Neck dissection
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NECK DISSECTION
AKANA MOHAN PHANEENDRA Final M.B.B.S part-2 8th SEMESTER
26th JULY , 2016
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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)
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• 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.
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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)
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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)
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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.
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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
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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
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Other incisions for RND / MRND
• SCHOBINGER• CONLEY / SCHECHTER• HOCKEY STICK• HAYES MARTIN• TRIRADIATE• APRON • FISCHEL T-J / CIRCLES
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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)
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• 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
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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
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• 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
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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
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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
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EXTENDED RADICAL DISSECTION
• Removal of one or more additional group of lymphatics or removal of non lymphatic structures with RND
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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