Modified and Radical Neck Dissection Technique
Modified and Radical Neck Dissection Technique
Modified and Radical Neck Dissection Technique
Neck dissection removes potential or Level I is bound by the body of the mandible
proven metastases to cervical lymph nodes. above, the stylohyoid muscle posteriorly,
It is a complex operation, and requires a and the anterior belly of the contralateral
sound knowledge of the 3-dimensional digastric muscle anteriorly. The revised
anatomy of the neck. classification (Figure 1) uses the posterior
margin of the submandibular gland as the
boundary between Levels I and II as it is
Indications clearly identified on ultrasound, CT, or
MRI. Level I is subdivided into Level Ia,
Neck dissection may be elective (END) (submental triangle) which is bound by the
when done for clinically occult metastases, anterior bellies of the digastric muscles and
therapeutic (clinical metastases) or may be the hyoid bone, and Level Ib (submandi-
a salvage procedure (previously treated bular triangle).
neck with surgery +/ radiation). END is
indicated when the risk of having occult Level II extends between the skull base and
cervical nodal metastases exceeds 15-20%. hyoid bone. The posterior border of the
sternocleidomastoid defines its posterior
border. The stylohyoid muscle (alternately
Nodal Levels the posterior edge of the submandibular
gland) defines its anterior border. The
The neck is conventionally divided into 6 accessory nerve (XIn) traverses Level II
levels; Level VII is in the superior obliquely and subdivides it into Level IIa
mediastinum (Figure 1). (anterior to XIn) and Level IIb (behind XIn).
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an experienced surgeon, blood transfusion posteroinferior corner has a tenuous blood
is rarely required. supply and may slough, having to heal by
secondary intention.
The patient is placed in a supine position
with the neck extended and turned to the
opposite side. Surgical draping must allow
monitoring for movement of the lower lip
with irritation of the marginal mandibular
nerve, and must provide access to the
clavicle inferiorly, the trapezius muscle
posteriorly, the tip of the earlobe superiorly
and the midline of the neck anteriorly. The
drapes are sutured to the skin.
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Figure 5: Wide apron flap
The neck is opened via a horizontal incision Next the superior flap is elevated with
placed in a skin crease at about the level of cautery until the submandibular salivary
the hyoid bone. The incision is made gland is identified. The submandibular
through skin, subcutaneous fat, and gland fascia is then incised inferiorly over
platysma muscle. Identify the external the gland so as to avoid injury to the
jugular vein and greater auricular nerve marginal mandibular nerve (Figure 9).
overlying the sternocleidomastoid muscle
(SCM) (Figure 8).
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Figure 9: Incision of submandibular Figure 11: Resection of submental triangle
salivary gland capsule onto mylohyoid muscles
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vessels for facial lymph nodes; if present,
they are dissected free using fine
haemostats, taking care not to traumatise
the marginal mandibular nerve. The facial
artery and vein are then divided and tied
close to the submandibular gland so as not
to injure the marginal mandibular nerve
(Figure 13).
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Figure 17: Separating the submandibular
ganglion from the lingual nerve
Figure 15: Finger dissection delivers the The facial artery is divided and ligated just
submandibular gland and duct, and brings above the posterior belly of digastric
the lingual nerve into view. The proximal (Figure 18).
stump of the facial artery is visible at the tip
of the thumb, and the XIIn behind the nail
of the index finger
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Figure 21: Divide the external jugular vein
Figure 19: Facial artery has been kept
intact; a branch is being divided Continue to expose the posterior belly of
digastric along its entire length, taking care
not to wander above the muscle as this
Step 3 (Figure 7) would jeopardise the facial nerve (Figure
22). This step is the key to facilitating
This step entails identifying the XIIn in subsequent exposure of the IJV and XIn.
Level IIa, and freeing and tracing the XIIn
posteriorly where it leads the surgeon
directly to the internal jugular vein (IJV).
First divide the fascia along the lateral
aspect of the digastric (Figure 20).
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Figure 23: Dividing the veins that cross the
XIIn
Figure 25: Dividing the sternomastoid
After the nerve has crossed the external branch of the occipital artery frees the XIIn
carotid artery, identify the sternomastoid that then leads directly to IJV. Note the XIn
branch of the occipital artery that tethers the and the tunnel created behind IJV
XIIn (Figure 24).
Step 4 (Figure 7)
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4 & 7). The transverse process of the C1
vertebra can be palpated imme-diately
posterior to the XIn and IJV, and serves as
an additional landmark for these structures
in difficult surgical cases. Note that the
occipital artery crosses the IJV at the top of
Level II, branches of which may need to be
cauterized should they be severed while
dissecting in Level II.
Step 5 (Figure 7)
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flap, but to leave them lying on the SCM
muscle. Movement of the shoulder is noted
as one approaches the XIn or the trapezius
muscle. The dissection continues until the
anterior border of trapezius is reached
(Figure 30). In a thin patient the XIn may
be extremely close to skin. Note that the
XIn, unlike branches of the cervical plexus,
passes deep to the trapezius muscle.
Step 7 (Figure 7)
Figure 32: XIn is dissected upward through
This step involves dissecting out the XIn the SCM muscle
and mobilizing Level IIb. The XIn is iden-
tified by dissecting with a haemostat at the
posterior border of the SCM muscle,
approximately 1-2cm posterior to the point
where the greater auricular nerve curves
around the muscle (Figure 31). The nerve is
often located by seeing movement of the XIn
Step 8: (Figure 7)
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branches of the cervical plexus come into
view (Figure 37). The XIn is now trans-
located posteriorly (Figure 38). Figure 39
illustrates the status of the neck dissection
at this point.
Step 9: (Figure 7)
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Figure 41: Exposing the IJV by incising the Figure 43: The haemostat is under the
carotid sheath omohyoid; the external jugular vein is more
posteriorly
Take care not to dissect immediately lateral
to the IJV, as the right lymphatic duct (right
neck) or thoracic duct (left neck) may be
injured leading to a trouble-some chyle leak
(Figure 42).
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Figure 48: The supraclavicular nerves
Figure 46: Exposing the supraclavicular fat Next incise the fatty vascular pedicle
containing the transverse cervical artery and
Once the fat has been exposed, a finger can vein (Figure 49).
be used to expose the fascia covering the
brachial plexus (Figure 47). The finger is
then swept medially to expose the phrenic
nerve, laterally towards the axilla and
superiorly along the carotid sheath. Take
care not to tear the transverse cervical
vessels with the medial sweep.
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descends obliquely across the scalenius
anterior muscle, deep to the prevertebral
layer of deep cervical fascia (Figure 53).
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Figure 55: The common carotid artery, the Figure 57: Inferiorly the pedicle adjacent to
vagus nerve and IJV the IJV is divided; note the proximity of the
phrenic nerve
The carotid sheath is incised along the full
course of the vagus nerve, and the neck
dissection specimen is stripped off the IJV Step 12: (Figure 7)
while remaining inside the carotid sheath.
The ansa cervicalis, which courses either The final step is to strip the neck dissection
deep or superficial to the IJV may be specimen off the infrahyoid strap muscles,
preserved (Figure 56). Inferiorly the to identify and preserve the superior thyroid
pedicle adjacent to the IJV containing fat, vascular pedicle, and to deliver the neck
thoracic or right lymphatic duct, and dissection specimen (Figure 58)
transverse cervical artery and vein is
divided, taking care not to include the vagus
or phrenic nerves in the pedicle (Figure 57). Closure
Postoperative care
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Figure 58: Completed MND type 2; note
the superior thyroid pedicle and ansa Author & Editor
cervicalis
Johan Fagan MBChB, FCORL, MMed
Professor and Chairman
Useful References Division of Otolaryngology
University of Cape Town
Robbins KT, Shaha AR, Medina JE, et al. Cape Town, South Africa
Consensus statement on the classification [email protected]
and terminology of neck dissection. Arch
Otolaryngol Head Neck Surg 2008;134: THE OPEN ACCESS ATLAS OF
536–8 OTOLARYNGOLOGY, HEAD &
Ferlito A, Robbins KT, Shah JP, et al NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
Proposal for a rational classification of neck
dissections. Head Neck. 2011
Mar;33(3):445-50
Harris T, Doolarkhan Z, Fagan JJ. Timing The Open Access Atlas of Otolaryngology, Head & Neck
Operative Surgery by Johan Fagan (Editor)
of removal of neck drains following head [email protected] is licensed under a Creative
and neck surgery. Ear Nose Throat J. 2011 Commons Attribution - Non-Commercial 3.0 Unported
License
Apr;90(4):186-9
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