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Surgical anatomy and approaches to neck

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Surgical anatomy and approaches to neck

  1. 1. Surgical Anatomy & Approaches To Neck Dr. Sadaf Syed MDS ‘OMFS” Saraswati Dental College Lucknow 2016.
  3. 3. Skin, Superficial Fascia, Platysma
  4. 4. Deep Cervical Fascia Layers A. Investing Layer B. Muscular Pretracheal Layer C. Visceral Pretracheal Layer D. Prevertebral Laye
  5. 5. The Neck And Its Divisions • Anterior triangle • Posterior triangle 2.
  6. 6. Example of a chart
  7. 7. Submental Triangle
  8. 8. Submandibular Triangle
  9. 9. CONTENTS
  10. 10. The base of the submandibular triangle consists mylohyoid and hyoglossus muscles framed by the stylohyoid muscle and the bellies of the digastric muscle. The lingual branch of the trigeminal nerve (V) and the hypoglossal nerve (XII) pass anterior between the two deep flat muscles. The submandibular ganglion lies below the lingual nerve. The marginal mandibular branch of the facial nerve (VII) lies a variable distance below the margin of the mandible and is superficial to the facial vessels. The facial branch of the external carotid artery passes deep to the stylohyoid muscle and posterior belly of the digastric, crosses the submandibular triangle and crosses the inferior margin of the mandible.
  11. 11. Carotid Triangle
  12. 12.  Thyrohyoid  Hyoglossus  Middle & inferior pharyngeal constrictor Borders Floor
  13. 13. Contents
  14. 14. Important Structures of the Carotid Triangle
  15. 15. Muscular Triangle
  16. 16. Posterior Triangle
  17. 17. Muscles
  18. 18. Contents
  19. 19. - Beclards - Pirogoff - Lessers Three nearly forgotten anatomical triangles of the neck: Triangles of Beclard, Lesser and Pirogoff and their potential applications in surgical dissection of the neck R. Shane Tubbs , Surgical and Radiologic Anatomy January 2011, Volume 33, Issue 1, pp 53-57
  20. 20. Cervical Lymph Nodes 3.
  21. 21. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Robbins KT et.al Arch Otolaryngol Head Neck Surg 2002 Jul;128(7):751-8 In addition to the five standard levels , nodal levels were subdivided into  Ia , Ib  IIa , IIb ( below & above Accessory Nerve )  Va , Vb (below & above Accessory Nerve in posterior triangle
  22. 22. Contd... Som PM et al. Imaging-based nodal classification for evaluation of neck metastatic adenopathy. Am J Roentgenol. 2000 Mar;174(3):837-44.
  23. 23. Drainage
  24. 24. Normal layer wise anatomy of the neck
  25. 25. The plane beneath this layer is easily separated from the underlying deep fascia  Facilitates anatomic dissection for thyroid surgery and neck dissection.
  26. 26. The deep cervical fascia splits to encompass the SCM and trapezius muscles, forming a girdle around the neck. The cervical plexus nerves and superficial veins penetrate the deep fascia.
  27. 27. . •The SCM and trapezius comprise the outermost layer of the deep cervical muscles. •The SCM lie superficial to the carotid sheath and are crossed diagonally by the external jugular vein. •Central venous access via the internal jugular vein can be obtained at the posterior border of the mid-portion of the muscle
  28. 28.  The narrow center of the omohyoid muscle crosses the jugular bulb at the base of the neck.  The strap muscles cover the larynx and cervical trachea and depress the laryngeal apparatus.  The neck has the largest concentration of lymph nodes ( internal jugular )
  29. 29.  IJV cross the carotids superficially and diagonally in their course from the jugular foramen at the base of the skull.  Their large common facial branch lies over carotid bifurcation and must be divided to gain access to the latter structure.  IJV converge with the subclavians behind the heads of the clavicles.
  30. 30.  The cervical plexus and brachial plexus nerves emerge between the anterior and middle scalene muscles.  The subclavian artery usually emerges through the same gap caudal to the brachial plexus.  The phrenic nerve descends diagonally across the anterior scalene to enter the chest at the medial border of the first rib.  The spinal accessory nerve descends to the trapezius across the posterior triangle of the neck.
  31. 31. The carotid sheaths containing carotid artery, internal jugular vein and vagus nerve lie in the angle formed by the deep lateral muscles scalene and the visceral compartment. The common carotid bifurcates at about the level of the tip of the hyoid cornu.
  32. 32. Surgical Approaches
  33. 33.  In 1906, George W. Crile of the Cleveland Clinic described the radical neck dissection.The operation encompasses removal of all the lymph nodes on one side along with the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle.  In 1967 - Oscar Suarez and E. Bocca described a more conservative operation which preserves spinal accessory nerve, internal jugular v. and sternocleidomastoid muscle which further improved the quality of life of patients post operatively. History
  34. 34. Radical Neck Dissection is the standard basic procedure for cervical lymphadenetomy and all other procedures represent one or more modifications of this procedure. Modification of the radical neck dissection preserves of one or more non- lymphatic structures, its termed as Modified Radical Neck Dissection Preserves one or more lymph node groups that are routinely removed in the radical neck dissection; the procedure is termed a Selective Neck Dissection Involves removal of additional lymph nodes or non-lymphatic structures relative to RND is termed an Extended Radical Neck Dissection. GENERAL DESCRIPTION
  35. 35. If one or more of three structures, the SCM the internal jugular vein, or the spinal accessory nerve, are spared, the procedure is termed as Modified Neck Dissection. If all three are spared, the procedure is called as Functional Neck Dissection.
  36. 36. Committee For Head & Neck Surgery And Oncology Of American Academy Of Otolaryngology
  37. 37. Medina classification (1989)
  38. 38. – . Classification of neck dissection: variations on a new theme. Spiro R : Am J Sur.1994 Nov;168(5):415-8.
  39. 39. INCISIONS
  40. 40. Modified Schobinger Lateral Utility incision Lahey’s
  41. 41. Hockey-stick incision for neck dissection combined with parotidectomy
  42. 42. Apron flap with lateral extensionsWide apron flap
  43. 43. Conleys incision
  44. 44. Double Y H Incision
  45. 45. MacFee Incision Y incision
  46. 46. Radical Neck Dissection
  47. 47. All tissue between the lower border of the mandible and the clavicle. Between the anterior edge of the trapezius and the anterior midline.  From the underside of the platysma to the deep muscular fascia. The carotids, brachial plexus, phrenic and vagus nerves are normally preserved except when directly invaded
  48. 48. The investing layer of cervical fascia (incorporating sternocleidomastoid and trapezius muscles) is exposed along with jugular vein branches and cervical plexus nerves. The marginal mandibular branch of the facial nerve may or may not be visualized along the edge of the mandible beneath the upper flap.
  49. 49. To preserve the marginal mandibular branch and prevent the corner of the mouth from drooping, the external facial artery and anterior facial vein are divided about a centimeter below the mandible and the upper cut ends tacked to the platysma of the upper flap forming a sling and lifting the nerve out of harm's way.
  50. 50. The insertions of the SCM and the posterior belly of the omohyoid muscle are divided along the upper margin of the clavicle and the investing fascia is opened posteriorly to the trapezius and anteriorly to the midline. Supra clavicular nerves, underlying transverse cervical vessels and external jugular vein are divided and the underlying lymphatic-containing areolar tissue is swept upward. The bulb of the internal jugular vein and the brachial plexus come into view.
  51. 51. The internal jugular vein is divided above the clavicle and the vein reflected upward with the overlying muscles and lymph nodes. It also involves opening the areolar carotid sheath. The underlying vagus and phrenic nerves are identified and preserved. Posteriorly, the investing fascia is opened along the border of the trapezius and the accessory nerve lying on the levator scapulae muscle is divided and reflected upward.
  52. 52. The upper end of the SCM muscle is divided near the mastoid process. The upper end of the accessory nerve and the internal jugular vein are divided as high as possible and lymph nodes are removed The hypoglossal nerve , beneath the posterior belly of the digastric muscle and preserved.
  53. 53. The submandibular gland is mobilized, preserving the lingual nerve and removed
  54. 54. The boundaries of the RND with removal of node-bearing tissue, along with the SCM muscle, the internal jugular vein, and the spinal accessory nerve. The platysma layer and skin are re-approximated, sutured and suction drains placed.
  55. 55. Modified Neck Dissection
  56. 56. In the majority of cases requiring wide lymph node dissection, the modified radical neck dissection is chosen. The area covered by a Modified Neck Dissection is shown.
  57. 57. A modified neck dissection is begun by elevating the skin flaps beneath the platysma anteriorly and posteriorly, exposing the deep cervical fascia, external jugular vein and cervical plexus cutaneous branches.
  58. 58. The deep cervical fascia is incised along the dashed lines, dividing greater auricular nerve and external jugular vein.
  59. 59. The fascia of the submandibular triangle is dissected downward, taking care to stay below the marginal mandibular nerve. The SCM is dissected off the deep layer of investing fascia and retracted posteriorly.
  60. 60. The submandibular gland may be resected in continuity with the specimen in order to include periglandular nodes
  61. 61. The fascia and nodes of level II are dissected from the mastiod downward, exposing the internal jugular vein at the skull base, and the spinal accessory nerve entering the upper part of SCM
  62. 62. Since all 3 structures are preserved, this is a functional neck dissection The SCM is retracted posteriorly, and the nodal tissue of the posterior triangle (level V) is dissected from posterior to anterior, dividing the omohyoid and cervical plexus cutaneous branches.
  63. 63. The lateral neck dissection outlined here includes levels II through IV.
  64. 64. A supraomohyoid dissection includes levels I through III.
  65. 65. THANK YOU
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  68. 68. THE NECK AND ITS DIVISIONS The neck is clinically divided into :
  69. 69. Submandibular Triangle (The Digastric or Submaxillary triang Borders  Anterior and posterior bellies of the digastric mus anteriorly and infero-posteriorly, respectively.  The superior aspect is bordered by the lower bord mandible. Contents
  70. 70. Levels
  71. 71.  Radical neck dissection is the standard basic procedure for cervical lymphadenectomy, and all otherprocedures represent one or more modifications of this procedure.  When the modification of the radical neck dissection involves preservation of one or more non-lymphatic structures, the procedure is termed a modified radical neck dissection  When the modification involves preservation of one or more lymph node groups that are routinely removed in the radical neck dissection; the procedure is termed a selective neck dissection .  When the modification involves removal of additional lymph node groups or non-lymphatic structures relative to the radical neck dissection, the procedure is termed an extended radical neck dissection.