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Neck dissection

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Neck dissection

  2. 2. • Systematic removal of lymph nodes, along with their surrounding fibrofatty tissue, from various compartments of neck • Aim : to remove neck lymph nodes into which cancer cells may have migrated • Metastases may originate from tumours of oral cavity, tongue, nasopharynx, oropharynx, hypopharynx, and larynx, as well as the thyroid, parotid and posterior scalp. INTRODUCTION:
  3. 3. • Therapeutic neck dissection is used when metastatic cervical lymphadenopathy is clinically evident. • Elective neck dissection is used to remove lymph node groups in pts who have clinically node-negative disease and who have increased risk of harboring occult disease in neck • Salvage neck dissection is done when metastatic disease is clinically evident in the neck after previous treatment
  4. 4. • 1888 - Jawdynski described en bloc resection with resection of carotid, internal jugular vein and sternocleidomastoid muscle. • 1906 - George W. Crile of the Cleveland Clinic describes radical neck dissection. • 1957 - Hayes Martin describes routine use of radical neck dissection for control of neck metastases. • 1967 - Oscar Suarez and E. Bocca describe a more conservative operation which preserves SAN, IJV and SCM. • Last 3 decades - Further operations have been described to selectively remove the involved regional lymph groups. HISTORY OF NECK DISSECTION:
  6. 6. • Suggested by Suen and Goepfert (1997) • Biologic significance for lymphatic drainage depending on site of tumor IMPORTANCE OF SUBDIVISIONS:
  7. 7. “N” classification – AJC (1997) NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in single ipsilateral lymph node, 3 cm or less in greatest dimension N2a: single ipsilateral lymph node >3 cm but <6 cm in greatest dimension N2b: multiple ipsilateral lymph nodes, none >6 cm N2c: bilateral or contralateral nodes, <6 cm N3: lymph node >6 cm STAGING OF HEAD AND NECK CANCER
  8. 8. • Thyroid and nasopharynx have different staging based on tumor behavior and prognosis • Staging in nasopharyngeal cancer  N1: unilateral  N2: bilateral (Both are above supraclavicular fossa & < 6 cm)  N3: > 6 cm or in supraclavicular fossa • Staging in thyroid cancer  N1a: ipsilateral  N1b: midline / bilateral / contralateral
  9. 9. Principles of Classification • RND: standard basic procedure for cervical lymphadenectomy, all other represent one or more modifications • MRND: When modification of RND involves preservation of one or more non-lymphatic strs. • SND: When modification involves one or more lymph node groups that are routinely removed in RND. • Extended RND: When modification involves removal of additional lymph node groups or non-lymphatic structures relative to RND. CLASSIFICATION OF NECK DISSECTIONS
  10. 10. • Removal of all ipsilateral cervical lymph node groups that extend from  Body of mandible superiorly to  Clavicle inferiorly and from  Contralateral anterior belly of digastric & lat border of strap muscles anteriorly to  Ant border of trapezius posteriorly RADICAL NECK DISSECTION
  11. 11. • extensive lymph node metastases with extension beyond capsule of node or nodes that involves SAN and IJV. • Untreatable primary tumor • Unfit form major surgery • Distant metastasis • Significant b/l neck diseases INDICATIONS: CONTRA-INDICATIONS:
  12. 12. • En bloc removal of lymph node– bearing tissue from one side of the neck (I-V) • Unlike RND, it preserves SAN, IJV, and/or SCM • TYPES: I. Type I preserves SAN II. Type II preserves SAN & IJV III. Type III preserves SAN, IJV & SCM MODIFIED RADICAL NECK DISSECTION:
  13. 13. • Type I :  Operable palpable neck disease (usually N1, N2a, N2b) not involving accessory nerve  Can occasionally be done for the N0 neck • Type II :  Where preservation of IJV is important either when performing a second side operation or  microvascular anastomosis or  when histology shows vein need not be resected, i.e. differentiated thyroid cancer. INDICATIONS:
  14. 14. • Type III :  comprehensive or functional neck dissection  Elective Rx for N0 neck in cell carcinoma of the upper aerodigestive tract
  15. 15. • Reduce postsurgical shoulder pain and shoulder dysfunction • Improve cosmetic outcome • Reduce likelihood of bilateral IJV resection BENEFIT OF MRND:
  16. 16. • En bloc removal of one or more lymph node groups at risk for metastatic cancer • Levels removed depend on location of primary lesion and its known pattern of spread. • Types: I. Supraomohyoid (m/c performed) II. Extended supraomohyoid III. Lateral IV. Postero-lateral: V. Anterior or central: VI. Superior mediastinum: SELECTIVE NECK DISSECTION
  17. 17. • Supraomohyoid:  SND for Oral Cavity Cancer  Dissection of I-III groups  Cutaneous branches of cervical plexus and post border of SCM mark posterior limit of dissection.  Inferior limit - junction betn sup belly of omohyoid & IJV  Indication: o SCC oral cavity T1–T4: N0. • Extended supraomohyoid:  Skin cancer (SCC and melanoma) ant to line of tragus in conjunction with superficial parotidectomy INDICATIONS:
  18. 18. • Lateral:  SND for Oropharyngeal, Hypopharyngeal, and Laryngeal Cancer  Dissection of II-IV groups  Sup. limit of dissection - skull base  Inf. limit – clavicle  Ant. (medial) limit - lat border of sternohyoid & stylohyoid m/s  Post. (lateral) limit - cutaneous branches of cervical plexus and post border of SCM.  Indication: o SCC larynx, oropharynx and hypopharynx, T2–T4: N0
  19. 19. • Posterolateral:  SND for Cutaneous Malignancies  Dissection of II-V & post-auricular nodes  Sup. limit - skull base ant and nuchal ridge post  Inf. limit - clavicle  Med. (ant) limit - lat border of sternohyoid and stylohyoid m/s  Lat. (post) limit - ant border of the trapezius muscle inferiorly and midline of neck superiorly
  20. 20. • Anterior or central:  SND for Cancer of Midline Structures of Anterior Lower Neck  Dissection of level VI groups  superior limit - body of hyoid bone  inferior limit - suprasternal notch  lateral limits - medial border of the carotid sheath (CCA).  Indications: • Differentiated thyroid carcinoma • Subglottic and hypopharyngeal SCC
  21. 21. • Sup. Mediastinum:  Differentiated and medullary thyroid carcinoma  Subglottic laryngeal and hypopharyngeal SCC  Cervical oesophageal carcinoma
  22. 22. • RND along with one or more additional lymph node groups or nonlymphatic strs or both • lymph node grps include retropharyngeal and parapharyngeal, parotid nodes, or lymph nodes in levels VI or VII. • nonlymphatic strs include part of mandible, parotid gland, part of mastoid tip, prevertebral fascia and musculature, digastric m/s, XIIn, ECA as well as skin. EXTENDED NECK DISSECTION
  23. 23. • compartmental removal of lymph nodes limited to one or two contiguous neck levels • INDICATION:  removal of lymph node disease as/w supraglottic cancer  residual disease following chemoradiation that is confined to a single level SUPERSELECTIVE NECK DISSECTION
  24. 24. • lymphoscintigraphy and sentinel lymph node biopsy (SLNB) • powerful adjunct to surgical treatment • minimally invasive, can accurately stage clinically occult neck LYMPHOSCINTIGRAPHY-DIRECTED NECK DISSECTION
  25. 25. • Position:  Supine  Roll placed beneath shoulders to optimally extend neck.  Skin is prepped and draped to allow full exposure of both sides of neck with clear visualization of surrounding landmarks TECHNIQUE:
  26. 26. • Optimal exposure of all lymph node levels to be dissected (I -V) • Preserve as much blood supply as possible • Flaps raised should be broadly based, sup or inf • Should avoid any trifurcations, particularly those that overlie carotid sheath • Incisions that fit these criteria  Hockey stick  Boomerang  McFee incision  Apron incision (b/l ND) INCISION:
  27. 27.  Y type (or Crile)  Schobinger incision  Modified Schobinger incision  horizontal-T (Hetter) incision  Utility incision DIFFERENT INCISIONS:
  28. 28. • Raised in subplatysmal plane • Major corners of consternation:  Lower end of internal jugular vein.  Junction of lateral border of clavicle with lower edge of trapezius.  Upper end of internal jugular vein.  Submandibular triangle. • Minor corners of consternation:  Retropharyngeal nodes.  Parapharyngeal nodes.  Chaissaignac’s triangle. RAISING THE FLAP:
  29. 29. • Step 1:  incision is made through skin, subcutaneous fat, and platysma muscle  superior flap is elevated  submandibular gland fascia is then incised  Resection of fat and lymph nodes from submental triangle (Level Ia)  submental triangle is resected inferiorly to hyoid bone with electro-cautery. Deep plane of dissection is mylohyoid muscles OPERATIVE STEPS FOR MRND:
  30. 30. • Step 2:  addresses Level Ib  submandibular gland capsule is dissected from gland in a superior direction in a subcapsular plane  Resection of fat and lymph nodes tucked anteriorly and deeply between ant belly of digastric & mylohyoid m/s
  31. 31.  Facial artery and vein are identified by blunt dissection with a fine haemostat  Facial lymph nodes; if present, are dissected  Divided and tied close to submandibular gland so as not to injure marginal mandibular nerve  This frees up gland superiorly, which can then be reflected away from mandible  addresses the lingual nerve, submandibular duct, and XIIn
  32. 32. • Step 3:  fascia along lateral aspect of digastric divided  EJV divided  post belly of digastric exposed along its entire length  Identification of XIIn deep to veins that cross nerve  Sternomastoid branch of occipital artery that tethers XIIn identified  Dividing this artery releases XIIn  Then courses vertically and leads directly to ant border of IJV
  33. 33. • Step 4:  fatty tissue in Level II dissected  XIn which may course lateral, medial or very rarely through IJV identified  transverse process of C1 vertebra can be palpated immediately post to XIn and IJV
  34. 34. • Step 5:  directed at anterior neck  anteriorly based subplatysmal flap raised  exposing omohyoid and SCM muscle inferiorly down the clavicle  anterior jugular vein left in elevated flap  Omohyoid divided and levels II, III cleared
  35. 35. • Step 6:  Posteriorly-based flap elevated  Platysma is often absent posteriorly hence flap may be very thin  Dissection continues until ant border of trapezius is reached
  36. 36. • Step 7:  dissecting out XIn and mobilizing Level IIb  XIn is identified by dissecting at post border of SCM, approx 1-2cm post to point where greater auricular nerve curves around m/s  Once XIn exposed and freed from IJV, it is exposed distally to where it disappears behind trapezius m/s  Freed completely and branches sectioned to SCM
  37. 37. • Step 8:  dissection of Level IIb and transposition of the XIn  SCM is divided below mastoid. exposing fat at top of Level IIb  dissection is carried deeper until deep muscles of neck that run in a posteroinferior direction appear  dissection is then directed postero- inferiorly, where greater occipital nerve (C1) is divided  Level IIb and IIa are then dissected off  XIn is now trans-located posteriorly
  38. 38. • Step 9:  clavicular and sternal heads of SCM divided  not to dissect immediately lateral to IJV, as right lymphatic duct (right neck) or thoracic duct (left neck) may be injured; chyle leak  EJV is divided and ligated and omohyoid divided  Supraclavicular fat exposed.  Brachial plexus, phrenic nerve & transverse cervical vessels identified
  39. 39. • Step 10:  freeing inferolateral part of Level V  Identifying and dividing supraclavicular nerves  Incision of fatty vascular pedicle containing transverse cervical artery and vein  isolation and division of transverse cervical artery and its proximity to XIn.
  40. 40. • Step 11:  anterograde dissection of Levels II -V with scalpel  dissection proceeds over a broad front until entire cervical plexus has been exposed  cervical plexus nerves are each divided, taking care not to injure phrenic nerve  This brings carotid sheath into view  carotid sheath is incised along full course of vagus nerve, and neck dissection specimen is stripped off the IJV
  41. 41. • Step 12:  final step is to:  strip neck dissection specimen off infrahyoid strap muscles  to identify and preserve superior thyroid vascular pedicle, and  to deliver neck dissection specimen • Closure:
  42. 42. • HAEMORRHAGE:  perioperative or postoperative  Damage to IJV at its upper or lower end before it has been ligated  Secondary haemorrhage may occur as a result of carotid artery rupture • WOUND INFECTION:  four most important factors 1. Contamination of surgical field. 2. Contamination of surgical field as operation involves in-continuity RND and primary excision 3. Postoperative haematoma which then becomes infected. 4. Flap necrosis and wound breakdown. COMPLICATIONS
  43. 43. • CAROTID ARTERY RUPTURE:  Following necrosis of arterial wall d/to infection  preoperative radiotherapy is implicated in most series • CHYLOUS FISTULA:  More usually, a leak of fluid occurs when lower end of jugular vein is being dissected  Mild leak, i.e. < 100mL/day: conservative management  Major leak: re-explore wound to identify source of leak and oversew it
  44. 44. • PNEUMOTHORAX  disease lower neck, apical pleura may be damaged during dissection • NERVE INJURIES:  standard radical neck dissection the nerves which are deliberately divided are:  accessory nerve;  branches of the cervical plexus.  descendens hypoglossi  Other nerves that may be damaged by accident include:  facial nerve or its mandibular or cervical division;  hypoglossal and lingual nerves;  vagus, symphathetic trunk, phrenic nerve or brachial plexus.
  45. 45. • CEREBRAL OEDEMA;  Usu. In b/l neck dissection .
  46. 46. THE END…..