A well-described neck dissection seminar, including landmark studies of neck dissection.

1. 1
By- Dr Akash Rajput
Department of Head & Neck Oncosurgery,
Rohilkhand Medical College and Hospital,
Bareilly.
dr_akashrajput@yahoo.co.in

2. Content
Part - I
 Introduction
 History
 Anatomy
 Anatomy of lymph nodes
 Levels of lymph nodes
 Nodal factors affecting prognosis
 Risk factors for nodal metastasis
 Stach lymph nodes
 Occult metastasis
 Micrometastasis
 Skip metastasis
 Sentinel node biopsy
 Method of lymph node examination
 Classification of neck dissection
 Indications of neck dissection
2

3. 3
Part - II
 Incisions
 Selective Neck Dissection
 Modified Neck Dissection
 Radial Neck Dissection
 Complication
 Intra-op
 Immediate Post-op
 Delayed Complications

4. Introduction
4

5. History of Neck Dissection
 In 1880 Theodore Kocher described submandibular
triangle dissection along with removal of tongue
cancer. He also discribed the classical double
trifurcate incision bears Kocher’s name (ie,
Kocher incision).
 Butlin in 1900 suggested elective removal of the
cervical lymph nodes.
5

6.  George Crile 1906
standardized the
technique of radical
neck dissection by
removal of the lymph
nodes in the neck
along with the
sternomastoid
muscle, internal
jugular vein, and
spinal accessory
nerve.
6

7.  Suarez from
Argentina and
Bocca from Italy
popularized modified
neck dissection
(Functional Neck
Dissection) in the
mid-1960s and early
1970s.
 Hayes Martin in
1951 described step-
wise procedure of
neck dissection.
Hayes Martin (1892–1977).
7

8. Algorithm for the management of neck in oral
cancers
8

9. Anatomy of the Lymphatic
System
 On an average 300 LNs are located in the neck
comprising approx. 30% of all LNs in the body.
 Cervical lymphatic system is divided into superficial
& deep part.
 Superficial part collected drains from skin and
drains into lymphatic vessels along the external
jugular system.
9

10. 10
 Deep part collects lymph from mucosal linings of
upper aero-digestive track, the thyroid and salivary
glands and eventually draining into the larger vessels
along the internal jugular vein up to its entry into
subclavian vein.
 Due to its structural differences and higher permeability
from interstitial space lymphatics absorbs tumour cells
more readily for regional metastasis from carcinomas.

11. 11
PATTERNS OF NODAL
METASTASES

12. 12

13. 13
 Pathologically identified nodal metastasis occurred 34% of the
time in ED (N0), 69% in ITD (N+) and 90% in STD (N+).
 Neck levels I, 11, and 111 to be at greatest risk of nodal
metastases.
 Level IV was rarely involved (3%) in the NO patients, but was
more
commonly involved (15%-16%)
in the N+ groups.
 Fifty percent of the NO
patients with level IV nodal
metastases had involvement
Conclusion

14. Conclusion
14
 Neck level V was rarely involved in any major clinical
group, occurring only once in the NO group and in ten
patients in the N+ groups.
 Level V involvement always associated with nodal
metastases in other neck levels.

15. 15
 n - 583
 95.7% metastases - at
levels I to IV.
 Metastases to levels IIB and
V - 3.8% and 3.3%,
respectively.
 Conclusion- Determining
status of level IIA is
important to guide dissection
of levels IIB and V.

16. 16
 Therefore it is not important to remove lymph
nodes from level IIb in cases of only oral
cancers. Level IIb should also be dissected
when there are clinically positive lymph nodes
in level IIa.
 Primary lesions from the oropharynx and
nasopharynx are more likely to involve
level IIb.

17. 17

18. NODAL FACTORS AFFECTING
PROGNOSIS
18
 Presence of pathologically positive nodes,
 Size of the metastatic lymph node (>1.5cm for level I, and
>1cm for other levels),
 Number of lymph nodes involved,
 Location of the lymph nodes. (Involvement of the lower
cervical nodes (level IV) and the lower posterior triangle
lymph nodes has a very poor prognosis).

19. 19
 Shape of lymph nodes (Spherical nodes are more
likely to be metastatic compared to oval/elliptical)
 Presence of extranodal spread (This increases both
the incidence of regional recurrence and also distant
metastases).
 Perivascular and perineural infiltration.

20. RISK FACTORS FOR NODAL
METASTASIS
20
 Characteristics of the
primary tumor such as
location, size, and
histology.
 As a general rule, the
risk for lymph node
metastases increases
for more posteriorly
located tumors, such as
those of the oropharynx
and hypopharynx
compared to lips and
oral cavity.

21. 21
 The greater the T size of the primary tumor, the
greater the probability of having lymph node
metastases. For example, T1, T2, and T3 tongue
cancers have an incidence of metastatic disease to
the neck of 30%, 50%, and 70%, respectively.
 Pathologic features such as endophytic versus
exophytic tumors, poorer degree of differentiation,
depth of invasion, vascular invasion, and perineural
invasion also determine the risk of cervical
metastases.

22. Terminologies
22
 Stach Lymph Nodes:
 Occult Metastasis:
 Micrometastasis
 Skip Metastasis
 Sentinel node Biopsy

23. Lymph nodes of face
23
 Found along the facial vessels.
 Classified by Rouviere into four groups:
 Malar (superficial to the malar eminence
just lateral to the eye);
 Infraorbital (in the canine fossa or
nasolabial fold);
 Buccinator (overlying the buccinator
muscle);
 Mandibular (supramandibular
group/Stahr Nodes) (along the outer
surface of the mandible, adjacent to the
facial artery, at the anterior border of the
masseter muscle).

24. Stahr Lymph Nodes:
24
 The node of Stahr is described in
Gray’s Anatomy as a constant node that
is found just where the facial artery
crosses the horizontal ramus of the
mandible. (nodes which are above the
inferior border of the mandible only).
 These nodes (Stahr Nodes) also
receive some drainage from the gingival
and buccal mucosae.
 The facial nodes may occasionally be
involved with cancer of the head and
neck; however, this is rarely

25. 25
 n- 1,406 of OSCC
 6 patients - metastasis to the buccinator (2) or
mandibular node (4).
 The primary sites- lower gingiva in 2 cases and the
buccal mucosa in 4 cases.
 Conclusion: The possibility of metastasis to the
buccinator and mandibular nodes should be
considered in oral cancer when primary tumor
invasion reaches the buccinator muscle with
submandibular node metastasis.

26. Occult Metastasis
26
 Occult lymph node metastases are defined as
tumor deposits that are initially undetected and
subsequently identified.

27. Risk of occult metastasis of oral cavity
cancers
27

28. 28
 n – 91
 Glossectomy + ND.
 All Patients with stage T2-T4
cancers of the oral tongue should
have an elective dissection of the
neck.
 Patients with T1N0 cancer who
have a double DNA-aneuploid
tumor, depth of muscle invasion > 4
mm, or have a poorly differentiated
cancer should definitely undergo
elective neck dissection.
• The best predictors are depth of muscle invasion, double
DNA aneuploidy, and histologic differentiation of the tumor.

29. Micrometastasis
 A micrometastasis is defined by size and must be less
than or equal to 2 mm in largest dimension. Metastases
larger than 2 mm are often referred to as
macrometastases.
 Are a small collection of cancer cells that have been shed
from the original tumor and spread to another part of the
body (Lymph nodes).
 They cannot be seen with any imaging tests such as
MRI, ultrasound, PET, or CT scans.
29

30. Skip Metastasis
30
 When the described order for neck node
metastasis is lost and metastases is found in a
higher level without involvement of the first series
nodes or an intermediary node group then it is
called Skip M.
 The concept of skip metastases was first reported
by Byers et al for oral tongue cancer.
 The proper knowledge of skip metastases will
enable a surgeon to avoid under treatment.
 The tongue especially is known to cause ‘skip
metastases’ to level IV.

31. 31
 N – 339
 T1-2/N0 cancer of tongue and floor of mouth
 1987 through 1997
 They found levels I and II (46.9 and 75.3%) to be
greater risk of developing nodal metastases.
 Level IV (6.5%) and level V (2%) were rarely
involved.
 Skip metastases bypassing level I and II was only
2%.
 Author supported the indication of supraomohyoid
neck dissection for N0 and a more
comprehensive neck dissection (levels I-V) for N+
patients in Stage I-II SCC of the tongue and
FOM.

32. Dissection to level IV in pt of tongue
cancer?
32
 N - 55
 T1-3, N0 carcinoma of the oral tongue
 Partial glossectomy and a selective neck dissection of levels I, II,
and III.
 Level IV was resected as part of the specimen in 17
 Metastasis was found in only 1 patient.
 Average follow-up of 4.1 years
 Consequently, the rate of metastases to undissected level IV was
2%.
 Conclusions: Dissection of level IV nodes only when there is
intraoperative suspicion of metastases in levels II or III

33. 33
 Byers et al studied 277 untreated patients with
SCC of the oral tongue.
 15.8% had skip metastases to either level III
and/or level IV, without disease in level I to II.
• Kafif et al calculated the incidence of skip metastases in Byers
study when patients with clinically positive neck nodes were
excluded. 5 patients were found to have skip metastases to level
IV in the initial neck dissection specimen and 8 patients in whom
level IV had not been dissected subsequently recurred in this
level.
• Thus in the entire series of 270
patients 13, i.e. 4.8% had skip
metastases or subsequent recurrence

34. 34
 According to Woolgar study,
 N- 326 neck, 60 cases of lateral tongue cancer,
metastasis was seen in 33 cases.

35. Conclusion
35
 For primary sites other than the tongue, metastasis
developed initially in a node(s) in the first drainage
group (level I or II) with progressive involvement of
neighbouring nodes (‘overflow’) (Level III, IV and V).
 An erratic distribution of metastases suggestive of
‘fast-tracking’ (skip lesions) was only seen in tongue
tumours.
 The pattern of metastatic spread indicates that level
IV nodes must be included in therapeutic neck
dissections in tongue cancer cases.

36. Sentinel Node Biopsy (SNB)
 First reported in 1993, Alex and Krag
 Concept based on the theory of orderly spread of
tumor cells within the lymphatic system.
 The first lymph node in a regional lymphatic that
receives lymphatic flow from a tumor.
 In the sentinel lymph node procedure, this lymph
node is identified using radioactive colloid and blue
dye.
 Important role in clinically N0 neck.
 Overall sensitivity of the procedure using the full
pathologic protocol is 94% & sentinel node biopsy
could be used to stage the N0 neck in patients with
early sub clinical nodal disease.
36

37. 37
 N- 26, cT1-2N0
 1 ml of indocyanine green (5 mg/ml) and 1.5 ml of
methylene blue (1 mg/ml) were injected sequentially
around the primary tumor in a four-quadrant pattern before
skin incision.
 After elevation of the platysma flap and posterior retraction
of the sternocleidomastoid muscle, fluorescence images
were taken with a near-infrared detector, with special
attention paid to any blue-dyed lymph nodes.

38. 38
 Lymph nodes identified first with fluorescent hot spots
with or without blue dye were defined as sentinel
nodes, and they were harvested and sent for
pathologic study.
 The number of sentinel nodes per case varied from 1
to 9, with an average of 3.4/case.
 Routine pathology demonstrated occult metastasis
exclusively in SNs in four cases (15.4 %).

39.  Clinical Palpation
 Most widely used method.
 Clinical palpation assesses criteria like site, size,
shape, number, regularity, painful, consistency &
fixity.
 Size of 0.5cm in submandibular area and 1.0 cm in
subdiagastric areas can be distinguised.
 Not uniformly reliable in the assessment of regional
metastatic disease as occult neck disease can occur
in up to 50% of patients, false negative rate ranges
between 0% and 77%.
39
Evaluation of neck nodes

40. Clinical Palpation (Video)
40

41.  Computed Tomography-
 Helpful for evaluation of the
primary tumour as well as for
evaluation of the neck nodes for
metastases.
 Criteria for diagnosing a malignant
nodes : Size, central necrosis,
pericapsular extensions, cyst
tumour growth.
 The most accurate CT criteria is
the presence of central necrosis
which is demonstrated as
peripheral/rim enhancement
41

42.  PET scan: The functional CT scan depicting
metabolism of cancer cell is more useful to
detect an occult primary with neck
secondaries or to detect a neck node in clinically
N0 neck after the primary tumour has been
resected.
42

43. US- Superior to clinical palpation.
 Ultrasound criteria for malignant and
benign nodes - size, shape, central
necrosis, extracapsular spread,
roundness index.
Shape:
 Benign lymph nodes have an
elongated fusiform shape
 Malignant infiltration commonly begins
in cortex of the lymph node.
 Metastatic lymph nodes tend to have
an irregular rounded shape that is
reflected by the decreased ratio
between the longitudinal and
transverse (L/S) diameters of node
43

44.  Size:
 Maximum transverse diameter
 Assesses true axial & transverse diameter
 Optimal minimal axial diameter to distinguish
between positive and negative node proved to be
8mm for subdigastric lymph node and 7mm for
all other types of lymph nodes.
44

45. 46
 USgFNAC showed to be the most accurate imaging modality to
detect cervical lymph node metastases.

46. 47
 N- 51,
 T1 to T2 N0 oral cavity SCC
 Preoperative ultrasound was performed in all patients. Ultrasound-guided
FNAC was performed in patients in whom the ultrasound result was
reported as indeterminate or positive.
 SNB was done in all patients followed by elective neck dissection (END).
 The incidence of occult metastasis - 26.4%.
 Conclusion: Ultrasound-guided FNAC lacked sufficient accuracy to detect
occult metastases. SNB is a reliable method to detect occult metastasis
that has potential to replace END.
Sensitivity Specificity Positive
predictive
value
Negative
predictive
value
USG guided
FNAC
14.3% 100% 100% 90.2%
SNB 71.5% 100% 100% 76.5%

47. 48
 n – 91
 Glossectomy + ND.
 Ultrasound and computed
tomography are of little
value in predicting which
patients have positive
nodes.

48. Assessment of cervical Lymph node
metastasis
AJCC Staging of H and N cancers
 8th edition 2016.
49

49. Types of Neck Dissection
 In 1991, the Committee for Head and Neck
Surgery and Oncology of the American
Academy of Otolaryngology/Head and Neck
Surgery developed a system for the classification
of neck dissections.
 Classical RND,
 Modified RND,
 Selective Neck Dissection,
 Supraomohyoid Neck Dissection,
 The Lateral Neck Dissection,
 Extended Neck Dissection
50

50. 1) Comprehensive neck dissection (all levels I to V)
Radical neck dissection
Modified radical neck dissection
 Type I (XI preserved)
 Type II (XI, IJV preserved)
 Type III (XI, IJV, and SCM preserved)
2) Selective neck dissection
Medina’s classification (1991):
51

51. Spiro’s classification
 According to time and effort involved in 1994, Spiro
suggested changes to the Academy’s classification:
1) Radical (4 or 5 node levels resected)
Conventional radical neck dissection
Modified radical neck dissection
Extended radical neck dissection
Modified and extended radical neck dissection
2) Selective (3 node levels resected)
Supraomohyoid neck dissection
Jugular dissection (Levels II-IV)
Any other 3 node levels resected
3) Limited (no more than 2 node levels resected)
Paratracheal node dissection
Mediastinal node dissection
Any other 1 or 2 node levels resected
52

52. Indications of Neck dissection
The primary goal of neck dissection can be pathologic
staging of the neck, to determine whether further
therapy is warranted with a clinically staged N0 neck.
 As a therapeutic procedure for patients with evidence
of metastatic disease either clinically or pathologically.
53

53. 54
 n - 359
 T1/2 and N0 neck
 END and Wait and watch group.
END W&W
3 years 5 years 3 years 5 years
Disease-free survival 76% 74% 71% 68%
Overall survival 69% 60% 62% 60%

54. 55
 Between 2004 and 2014,
 n- 500.
 245 in the elective-surgery group and 255 in the therapeutic surgery
group,
 Median follow-up of 39 months.
 Early-stage SCC, elective neck dissection resulted in higher rates of
overall and disease-free survival than did therapeutic neck dissection.
n - 500 END (245 n) TND (255 n)
(W&W)
Recurrences 81 146
Deaths 50 79
3 years overall
survival
80% 67%
3 years disease free
survival
69.5% 45.9%

55. 56
 MRND is indicated in patients with clinical or
radiographic evidence of nodal metastasis to the
neck that does not directly infiltrate or adhere to
the nonlymphatic structures.
 Radical neck dissections typically are reserved
for patients with bulky N3b neck disease.

56. 57
Thank you
Continue for Part- II

57. Part- II
58

58. Content
59
 Incisions
 Selective Neck Dissection
 Modified Neck Dissection
 Radial Neck Dissection
 Complication
 Intra-op
 Immediate Post-op
 Delayed Complications

59. Criteria for selecting Skin Incision
60
 Location of primary tumor
 A unilateral or bilateral neck dissection.
Goals of skin incision:
 Allow adequate exposure.
 Assure adequate vascularization of the skin flaps.
 Protect the carotid artery when SCM is sacrificed.
 Include scars from previous procedures.
 Facilitate the use of reconstructive techniques and
cosmetic results.
 Contemplate the potential need of postoperative
radiotherapy.

60. 61
Vascular Supply to the Skin of the
Neck

61. 62

62. Incision
 In chronological order:
 ‘Y’ incision of Crile (1906)
 Double ‘Y’ incision of Martin et al (1951)
 Schobinger incision (1957)
 Superiorly based ‘Apronlike’ incision of Latyshevesky
& Freund (1960)
 Mcfee incision (1960)
 Conley incision (1970)
 Modified Conley incision by Lasaridis et al (1994)
63

63.  Incisions can also be classified into
 Vertical
 Transverse
Differences between incisions
 Transverse incision
 Have cosmetic
advantage as they
follow natural skin
folds of the skin
 Recovery of scar
tissue in these folds
are rapid and
successful
 Easy to modify
 Vertical incision
 Disadvantages
because they
intersect to the natural
skin folds of the skin
and the vascular
supply of the neck
 They tend to contract
along their long axis –
leads to deformity and
restricted action.
64

64.  The incisions used for neck dissections are mainly
three types (McGregor)
 Tri-radiate incision and its modification
 Hayes martin double ‘Y’ incision
 McFee incision
 For a straight-line neck dissection, the incision
should be placed in a resting skin tension line
midway between the angle of the mandible and
clavicle, extending just slightly anterior to the
auricle to the midline.
65

65. Incisions for neck dissections
66

66. Tri-radiate incision
 Advantages
 Incision provides good
exposure to surgical site.
 Disadvantages
 Flap necrosis is high due
to disruption of
vasculature of skin flaps
 Occurrence of flap
separation at the
trifurcation site.
67

67. Schobinger (1957)
 ‘Vertical limb at
more posterior
region.
 Modified S. -
‘Vertical limb
instead of
being straight
should be
curved
posteriorly.
68
MODIFIED SCHOBINGER
INCISION

68. Conley (1970)
 Suggested a posteriorly
curving vertical incision
rather than a horizontal
incision.
 The incision starts from the
submental region and ending
by running downwards along
the anterior border of the
trapezius to the level of clavicle
gently curving posteriorly.
69

69. Hayes Martin Incision
 It is a paired ‘Y’ incision.
 Here the submandibular
component is met by a
vertical limb which below
becomes continuous with
an inverted ‘Y’ in the
suprascapular region.
 This flap most often gets
cyanosed.
 Flap necrosis and carotid
exposure is more in this
type of incision.
70

70. McFee Incision
 It avoids a vertical limb.
 Two horizontal incisions
are used one in
submandibular region
and other in the
suprascapular region.
71

71.  Advantages
 Excellent cosmetic result
 There is no lessening of
vascularity in the centre
of the flap
 There is no angle
intersection in incision
 Post operative wound
recovery is rapid
 Suitable in necks
receiving radiotherapy
and in peripheral
vascular disease
 Recovery of flap
excellent due to wide
bipedicled flaps
 Disadvantages
 Exposure is not good
 It is not suitable for
bilateral simultaneous
neck dissection
 Operating period is
long
 Posterior triangle
dissection is difficult
 Difficulty may arise
while working under
the bridge flap
 In short neck it might
be difficult to
distinguish between
the front tip of the
72

72. Apron flaps
 Described by Latyschevsky
and Freund 1960.
 Only a horizontal incision from
mastoid to mentum gently
curving inferiorly upto upper
border of the thyroid cartilage
is used.
 Advantages
 Carotid artery is well protected.
 Protects the descending
arterial recovery.
 Disadvantages
 It will damage the ascending
arterial and venous recovery.
 Venous congestion and
oedema might develop at the
bottom corner.
73

73. Modification of Apron flap with lateral
extensions
74

74. Hockey stick incision
 Lahey et al (1940) described.
 Modified for RND by Eckert & Byars
1952.
 It has a longitudinal and transverse
incision
 B/L hockey stick incision allows the
deglovement of the whole neck.
75

75. Drop down Incision
76
 In cases of skin involvement.

76. 1) Selective Neck Dissection
Supraomohyoid Type (Level I-III)
 Involves en bloc removal of cervical lymph node
groups I-III.
 The posterior limit of this dissection is marked by
the posterior border of the SCM.
 The inferior limit is the superior belly of the
omohyoid muscle where it crosses the IJV.
77

77. Rationale
 The expectant management of patients with oral
cavity tumors and N0 necks has been condemned
because of the high incidence of occult nodal
metastasis and poor salvage rates.
78

78.  In 2001, Hoffman reviewed 5 of the largest series of oral
cavity and calculated the mean percent occurrence of
oral cavity tumors in all levels of the neck. Many of these
studies included N+ necks. The results are a follows:
 Level I – 30.1%,
 Level II – 35.7%,
 Level III – 22.8%,
 Level IV – 9.1%,
 Level V – 2.2%.
 When factoring in only No necks, the occurrence of
occult nodal metastases in both Level IV and Level V
was less than 3%. This finding supports the use of the
SOHND in treatment of patients with N0 necks with oral
cavity carcinoma.
79

79. 80

80. 81

81. • The superficial layer of the
deep cervical fascia is
dissected and raised to the
level of the inferior border of
the mandible to protect the
marginal branch of the facial
nerve.
• The submandibular gland is
then retracted inferiorly into
the neck and is
circumferentially dissected
along the contents of level I.
82

82.  The common facial vein
and artery are ligated
once at posterior aspects
of the gland and later on
the medial side of the
gland.
 The gland is retracted
into the neck, the lingual
nerve typically is
visualized here and
protected.
83

83. 84
 The lingual and the
hypoglossal nerves are
shown, with Wharton’s
duct in the middle.
 The submandibular duct
is then skeletonized, and
divided.
 The secretomotor fibers
to the submandibular
gland shown here are
divided.

84. 85
 The entire contents
of level I should be
pedicled inferiorly on
the digastric muscle.

85. 86
 The fascia along the
anterior border of the
sternomastoid muscle is
retracted medially to
provide traction along its
anterior border.
 The carotid sheath is
exposed.

86. 87
 The fascia of the carotid
sheath is divided and
retracted medially.
 SCM is retracted medially.
 The accessory nerve and the
cutaneous and muscular
branches of the cervical
plexus should be identified
below the SCM and
preserved carefully.

87. 88
 The specimen is reflected anteriorly and the
common facial vein is divided and ligated.
 Dissection is continued caudad toward the
apex of the supraomohyoid triangle.

88. 89
 The surgical field after removal of the
specimen.

89. MRND-I

90. Technique
91
 The transverse incision is at least two finger
breadths below the angle of the mandible. A
curvaceous vertical limb was marked, beginning
at a point posterior to the carotid artery.

94.  Dissection of the upper part of the posterior triangle
lymph nodes is carefully completed, preserving the
spinal accessory nerve.

95.  The spinal accessory nerve is lifted off the specimen and
meticulously dissected from the lymph nodes in the lower
part of the posterior triangle of the neck.

96.  Further dissection of the nerve requires splitting of the
sternocleidomastoid muscle in its upper half.
 Dissection of the posterior triangle of the neck is complete with
preservation of the accessory nerve.

97.  Dissection now proceeds along the medial border of the levator
scapulae and scalene muscles, exposing the roots of the cervical
plexus.
 The cervical roots have three components. Cutaneous roots of the

98.  Medial retraction of the specimen exposes the internal
jugular vein.

99.  The surgical specimen is now flipped laterally to expose the
lower insertion of the sternocleidomastoid muscle.
 With use of the electrocautery, both heads of the
sternocleidomastoid muscle are divided just near their

100.  A layer of fibro-fatty tissue is present between the undersurface of
the sternocleidomastoid muscle and the carotid sheath.
 At this stage, the lymphatic ducts between the deep jugular lymph
nodes at the lateral aspect of the lower end of the internal jugular
vein are identified, divided, and ligated with care

101.  The lower end of
the IJV is divided
and ligated. while
carefully protecting
the common carotid
artery, the vagus
nerve and the
sympathetic chain
and the phrenic
nerve.

102.  Further dissection cephalad
along the carotid sheath
exposes the hypoglossal
nerve.
 Medially the dissection
proceeds along the superior
belly of the omohyoid muscle
up to the hyoid bone, from
which it is detached.
 The superior thyroid artery is
preserved carefully, but the
superior thyroid vein is
divided and ligated.
 At this juncture, the dissection
of the lower part of the neck is

103.  The upper skin flap is elevated, carefully preserving the
mandibular branch of the facial nerve.

104.  The anterior belly of the
digastric muscle of
contralateral side is
identified next and the
submental group of
lymph nodes is dissected
from the midline and
brought toward the right-
hand side.
 The nerve and blood
supply to the mylohyoid
muscle is divided and
ligated.
 This maneuver permits
retraction of the
submandibular salivary
gland, which is freed up
by dividing the facial

105.  The secretomotor fibers
to the submandibular
salivary gland are
divided.
 Division of Wharton’s
duct and facial artery
permits the dissection
and delivery of the
submandibular salivary
gland.
 Followed by division and
double ligation of the
upper end of the internal
jugular vein done.

106.  The surgical field after removal of the specimen.

107.  Two suction drains are placed in the surgical
field.

108.  The skin incision is closed in layers.

109. Through a Single Transverse
Incision
 Incision is outlined along the skin crease in the
midcervical region below the hairline

111. Modified Radical Neck Dissection
Type II

112. Modified Radical Neck Dissection
Type III

113.  The lateral view of the surgical field with the sternomastoid
muscle retracted anteriorly demonstrates the carotid sheath
with its contents clearly dissected.

114. Classical Radical Neck
Dissection

116.  The incision begins with the posterior half of the transverse
incision at the mastoid process and continues with the
vertical incision up to the clavicle.

117.  Dissection of the posterior triangle begins at the anterior
border of the trapezius muscle.

118.  Dissection of the posterior triangle medially leads to
exposure of the cutaneous roots of the cervical plexus.

119.  The specimen is reflected posteriorly, and the anterior
flap is elevated to expose the sternal head of the
sternocleidomastoid muscle.

120.  The sternomastoid muscle is detached from the
sternum and clavicle and retracted to expose the
carotid sheath.

121.  The internal jugular vein is ligated and divided after
the common carotid artery and the vagus nerve
are exposed and retracted medially.

122.  Dissection proceeds cranially along the carotid sheath
up to the base of the skull.

123.  The upper skin flap is now elevated, preserving the
mandibular branch of the facial nerve.

124.  The surgical field after radical neck dissection

126. Complications of Neck Dissection
 Intra operative problems
 Post operative problems
 Early
 Late
127

127. Intra-operative problems
 Bleeding (Common carotid injury)
 Injury to vagus nerve
 Brachial plexus injury
 Injury to prenic nerve
 Hypoglossal nerve injury
 Lingual nerve injury
 Increased ICP
128

128. Post operative problems (Early)
 Haemorrhage
 Lymph leak
 Infection
 Dysphagia
 Shoulder droop and pain
 Carotid blow out
 Facial edema
129

129. Late complications
• Recurrence
• Parotid tail hypertrophy
• Lymphoedema
• Hypertrophic scar

130. Management of neck dissection complications
1. Intra-operative complications
 In case of vascular injury, internal jugular vein - intra-
operative repair.
 In case of lymphatic injury, thoracic duct – identify
intra-operatively and serial ligations.
2. Immediate post-operative complications
 Hemorrhage- Compression dressing or re-open and
achieve hemostasis.

131. Chyle:
 Fluid consisting of lymph from interstitial fluid and emulsified fat from
interstitial lacteals.
 Composed of 1-3% fat mostly in the form of triglycerides and 3% protein.
 2-4 L of chyle flow through thoracic duct everyday.
 Incidence of chyle leak: 1-2.5% in neck dissection.
Thoracic Duct Injury

132. Complications :
 Malnutrition and immune compromise.
 Hypovolemia and electrolyte imbalance.
Prolonged chyle leak leads to:- increased fluid loss
associated with hypovolemia, hyponatremia,
hypocalcaemia and metabolic acidosis.
If left uncontrolled, chyle leak following neck dissection
can lead to necrosis of skin flap and carotid damage.
Massive chylothoraces have associated mortality rate of

133. • Nutritional t/t leads to closure of fistula in 80%.
Goals- to reduce production of chyle, replace fluid and electrolytes and
maintain nutrition status.
• Treatment:
1. Conservative :-
• Adequate drainage, serial aspirations of pleural or other body fluids
• Pressure dressing
• Bed rest
• Nutrition modification involving a “fat-free” or “low-fat” diet.
2. Use of octreotide injections subcutaneous TID: synthetic somatostatin
analog
• Decreases chyle leak – decreasing absorption of triglycerides
3. Aggressive surgical intervention:
• Chyle fluid loss > 500ml/day for >5-7 days.
• Surgical re-exploration and ligation.

134. Intracranial Pressure:
Rises three times when one IJV is divided and five times when both are tied.
Measures to reduce ICP:
• No constricting dressings around the neck.
• Avoid hyperextension of the neck.
Symptoms of raised ICP :-
• Restlessness and bradycardia
• Raised B.P.
• Facial cyanosis and swelling
Treatment:
Osmotic diuresis using mannitol(i.v.) 200ml

135.  Massive venous and
lymphatic edema of the
face following
simultaneous bilateral
radial neck dissections
and laryngectomy.
 Resolution of facial
edema through
prevertebral venous
collaterals 3 months after
surgery.

136.  Chronic lymphedema of the
face with thickening of the
subdermal plane and
cutaneous telangiectasia
after bilateral radical neck
dissections.

137. Shoulder dysfunction and Pain
 Associated with RND
 Nahum 1961, described it as Shoulder Syndrome-
 Pain in shoulder,
 Limited Abduction of shoulder,
 Anatomic deformities such as scapular flaring,
 Shoulder droop and protraction,
 Abnormal electromyograms of trapezius
 If this nerve is resected, then:
1. Immediate intra-operative preservation of C2,C3 and C4
branches.
2. Primary anastomosis of nerve endings or cable grafting-

138. Cranial Nerve Injury
 Hypoglossal nerve is vulnerable to injury as it
crosses the occipital artery, superficial to external
carotid artery and lingual arteries
 Injury of hypoglossal nerve can lead to ipsilateral
tongue paralysis, interference with elevation and
depression of larynx (swallowing mechanism).
 Injury to marginal mandibular branch of facial
nerve can lead to significant deformity of lower
lip.

139. Carotid Artery Rupture
 Carries a high mortality rate 18 – 50%.
 Chances of occurrence - 3%.
 Heller and Strong found 56 of 63 (88%) patients
with carotid artery hemorrhage had previously
received radiation therapy.
 Radiation therapy has been demonstrated to
cause premature artherosclerotic changes in
large arteries progressive weakening of the
vessel walls and thinning of the vessel media and
fibrosis of the adventitia.

140. Recent Advancements
 In recent years, advances in
oncologic surgery has made
remarkable progress to
improve functional outcome
in oncologic safety.
 Endoscopic, robot-assisted
procedures and navigation
surgeries have made a
considerable contribution by
facilitating less and even
minimal invasive approaches.
141

141.  Robot-assisted procedures :
 Advantages: It affords better visualization and
access to tumors via a minimally invasive, less
morbid approach.
 Technically feasible to gain access to the oral cavity,
oropharynx, hypopharynx, supraglottis and glottis.
 Reduced total operative time.
 Disadvantages: High initial costs, costs of
(disposable) instruments.
 Increased setup time
 Weinstein et al. report on 27 patients who were
treated using Robotic Surgery for carcinomas. In
93% of the patients, negative margins were
obtained.
142

142. Endoscopic neck Dissection
 In 2001, Dulguerov et al.
performed ten endoscopic
neck dissections on five
human cadavers and found
that the majority of neck
lymph nodes can be
removed by this approach.
 This method may help to
reduce the degree of
invasiveness frequently
attributed to sentinel
lymphadenectomy once it
has been established for
head and neck cancer.
Dulguerov P, Leuchter I, Szalay‐Quinodoz I, Allal AS, Marchal F, Lehmann
W, Fasel JH. Endoscopic neck dissection in human cadavers. The
Laryngoscope. 2001 Dec;111(12):2135-9.
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143. Thank you
144