Draping

• Head up- which decreases amount of blood loss during surgery

Disinfectant surgical solution applied with ample margins to prepare operative field

• Drapes- 2 horizontal and 2 vertical drapes are fixed to skin. Mastoid tip, ear lobe,body of mandible, midline of chin, suprasternal notch,clavicle,region of trapezius muscle insertion should be visible on one side completely for identifying landmarks.

Neck incisions

Planned to utilize the blood flow of cervical skin

Considerations: -To protect carotid artery, -Viability of the flap.

Decisions to use certain incisions depends on:

Personal preference. Previous radiotherapy and surgery. Number of levels involved. Access to primary tumour.

Goals to be achieved by incision :

• 1.Assure adequate vascularisation of skin flaps
• 2.Adequate exposure of surgical field
• 3.Consider localisation of primary tumour
• 4.Adequate protection of major vessels if SCM is resected
• 5.Consider as well as facilitate reconstructive surgery if needed 6.Include previous surgical fields  (eg-scars, Incisions,biopsies)
• 7.Produce acceptable cosmetic result

Neck incisions :

MacFee Incision^​1,3​

Most widely used – Two horizontal lines usually parallel to each other (as shown above). Lower flap, upper flap and middle flap also called a bridge is elevated by dissecting from both caudal and cranial field of dissection.

Submandibular Component i.e. First limb begins over mastoid, goes down to hyoid, again superiorly to submental area.
Supraclavicular Component i.e. Second limb – 2cm above clavicle, laterally from anterior border of trapezius to midline.

Advantages of MacFee Incision-

1. Excellent cosmetic effect

2. Used when there is fear of viablitiy of neck skin

3. Lower incidence of wound dehiscence

Disadvantage of MacFee Incision- Restricted access if a primary resection is carried out at same time.

Modified MacFee Incision Read here^​3,4​

Criles incision/ Y Incision

Criles incision begins from the mastoid process as a curvilinear fashion upto the tip of the hyoid, extending superiorly to the submental area. The vertical limb starts behind the carotid artery and goes down to the middle portion of the clavicle in a lazy ‘S’ fashion.

Disadvantage of Criles incision/ Y Incision – 3 point junction may lie over carotid artery, Vertical limb of this incision overlies carotid artery. Compromised healing results in exposure of carotid vessels with disastrous results.

Most widely accepted operation i.e. RND was given by crile in 1960. Incision is taken from mastoid to mentum.

Head and Neck Dissection

Schobinger Incision

Described in 1957 – Variation of Criles is schobinger.

Advantages of Schobinger Incision-

• 1.Good exposure due to large anterior flap.
• 2.Protection to carotids.
• 3.Anterior flap- good blood supply so healing is good.

Main Disadvantage of Schobinger Incision– Dissection of supraclavicular fossa is difficult

Upper incision is 2 mm behind angle of mandible. It is this point that the vertical incision starts at right angle thus avoiding acute angles as they produce narrow section of skin and reults in necrosis. Vertical limb extends into anterior edge of trapezius muscle. This large anterior flap has good blood supply

Conley Incision

Described in 1955

Advantages of Conley Incision–

1.Good exposure

2.Protection to carotids

3.Anterior flap- good blood supply so healing is good

Disadvantage of Conley Incision– Trifurcation point and narrow flaps are prone for breakdown.

Variation of Criles is conley, brings the posterosuperior arm of the incision a little further anteriorly. The vertical arm of the incision is extended more posteriorly, toward the lateral third of the clavicle

Martins incision/ Double Y incision 

Described in 1951

Advantages of Martins incision/ Double Y incision – Good exposure.

Disadvantages of Martins incision/ Double Y incision  –

• 1.Sharp triangular trifurcation.
• 2.Poor protection of carotid arteries if superior trifurcation breaks down.
• 3.Posterior flap – poor blood supply so high chances of necrosis.

A well-known disadvantage of this incision is the compromise to the blood supply, especially in the two crossings of the incision. Thus, the vertical arm of the incision should be placed posterior to the carotid artery. The cosmetic result is improved by giving the vertical arm a slightly S-shaped curve

Double-Y Incision/ Slaughter incision

Modification of martins incision, Described in 1955

Advantages of Double-Y Incision/ Slaughter incision

• 1.Smooth curves of upper and lower flaps which eliminate sharp trifurcation closure.
• 2.Excellent exposure.
• 3.Widely accepted.

Disadvantage of Double-Y Incision/ Slaughter incision – poor protection of carotid artery superiorly.

Gluck incision

A popular incision in our practice is the classic Gluck incision ,which is basically an apron flap incision, with a vertical posterolateral arm to approach the supraclavicular area.

Incision extends between both mastoid tips, crossing the midline at the level of the cricoid arch. Can be extended downwards by taking perpendicular incision bilaterally as and if required.

Sometimes the vertical arm can be avoided by prolonging the apron flap in a posteroinferior direction, thus producing a better cosmetic result.

When total laryngectomy is done- the tracheostomy is usually incorporated in the incision. While for partial laryngectomies and other tumors requiring temporary tracheostomy, a small independent horizontal incision is made at the level of the second tracheal ring for the tracheostomy.

Advantage – Better cosmetic result

Half Apron Incision/ Hockey stick incision

Advantage – Good exposure when neck dissection is combined with total/partial laryngectomy.

Head and Neck Dissection

Method of Flap Elevation

• In subplatysmal plane
• Superficial to EJV, IJV &greater auricular nerve.
• Goal of surgery- complete resection of visible and occult disease.

Limits of RND are-

• Mandible- superiorly,
• clavicle-inferiorly,
• trapezius-posteriorly,
• strap muscles – anteriorly

This dissection includes- LN in submandibular triangle,deep cervical LN,posterior triangle nodes and supraclavicular nodes.

After positioning and draping desired incision is drawn with marking pen or ink . Incision should provide adequate exposure and suitable access to complete operative field. Goal of surgery is complete resection of both visible and occult disease.

Spl precaution- do not place 3 point junction over carotid artery. Incision made by 10 no blade through the skin down to and through the fibers of platysma muscle. During incision assistant should provide good traction and counter traction to skin. Skin flaps are elevated using platysma as identification of correct dissection plane. Keeping platysma muscle into the skin flaps ensures appropriate blood supply to flaps and increases strength of wound in postoperative period.

Golden Point – Protect 2 branches of facial nerve i.e.cervical & marginal mandibular nerves.

Dissection in subplatysmal plane results in minimal bleeding. When upper skin flap is raised care should be taken to preserve marginal branch of facial nerve.  Marginal branch supplies muscles of corner of mouth ,cervical supplies platysma that crosses the mandible and is inserted into corner of mouth. Both branches emerge from lower pole of parotid gland curve around angle of mandible cross the facial vessels and then run parallel approx a finger breadth to the body of mandible. At the level of submandibular gland marginal branch is found immediately superior to and cervical branch lateral to gland.

Golden Points -Lower end of IJV

1. Divide lower end of SCM
2. Identify lower end of carotid sheath.
3. Dissect atleast 2cm.
4. Chassaignac`s triangle identified.
5. Scalene lymph nodes removed

Ligation of the lower end of IJV. Danger of tearing lower end is not bleeding but air embolism. On left side of neck,if thoracic duct seen,must be ligated.

IJV lies in between sternal and clavicular heads of SCM and dividing the muscle fibers just above clavicle reveals this vein. After dividing SCM blueness of IJV is seen as  the vein lies encompassed within carotid sheath.

Carotid sheath is opened and IJV is exposed atleast few cms in order to follow adequate access for ligation.

Ligation of lower end of IJV prevents transfer of tumour emboli into blood stream but causes distenstion above the ligature leading to difficulty in dissection. 3 ligatures are placed around vein;a ligature and an additional transfixation at lower end and ligature at upper end

Damage to IJV results in alarming bleeding but surgeon should be calm if this happens and instruct assistant not to grab bleeding vessel with artery forcep. Trick in stopping bleeding is to apply pressure with finger or apply arterial clamp and then ligate a vessel.

Thoracic duct passes medial to jugular vein then posterior to it and finally curves around to enter the junction of IJV and subclavian vein.

After ligation of vein, carotid artery and vagus are carefully retracted medially for further dissection. Once the IJV is ligated dissection extends laterally towards Chassignas triangle which is triangle between where the longus colli(origin- C5 to T3 , insertion- atlas) and scalenus anterior(origin- C2 to C6, insertion- 1^st and 2^nd ribs)  attach to tubercle of 6 (Chassignas/ carotid tubercle).

Golden Points- Junction of Clavicle and anterior border of Trapezius

1. Fatty tissues in supraclavicular area- divided
2. Inferior belly of omohyoid-identify,cut/ligated
3. Transverse cervical artery and vein- ligated
4. Beneath prevertebral fascia- phrenic nerve and brachial pleuxes are seen

Deep to omohyoid –transverse cervical vessels are found as they run laterally across floor of posterior triangle. They are ligated.

The prevertebral fascia is attached to the spinous processes of the vertebrae and forms a fascial floor for the posterior triangle of the neck.

Posterior triangle dissection :

• This dissection continues upto anterior border of trapezius.
• Everything that is important here lies caudal to XI nerve.
• Identification of XI th nerve is important.(sacrifised if required).
• Ascending branch of transverse cervical artery and & vein run up    anterior border of trapezius.

Dissection upto uppermost point of triangle at mastoid tip where trapezius and SCM meet. Lateral border- anterior border of trapezius , floor- prevertebral fascia overlying deeper muscles of neck such as splenius capitis and levator scapulae. Before starting dissection in posterior triangle identification of SAN is imp. As Nerve runs in roof of post triangle it is often identified by surgeon early during neck dissection when skin flaps are raised

Golden point – Upper end of IJV

• Retract posterior belly of digastric.
• Palpate transverse process of C2.
• Identify & preserve XII th nerve.

Posterior belly of digastric is called a residents friend which is often retracted superiorly exposing the IJV and SAN. The SAN along with IJV exit from jugular foramen and crosses jugular vein from medial to lateral as the nerve enters SCM . Transverse process of atlas serves as a anatomical landmark.

Vein is now divided and transfixed with sutures.

Two imp structures should be identified

1- vagus – which runs along internal and common carotid artery

2- hypoglossal nerve- useful landmark during dissection- situated near bifurcation.

Dissection across carotid bifurcation may lead to bradycardia and changes in BP due to trigerring of carotid sinus lying within bifurcation

Dissection is completed by following anterior belly of omohyoid muscle which is anterior border of dissection – which is inserted into hyoid bone and divided from it

Golden Points- Submandibular Triangle

• Clearence of level 1
• Removal of submandibular salivary gland,LN,fatty tissue
• Facial artery and vein –ligated
• Ganglion is divided Submandibular duct- ligated or divided Specimen mobilised.

By retracting mylohyoid muscle medially and submandibular gland inferolaterally floor of submandibular triangle is visible with lingual and hypoglossal nerve overlying deep plane formed by genioglossus and hyoglossus.

Facial artery can be ligated at its origin i.e near the ECA or near the gland..it is preferred to tie near gland as it preserves large part of artery and forms suitable microvascular anstomosis site for free flaps

Completion of Head and Neck Dissection

• Check for any bleeding points,chylous leak.
• 2 large drains secured in place & wound closed in 2 layers

Hemostasis achieved before the closure of wound. Irrigation is given. 2 drains are placed taking care that they are not placed in proximity to microvascular anastomosis sites and that they do not cross the carotid.

Wound is closed in 2 layers- subcutis with vicryl and cutis with stapler/ethilon sutures

Head and Neck Dissection

Orientating specimen for Pathological Examination

• Orient the resected specimen
• Can be pinned to block/cork with coloured pins to identify levels
• Separate node groups- superior margin of each group with a suture and place in seperately labelled container
• Surgical important margins marked with surgical ink
• Just like this Photo for documentation

Post of Care :

• 1.Continuous suction to the drains.
• 2.IV fluids until the next day.
• 3.Feeding by mouth can begin the next day.
• 4.Antibiotics should never be needed unless basic surgical principles have been contravened.
• 5.The drains are not removed until drainage is less than 10 ml per day-usually about the 4^th day.
• 6.Stitches are  removed on about 5^th day.

Complications of Neck Dissections^​5,6​

Modified Radical Neck Dissection (MRND) :

 Rationale-

• – Reduce postsurgical shoulder pain and shoulder dysfunction.( Reduce pain due to preservation of SAN )
• – Improve cosmetic outcome. (Cosmetic as it preserves major structures)
• – Reduce likelihood of bilateral IJV resection.

Definition- Excision of same lymph node bearing regions as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV).

MRND type III is analogous to the “functional neck dissection” described by Bocca

Head and Neck Dissection

Three types (Medina 1989)

• Type I: Preservation of SAN.
• Type II: Preservation of SAN and IJV.
• Type III: Preservation of SAN, IJV, and SCM ( “Functional neck dissection”).

MRND Type I :

Indications-

1. Operable palpable neck disease (usually N1,
   N2a, N2b) not involving SAN.
2. Occasionally for N0 neck.

MRND Type II :

Removal of Level I to V + SCM only

Indications- Intraoperative tumor found adherent to the SCM, but not IJV and SAN. Need for microvascular anastomosis Usually done when bilateral neck dissections are carried

MRND Type III :

Removal of only Level I to V lymph nodes

Also called SUAREZ FUNCTIONAL NECK DISSECTION or BOCCA NECK DISSECTION Indications: Neck dissection of choice of N0 neck. Differentiated thyroid ca. Skin tumors, such as melanoma,squamous cell carcinoma  

Selective Neck Dissections :

Definition- Cervical lymphadenectomy with preservation of one or more lymph node groups.

• Also known as an elective neck dissection
• Rate of occult metastasis in clinically negative neck 20-30%.
• Indication: primary lesion with greater risk of occult metastasis.

• Used for a clinically disease free neck in which LN levels at the highest risk of containing possible micrometastatic disease are dissected.
• Done in N1 dis
• Occult dis- prescence of mets in neck nodes that cannot be assessed clinically or radiologically.

Four common subtypes of Selective Neck Dissection:

• 1.Supraomohyoid neck dissection.
• 2.Posterolateral neck dissection.
• 3.Lateral neck dissection.
• 4.Anterior neck dissection.

SND: Supraomohyoid type :

• Most commonly performed SND
•  Definition- En bloc removal of cervical lymph node groups I-III.
• – Posterior limit is the cervical plexus and posterior border of  the SCM.
• – Inferior limit is the omohyoid muscle overlying the IJV.

Indications of Supraomohyoid type-

• Oral cavity carcinoma with N0 neck.
• Selected stage I Melanoma of cheek.
• Along with superficial parotidectomy.
• Squamous cell ca of face anterior to tragus.

Indications of Extended SOHND (level 1-4)

• Oral cancer of anterolateral part of tongue.
• Floor of mouth ca. that approach the midline.

SND: Lateral Type:

Definition- En bloc removal of the jugular lymph nodes levels II-IV Indications: Removal of nodal diseases associated with Ca of oropharynx, hypopharynx & larynx.

SND: Posterolateral Type :

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

SND: Anterior Compartment :

• 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

• Indications-
• Selected cases of thyroid carcinoma.
• Parathyroid carcinoma. Subglottic carcinoma.
• CA of the cervical esophagus.

Extended Neck Dissection :

• Definition- Removal of all structures resected in RND with one or more additional lymph node groups or non lymphatic structures or both.
• Usually performed with N+ necks in MRND or RND when metastases invade structures.
• Indications– Involvement of other structures Trans or sub glottic ca with ca of cervical esophagus &thyroid
• Additional LN groups: retropharyngeal, parotid,LN in level VI or VII
• Non lymphatic structures: mastoid tip, digastric muscle, ECA and skin

Head and Neck Dissection

Head and Neck Dissection