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Neck dissections

  1. 1. NECK DISSECTIONS BY Dr Priyanka Malekar Dept of surgical oncology 24/6/2017
  4. 4. FASCIAL LAYERS OF NECK Superficial cervical fascia - Platysma • Deep cervical fascia – Superficial layer • SCM, strap muscles, trapezius – Middle or Visceral Layer • Thyroid • Trachea • esophagus – Deep layer (also prevertebral fascia) • Vertebral muscles • Phrenic nerve
  5. 5. Superficial Fascia- Platysma • Origin – subcutaneous tissues of infra and supraclavicular regions • Insertion – 1) depression muscles of the corner of the mouth, 2) base of the mandible • Nerve: Cervical branches of fascial nerve • Artery: Submental and suprascapular arteries
  6. 6. Function – 1) wrinkles the the neck 2) depresses the corner of the mouth 3) increases the diameter of the neck 4) assists in venous return Surgical considerations – Increases blood supply to skin flaps – Absent in the midline of the neck – Fibers run in an opposite direction to the SCM
  7. 7. PLATYSMA
  9. 9. DEEP CERVICAL FASCIA • SCM: Origin – 1) medial third of the clavicle (clavicular head) 2) manubrium (sternal head) Insertion – mastoid process Nerve supply – spinal accessory nerve (CN XI) Blood supply – 1) occipital a. or direct from ECA 2) superior thyroid a. 3) transverse cervical a.
  11. 11. • OMOHYOID : • Origin – upper border of the scapula • Insertion – 1) via the intermediate tendon onto the clavicle and first rib 2) hyoid bone lateral to the sternohyoid muscle • Blood supply – Inferior thyroid a. • Function – 1) depress the hyoid 2) tense the deep cervical fascia
  13. 13. • Surgical considerations – Absent in 10% of individuals – Landmark demarcating level III from IV Inferior belly lies superficial to • The brachial plexus • Phrenic nerve • Transverse cervical vessels Superior belly lies superficial to • IJV
  14. 14. • TRAPEZIUS • Origin – 1) medial 1/3 of the sup. Nuchal line 2) external occipital protuberance 3) ligamentum nuchae 4) spinous process of C7 and T1-T12 • Insertion – 1) lateral 1/3 of the clavicle 2) acromion process 3) spine of the scapula • Function – elevate and rotate the scapula and stabilize the shoulder
  15. 15. TRAPEZIUS Surgical considerations – Posterior limit of Level V neck dissection – Denervation results in shoulder drop and winged scapula
  16. 16. • DIGASTRIC MUSCLE • Origin – 1. anterior belly :digastric fossa of the mandible (at the symphyseal border) –(N:- mandibular br) 2. Posterior belly: mastoid process of temporal bone ( N :- fascial N) • Insertion – hyoid bone via the intermediate tendon • Function – 1) Opens the jaw when masseter and temporalis are relaxed
  18. 18. • Surgical consideration Posterior belly is superficial to: • ECA • Hypoglossal nerve • ICA • IJV Anterior belly • Landmark for identification of mylohyoid for dissection of the submandibular triangle
  19. 19. DIVISIONS OF NECK • Anterior triangle • Suprahyoid region: submental triangle submandibular triangle • Infrahyoid region: muscular triangle carotid triangle • Posterior triangle
  20. 20. Suprahyoid triangle Submental triangle • Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone • Covered by skin, superficial fascia and investing fascia • Floor-mylohyoid muscles • Contents-submental lymph nodes
  21. 21. digastric (posterior belly) stylohyoid Mylohyoid
  22. 22. Submandibular triangle • Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible • Floor- mylohyoid, hyoglossus and middle constrictor of pharynx • Contents-submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes
  23. 23. • Why we remove submandibular gland in neck dissection?
  24. 24. • Level I of neck includes pre- glandular and post glandular nodes and pre – post vascular LN • Submandibular gland has no intraparenchymal LN • Tumour involvement in the submandibular gland must be through extension from locally involved LN or primary tumour. • Cases has been reported for preservation of submandibular gland in early stage lower lip carcinomas
  25. 25. Infrahyoid triangles Carotid triangle sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles • Floor-prevertebral fascia and lateral wall of pharynx • Contents-common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes
  26. 26. Muscular triangle • Bounded by midline of the neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid. • Floor-prevertebral fascia • Contents-sternohyoid, sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus
  27. 27. Lateral regions of neck • Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle • Divided by inferior belly of omohyoid into occipital and supraclavicular triangles
  28. 28. contents Arteries: 1. Subclavian (3rd part) 2. Superficial cervical & suprascapular (branches of thyrocervical trunk, a branch of 1st part of subclavian artery 3. Occipital, a branch of external carotid artery
  29. 29. Nerves:  Branches of cervical plexus  Spinal part of accessory nerve  Brachial plexus
  30. 30. Occipital triangle • Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid • Floor-prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae • Contents – Accessory n.emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius – Cervical and brachial PLEXUS
  31. 31. Supraclavicular triangle • Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle • Floor-prevertebral fascia and inferior parts of scalenus • Contents – Subclavian v. and venous angle – Subclavian a. – Brachial plexus
  32. 32. Marginal mandibular nerve • Most commonly injured dissection level Ib • Landmarks: – 1cm anterior and inferior to angle of mandible – Mandibular notch • Subplatysmal • Deep to fascia of the submandibular gland • Superficial to facial vein • It lowers lip & corner of mouth down and laterally
  33. 33. Hypoglossal nerve • Motor nerve to the tongue • • Cell bodies are in the Hypoglossal nucleus of the • Medulla oblongata • • Exits the skull via the hypoglossal canal • • Lies deep to the IJV, ICA, CN IX, X, and XI • Iatrogenic injury Most common site - floor of the submandibular triangle, just deep to the duct
  34. 34. Spinal accessory nerve • Penetrates deep surface of the SCM • Exits posterior surface of SCM deep to Erb’s point • Traverses the posterior triangle on the levator scapulae • Enters the trapezius about 5 cm above the clavicle Hypoglossal N Vagus N Spinal Acc N
  35. 35. CN XI – Relationship with the IJV Crosses the IJV • Crosses lateral to the transverse process of the atlas • Occipital artery crosses the nerve • Descends obliquely in level II (forms Level IIa and IIb
  36. 36. Phrenic nerve • Sole nerve supply to diaphragm • Nerve roots C3-5 • Runs obliquely towards midline on the anterior surface of anterior scalane • Covered by prevertebral fascia • Lies posterior and lateral to carotid sheath Phrenic ner
  37. 37. Lingual nerve
  38. 38. Thoracic duct • Conveys lymph from entire body back to blood • Exception: right side of head & neck, RUE, right lung & right side of heart, and portion of liver • Begins at cisterni chyli • Enters post mediastinum between azygous vein & thoracic aorta • Courses left into neck anterior to vertebral vessels • Enters junction of left subclavian and IJV
  39. 39. Lymph nodes of neck • Developed by Memorial Sloan-Kettering Cancer Center • Ease and uniformity in describing regional nodal involvement in cancer of the head and neck
  40. 40. Positions of neck nodes 1. Submental 2. Submandibular 3. Parotid / tonsilar 4. Preauricular 5. Postauricular 6. Occipital 7. Anterior cervical superficial and deep 8. Supraclavicular 9. Posterior cervical
  41. 41. Level of LN • Ia: submental triangle • Ib: submandibular triangle • II: Base of skull to bifurcation of common carotid A • III: Hyoid bone upto inferior border of cricoid • IV: inferior border of cricoid cartilage to clavicle • V: posterior traignle: below spinal A N and transverse cervical vessels • VI: central compartment • VII: mediastinal LN
  42. 42. The regional lymph node groups draining a specific primary site as first echelon lymph nodes
  43. 43. Regional drainage
  44. 44. Staging of neck • Nx: regional lymph node cannot be assessed • No: no regional lymph nodes • N1: mets in single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE – • N2: 1. N2a: metastasis in single ipsilateral node larger than 3 cm but not larger than 6 cm In GD and ECE- 2. N2b: mets in multiple ipsilateral nodes, none larger than 6 cm in GD ENE – 3. N2c: mets in bil or contralateral LN, none larger than 6 cm in GD
  45. 45. • N3: 1. N3a: mets in a lymph node larger than 6 cm in greatest dimension and ENE – 2. N3b: mets in any nodes with clinically overt ENE +, ENCc Midline nodes: ipsilateral nodes ENCc: defined as invasion of skin, infiltration of musculature, dense tethering or fixation to adjacent structures or cranial nerves, brachial plexus, sympathatic trunk, phrenic nerve invasion with dysfunction Designation of U & L category : positive nodes above the cricoid cartilage : U positive nodes below the cricoid cartilage : L
  46. 46. Classifications of neck dissection • Standardized until 1991 • Academy’s Committee for Head and Neck Surgery and Oncology publicized standard classification system
  47. 47. • Academy’s classification Based on 4 concepts 1) RND is the standard basic procedure for cervical lymphadenectomy against which all other modifications are compared 2) Modifications of the RND which include preservation of any non-lymphatic structures are referred to as modified radical neck dissection (MRND)
  48. 48. • Academy’s classification 3) Any neck dissection that preserves one or more groups or levels of lymph nodes is referred to as a selective neck dissection (SND) 4) An extended neck dissection refers to the removal of additional lymph node groups or non-lymphatic structures relative to the RND
  49. 49. • Academy’s classification(1991) 1) Radical neck dissection (RND) 2) Modified radical neck dissection (MRND) 3) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type 4) Extended radical neck dissection
  50. 50. • Medina classification (1989) – Comprehensive neck dissection • Radical neck dissection • Modified radical neck dissection – Type I (XI preserved) – Type II (XI, IJV preserved) – Type III (XI, IJV, and SCM preserved) – Selective neck dissection
  51. 51. Spiro’s classification – 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 – Selective (3 node levels resected) • SOHND • Jugular dissection (Levels II-IV) • Any other 3 node levels resected – 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: 1. Presence of clinically positive N1, N2a, N2b & N3 nodes 2. Extra nodal spread (including skin involvement) 3. Recurrence after RT treatment 4. Selective neck dissection in No neck where higher risk of micrometastasis
  53. 53. • Contraindications: 1. Uncontrolled primary lesion 2. Involvement of internal / common carotid artery 3. Presence of distant metastasis. 4. Poor anaesthetic risk patient.
  54. 54. Most commonly used neck incision: transverse incision
  55. 55.  TYPES - Criles incision - Apron incision -Half apron incision -Conley incision -Double Y incision -H incision -Macfee incision - Y incision -Modified Schobinger incision -Schobinger
  56. 56. CRILES
  58. 58. Basic needs of neck incisions 1.Good exposure of the neck and primary disease. 2. Ensure viability of the skin flaps. Avoid acute angles 3. Protect carotid artery even in the cases of wound infection. 4. Facilitate reconstruction Example, if pectoral muscle is used a lower limb should be near the clavicle to enable flap accommodation. 5. It should be cosmetically acceptable.
  59. 59. Criles 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
  60. 60. MACFEE
  61. 61. • Hyes Martin: • Disadvantage: • This flap most often gets cyanosed. • Flap necrosis and carotid exposure is more in this type of incision. • Apron flaps: • 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
  62. 62. Radical neck dissection • Removes – Nodal groups I-V – SCM, IJV, XI – Submandibular gland, tail of parotid • Preserves – Posterior auricular – Suboccipital – Retropharyngeal – Periparotid – Perifacial – Paratracheal nodes
  63. 63. Modified radical neck dissection • Removes – Nodal groups I-V • Preserves – SCM, IJV, XI (any combination) – TYPE I MRND • Indications – Clinically obvious lymph node metastases – SAN not involved by tumor –Intraoperative decision – Spinal acc N
  64. 64. Spinal ACC N IJV TYPE II MRND Spinal Acc N SCM IJV TYPE II MRND Rarely planned – Intraoperative tumor found adherent to the SCM, but not IJV and SAN Nodes not within muscular aponeurosis or glandular capsule (submandibular gland) NO neck ( functional neck dissection)
  65. 65. Selective neck dissection • Definition – Cervical lymphadenectomy with preservation of one or more lymph node groups – Four common subtypes: • Supraomohyoid neck dissection • Posterolateral neck dissection • Lateral neck dissection • Anterior neck dissection
  66. 66. • Also known as an elective neck dissection • Rate of occult metastasis in clinically negative neck 20-30% • Indication: primary lesion with 20% or greater risk of occult metastasis
  67. 67. supraomohyoid Most commonly performed SND • Definition – En bloc removal of cervical lymph node groups I-III – Posterior limit is the cervical plexus and posterior border of the SCM – Inferior limit is the omohyoid muscle overlying the IJV • Oral cavity cancers with No • T2-T3 No – if intraoperative suspicion of mets at level II – III then level IV clearance: extended SOHND
  68. 68. B/L SOHND • Anterior tongue • Oral tongue and FOM that approach the midline – SOHND + parotidectomy • Cutaneous SCCA of the cheek • Melanoma (Stage I – 1.5 to 4mm) of the cheek
  69. 69. SND lateral type • Definition – En bloc removal of the jugular lymph nodes including Levels II- IV. • Indications N0 neck in carcinomas of the oropharynx, hypopharynx, supraglottis, and larynx
  70. 70. SND posterolateral Definition – En bloc excision of lymph bearing tissues in Levels II-IV and additional node groups – suboccipital and postauricular. • Indications – Cutaneous malignancies • Melanoma • Squamous cell carcinoma • Merkel cell carcinoma – Soft tissue sarcomas of the scalp and neck
  71. 71. SND 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, suprasternal notch and carotid sheaths
  72. 72. • Indications – Selected cases of thyroid carcinoma – Parathyroid carcinoma – Subglottic carcinoma – Laryngeal carcinoma with subglottic extension – CA of the cervical esophagus
  73. 73. Extended 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
  74. 74. • 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.
  76. 76. Intraoperative • Inadvertent injury to local blood vessels and nerves . -marginal mandibular N. - Spinal accessory N. - Cervical plexus - Brachial plexus - Thoracic duct injury .
  77. 77. Immediate post op • Haemorrhage: Needs evaluation of the extent of bleeding and occasionally may need re-exploration. • Lymph leak: When the drainage is of milky fluid and is persistently high >100ml /day after 2days.A possibility of lymph leak has to be considered.
  78. 78. • Carotid blow out: A dreaded complication that occurs secondary to wound break down. If exposed the carotids have to be covered using vascularised flaps. • Facial oedema: A common occurrence usually settles down in 4-6 weeks.
  79. 79. Late complications • Wound infection • Fistulae • Devitalisation of the reconstructed flap DELAYED COMPLICATIONS • Dysphagia ( CN V,IX, X, XI) • Shoulder weakness • Trismus
  80. 80. THANK YOU

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  • Supplies: depressor labii inferioris & depressor anguli oris