management of neck in ORAL CANCER

8/12/2019 management of neck in ORAL CANCER

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Surgical Neck Management in Head

and Neck Carcinoma

Chul-Ho Kim, MD. Ph.D

Level I : submental

submandibular(6)

Level II : upper jugular

Level III : Mid jugular

Level IV : lower jugular

Level V : posterior

Level VI : central neck

Level VII : upper mediastinal

IIb IIa

Levels of the Neck (1998, T. Robbins)

VI

IbIa

III

IVb IVa

Va

Vb

VII

SAN

IJV

SCM

Radical Neck Dissection( RND )

1. Spinal accessory nerve

2. Internal jugular vein

3. Sternocleidomastoid m.

Modified RND ( mRND )Type I SAN

II SAN + IJV

III SAN + IJV + SCM

( = FND )

Classification of Neck Dissection

AAO-HNS(1991) Medinas modification(1989)

Radical ND Comprehensive neck dissection

Modifed RND(I, II, III) Radical ND

Selective ND Modified RNDSupraomohyoid Type I(CN XI)

Lateral Type II( + IJV)

Posterolateral Type III(+ SCM)

Anterior compartment Selective ND

Extended RND

Definition

All lymph nodes in Levels I-V

including spinal accessory nerve (SAN), SCM, and IJV

Indications

Extensive cervical involvement or matted lymph nodes

with gross extracapsular spread and invasion

into the SAN, IJV, or SCM

Radical Neck Dissection Modified Radical Neck Dissection (MRND)

Definition

Excision of same lymph node bearing regions as RND

with preservation of one or more non-lymphatic structures

(SAN, SCM, IJV)

Spared structure specifically named

MRND is analogous to the functional neck dissection

described by Bocca


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Modified Radical Neck Dissection

Three types (Medina 1989) commonly referred to not

specifically named by committee.

Type I: Preservation of SAN

Type II: Preservation of SAN and IJV

Type III: Preservation of SAN, IJV, and SCM

( Functional neck dissection)

Modified Radical Neck Dissection

Rationale

Reduce postsurgical shoulder pain and shoulder dysfunction

Improve cosmetic outcome

Reduce likelihood of bilateral IJV resection

Contralateral neck involvement

MRND Type I

Indications

Clinically obvious lymph node metastases

SAN not involved by tumor

Intraoperative decision

Rationale RND vs MRND Type I:

Actuarial 5-year survival and neck failure rates for RND (63%

and 12%) not statistically different compared to MRND I

(71% and 12%) (Andersen)

No difference in pattern of neck failure

MRND Type II

Indications

Rarely planned

Intraoperative tumor found adherent to the SCM, but

not IJV and SAN

MRND TYPE III

Rationale

Suarez (1963)necropsy and surgery specimens of larynx

and hypopharynxlymph nodes do not share the same

adventitia as adjacent BVs

Nodes not within muscular aponeurosis or glandular capsule

(submandibular gland)

Sharpe (1981) showed ) 0% involvement of the SCM in 98

RND specimens despite 73 have nodal metastases Survival approximates MRND Type I assuming IJV, and

SCM not involved

CND : 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, suprasternalnotch and carotid sheaths


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Boundaries

- hyoid- suprasternal notch

- medial border of carotid sheath

Indications

Selected cases of thyroid

carcinoma

Parathyroid carcinoma

Subglottic carcinoma

Laryngeal carcinoma with

subglottic extension

CA of the cervical esophagus

CND: Anterior CompartmentExtended Neck Dissection

Definition

Any previous dissection which includes removal of one

or more additional lymph node groups and/or non-

lymphatic structures.

Usually performed with N+ necks in MRND or RND

when metastases invade structures usually preserved

Extended Neck Dissection

Indications

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.

A. Preoperative considerations

1. Planning of operation

1) Thorough knowledge of patients history

2) Understanding of the extent of disease

3) Awareness of relevant laboratory and

radiologic data

4) Discussion with the patient about what to

expect and possible contingencies

; essential to a smooth course through the

operative and postoperative periods

2. Airway

1) Awake tracheotomy under local anesthesia in

compromised airway

2) Awake intubation in less tenuous airway

3) Tracheotomy

Routine unilateral RND or bilateral MND

: not always necessary

Bilateral RND

: protective tracheotomy should be

performed

3. Skin injection

- Best to inject the proposed skin incision with

epinephrine

- Most conveniently done with a mixture of

local anesthetics (Xylocaine)

- 10-15 minutes should be allowed to attain

maximum benefits

4. Skin marking

- methylene blue

- Gentian violet- Tip of 23G needle punctures the skin edges

opposite one another


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5. Location of tracheotomy or other incisions

- Incorporation or not

- entirely depends on the incision types used

- Any neck incisions used for previous biopsy

should be incorporated

6. Perioperative antibiotics

- If RND is included as part of an operation inwhich upper aerodigestive tract is open

- Appropriate antibiotic coverage for G(+),

anaerobic and possibly G(-) bacteria

- In case of RND alone, no evidence that

antibiotics prophylaxis is advantageous

- Broad-spectrum antibiotics at least until the

drains are removed

B. Considerations in selection of incision

1.Provide appropriate exposure to underlying

compartment

- L/N groups targeted for removal

- the possibility of performing a bilateral neckdissection

- Surgical exposure for removing cancer of the

primary site

B. Considerations in selection of incision

2. Minimize wound complication

- Protect the carotid artery

No long vertical segments directly over the

carotid

No trifurcation directly over the carotid

- Avoid devascularizing portions of any skin flaps

3.Optimize aesthetic results

- natual skin crease, curvilinear incision,

minimizing the use of T-shaped and/or Y-shaped

incision

C. Skin flap elevation

- Subplatysmal layer

- Traction and counter-traction

- Hemostasis

- Care to be in the proper surgical plane

superoposteriorly and at the midline where

platysma is absent

1. Superiorly up to inferior border of the mandible

* Preservation of marginal mandibular nerve

Upward dissection of superficial layer of deep

cervical fascia off the capsule of submandibular gland

Careful dissection and suspension by ligatures

placed on anterior facial vein

: best, especially in oral cavity primary, to remove

pre- and post-vascular facial lymph nodes

Postero-superiorly, raise the flap superficial to theaponeurosis over the parotid as in parotidectomy


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2. Anteriorly to strap muscles and midline

3. Inferiorly to the level of clavicle4. Posteriorly to the anterior border of trapezius

muscle

- best by dissection quite superficial to avoid the

vertical branch of transverse cervical vein

5. Secure the skin flaps by suturing either to the drapes

or to the skin

Exposure of Surgical Field

1. Superior dissection

1) Level Ia

Fibrofatty tissues are

incised along the anterior belly

of contralateral digastric muscle

and swept inferoposteriorly

from central portion of

mylohyoid muscle

Remove pre- & post-vascular facial lymph nodes

Anterior belly of ipsilateral digastric muscle is cleaned,

leaving submental contents (Level Ia) attached to

submandibular triangle (Level Ib)

2) Level Ib

SMG is elevated from floor of submandibular triangle,

facilitating identification of hypoglossal nerve

On inferior traction, soft tissue separation from

inferior border of mandible

Anterior traction of posterior border of mylohyoid muscle

Identification of lingual nerve, submandibular ganglion, and

postganglionic parasympathetic fibers to the gland

2) Level Ib (contd)

Ganglion is divided between clamps

Submandibular duct is divided and tied

Identification, clamping, and division of facial artery by

posterior and downward traction of the tissues

Level II

Tail of parotid gland

Posterior belly of digastric muscle is identified Division of parotid tail and control of posterior

facial vein


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Level II

Delineation of inferiorborder of digastric m.

Upward retraction of the

belly with Army-Navy

Identification of upper

stump of IJV

Cut the proximal end of

spinal accessory nerve

1) Division of SCM m.

Delineation of anterior

border of trapezius muscle

from clavicle upward to its

junction with mastoid tip

SCM muscle is divided

along the anterior border of

trapezius and is freed from

its mastoid insertion

Division of SCM muscle

1) Dissection of tissue (Level V)

2. Posterior dissection

Four clamps placed on the posterior margin of neck contents

anterior to the border of trapezius for traction

Sharp dissection of the tissue from the deep layer of deepcervical fascia : allows preservation of posterior (motor)

branch of cervical plexus, thereby preserving innervation to

the levator scapulae, splenius capitis, and scalene muscles

Trapezius

Innervation

CN XI : 5 cm from clavicle

Surgical considerations

Posterior limit

of Level V neck dissection

Denervation results in

shoulder drop and winged

scapula

*

*

**

3. Inferior dissection: Level IV

1) Division of SCM muscle

Sternal and clavicular heads divided while

placing upward traction on the belly

Cautious incision by layers

- paying great attention to the carotid sheath

and its contents lying immediately deep to

the muscle

Alternately, the muscle can be separated from

the underlying carotid sheath by gentledissection with a blunt Kelly clamp

2) Identification and opening of carotid sheath

Soft tissue overlying sternothyroid muscle is

separated from posterior border of the muscle

Medial traction of sternothyroid muscle

identification of carotid sheath

Open the sheath with Metzenbaum scissors


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Four clamps to the lower aspect of IJV

(or 2 inferiorly and 1 superiorly)

Cut between middle two clamps

Double ligation with 2-0 silk ties and 3-0 silksuture ligatures or four 2-0 silk ties

Care must be taken not to saw through the

vein with these ties

4) Dissection of supraclavicular tissue (Levels IV & V)

Retraction with sponge

and incision in sequentiallayers after incision of

fascia superficial to

clavicle

Control of EJV

Division of omohyoid m.

Extend from IJV to

anterior border of

trapezius muscle

3) Internal jugular vein (IJV)

Blunt dissection with blunt Kelly clamps

Avoiding undue forces on IJV preventing

severe hemorrhage or air embolism

Exposure of adequate length of IJV to allow

easy passage of the clamps

Visual identification of vagus nerve and CCA

* Fascial carpet

Dissection down to deep

layer of deep cervical

fascia overlying phrenic

nerve, brachial plexus &

posterior branches of

cervical plexus

Continued cephalad

traction

Preservation of this

fascia prevents injury to

the above structures

* Thoracic duct on

the left neck

If injured, clear

identification and ligation

needed to prevent

chylous fistula

Tissue pedicle in IJV

stump area between

phrenic and vagus nerves

should always be dividedbetween clamps and tied

Thoracic duct


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Upward and medially to the level of cervical plexus

Division & ligation of anterior (sensory) branches ofcervical plexus : transition from level V to levels II, III, IV

Posterior approach to the carotid sheath

- Separating IJV from vagus and carotid

- Care not to dissect deep to carotid

(cervical sympathetic trunk)

Completion of Levels II~V

Level II

-Roll the specimen forward, clear separation of

vagus nerve and carotids

(together with Levels III & IV)

-Identification of hypoglossal nerve above carotid

bifurcation - Control of veins

Venae commitantes nervi hypoglossi

Lingual vein

Veins draining pharyngeal plexus

-Division of ansa hypoglossi

3. Anterior dissection

- along the undersurface

of omohyoid

- Up to the level of hyoid

bone, at which pointanterior belly of

omohyoid is divided

F. Closure

Meticulous hemostasis

Wound irrigation with sterile saline

Place suction drains through separate stab

incisions in the lower flapbelow clavicle,

considering last functioning hole of the catheter

Secure the drains away from the carotid, cranial

nerves, and mucosal suture lines

Closure of skin incisions in layers

Airtight closure of platysma with absorbable sutures

Placement of Suction Drain

management of neck in ORAL CANCER

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