and Neck Carcinoma Chul-Ho Kim, MD. Ph.D Level I : submental submandibular(6) Level II : upper jugular Level III : Mid jugular Level IV : lower jugular Level V : posterior Level VI : central neck Level VII : upper mediastinal IIb IIa Levels of the Neck (1998, T. Robbins) VI Ib Ia III IVb IVa Va Vb VII SAN IJV SCM Radical Neck Dissection ( RND ) 1. Spinal accessory nerve 2. Internal jugular vein 3. Sternocleidomastoid m. Modified RND ( mRND ) Type I SAN II SAN + IJV III SAN + IJV + SCM ( = FND ) Classification of Neck Dissection AAO-HNS(1991) Medinas modification(1989) Radical ND Comprehensive neck dissection Modifed RND(I, II, III) Radical ND Selective ND Modified RND Supraomohyoid Type I(CN XI) Lateral Type II( + IJV) Posterolateral Type III(+ SCM) Anterior compartment Selective ND Extended RND Definition All lymph nodes in Levels I-V including spinal accessory nerve (SAN), SCM, and IJV Indications Extensive cervical involvement or matted lymph nodes with gross extracapsular spread and invasion into the SAN, IJV, or SCM Radical Neck Dissection Modified Radical Neck Dissection (MRND) Definition Excision of same lymph node bearing regions as RND with preservation of one or more non-lymphatic structures (SAN, SCM, IJV) Spared structure specifically named MRND is analogous to the functional neck dissection described by Bocca 2 Modified Radical Neck Dissection Three types (Medina 1989) commonly referred to not specifically named by committee. Type I: Preservation of SAN Type II: Preservation of SAN and IJV Type III: Preservation of SAN, IJV, and SCM ( Functional neck dissection) Modified Radical Neck Dissection Rationale Reduce postsurgical shoulder pain and shoulder dysfunction Improve cosmetic outcome Reduce likelihood of bilateral IJV resection Contralateral neck involvement MRND Type I Indications Clinically obvious lymph node metastases SAN not involved by tumor Intraoperative decision Rationale RND vs MRND Type I: Actuarial 5-year survival and neck failure rates for RND (63% and 12%) not statistically different compared to MRND I (71% and 12%) (Andersen) No difference in pattern of neck failure MRND Type II Indications Rarely planned Intraoperative tumor found adherent to the SCM, but not IJV and SAN MRND TYPE III Rationale Suarez (1963) necropsy and surgery specimens of larynx and hypopharynx lymph nodes do not share the same adventitia as adjacent BVs Nodes not within muscular aponeurosis or glandular capsule (submandibular gland) Sharpe (1981) showed ) 0% involvement of the SCM in 98 RND specimens despite 73 have nodal metastases Survival approximates MRND Type I assuming IJV, and SCM not involved CND : 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 CommandB 3 Boundaries - hyoid - suprasternal notch - medial border of carotid sheath Indications Selected cases of thyroid carcinoma Parathyroid carcinoma Subglottic carcinoma Laryngeal carcinoma with subglottic extension CA of the cervical esophagus CND: Anterior Compartment 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 usually preserved Extended Neck Dissection 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. A. Preoperative considerations 1. Planning of operation 1) Thorough knowledge of patients history 2) Understanding of the extent of disease 3) Awareness of relevant laboratory and radiologic data 4) Discussion with the patient about what to expect and possible contingencies ; essential to a smooth course through the operative and postoperative periods 2. Airway 1) Awake tracheotomy under local anesthesia in compromised airway 2) Awake intubation in less tenuous airway 3) Tracheotomy C Routine unilateral RND or bilateral MND : not always necessary C Bilateral RND : protective tracheotomy should be performed 3. Skin injection - Best to inject the proposed skin incision with epinephrine - Most conveniently done with a mixture of local anesthetics (Xylocaine) - 10-15 minutes should be allowed to attain maximum benefits 4. Skin marking - methylene blue - Gentian violet - Tip of 23G needle punctures the skin edges opposite one another 4 5. Location of tracheotomy or other incisions - Incorporation or not - entirely depends on the incision types used - Any neck incisions used for previous biopsy should be incorporated 6. Perioperative antibiotics - If RND is included as part of an operation in which upper aerodigestive tract is open - Appropriate antibiotic coverage for G(+), anaerobic and possibly G(-) bacteria - In case of RND alone, no evidence that antibiotics prophylaxis is advantageous - Broad-spectrum antibiotics at least until the drains are removed B. Considerations in selection of incision 1.Provide appropriate exposure to underlying compartment - L/N groups targeted for removal - the possibility of performing a bilateral neck dissection - Surgical exposure for removing cancer of the primary site B. Considerations in selection of incision 2. Minimize wound complication - Protect the carotid artery CNo long vertical segments directly over the carotid CNo trifurcation directly over the carotid - Avoid devascularizing portions of any skin flaps 3.Optimize aesthetic results - natual skin crease, curvilinear incision, minimizing the use of T-shaped and/or Y-shaped incision C. Skin flap elevation - Subplatysmal layer - Traction and counter-traction - Hemostasis - Care to be in the proper surgical plane superoposteriorly and at the midline where platysma is absent 1. Superiorly up to inferior border of the mandible * Preservation of marginal mandibular nerve C Upward dissection of superficial layer of deep cervical fascia off the capsule of submandibular gland C Careful dissection and suspension by ligatures placed on anterior facial vein : best, especially in oral cavity primary, to remove pre- and post-vascular facial lymph nodes C Postero-superiorly, raise the flap superficial to the aponeurosis over the parotid as in parotidectomy 5 2. Anteriorly to strap muscles and midline 3. Inferiorly to the level of clavicle 4. Posteriorly to the anterior border of trapezius muscle - best by dissection quite superficial to avoid the vertical branch of transverse cervical vein 5. Secure the skin flaps by suturing either to the drapes or to the skin Exposure of Surgical Field 1. Superior dissection 1) Level Ia C Fibrofatty tissues are incised along the anterior belly of contralateral digastric muscle and swept inferoposteriorly from central portion of mylohyoid muscle C Remove pre- & post-vascular facial lymph nodes C Anterior belly of ipsilateral digastric muscle is cleaned, leaving submental contents (Level Ia) attached to submandibular triangle (Level Ib) 2) Level Ib C SMG is elevated from floor of submandibular triangle, facilitating identification of hypoglossal nerve C On inferior traction, soft tissue separation from inferior border of mandible C Anterior traction of posterior border of mylohyoid muscle C Identification of lingual nerve, submandibular ganglion, and postganglionic parasympathetic fibers to the gland 2) Level Ib (contd) C Ganglion is divided between clamps Submandibular duct is divided and tied C Identification, clamping, and division of facial artery by posterior and downward traction of the tissues Level II Tail of parotid gland C Posterior belly of digastric muscle is identified C Division of parotid tail and control of posterior facial vein 6 Level II C Delineation of inferior border of digastric m. C Upward retraction of the belly with Army-Navy C Identification of upper stump of IJV C Cut the proximal end of spinal accessory nerve 1) Division of SCM m. CDelineation of anterior border of trapezius muscle from clavicle upward to its junction with mastoid tip CSCM muscle is divided along the anterior border of trapezius and is freed from its mastoid insertion Division of SCM muscle 1) Dissection of tissue (Level V) 2. Posterior dissection C Four clamps placed on the posterior margin of neck contents anterior to the border of trapezius for traction C Sharp dissection of the tissue from the deep layer of deep cervical fascia : allows preservation of posterior (motor) branch of cervical plexus, thereby preserving innervation to the levator scapulae, splenius capitis, and scalene muscles Trapezius Innervation CN XI : 5 cmfrom clavicle Surgical considerations Posterior limit of Level V neck dissection Denervation results in shoulder drop and winged scapula * * * * 3. Inferior dissection: Level IV 1) Division of SCM muscle C Sternal and clavicular heads divided while placing upward traction on the belly C Cautious incision by layers - paying great attention to the carotid sheath and its contents lying immediately deep to the muscle C Alternately, the muscle can be separated from the underlying carotid sheath by gentle dissection with a blunt Kelly clamp 2) Identification and opening of carotid sheath C Soft tissue overlying sternothyroid muscle is separated from posterior border of the muscle C Medial traction of sternothyroid muscle identification of carotid sheath C Open the sheath with Metzenbaum scissors 7 C Four clamps to the lower aspect of IJV (or 2 inferiorly and 1 superiorly) Cut between middle two clamps C Double ligation with 2-0 silk ties and 3-0 silk suture ligatures or four 2-0 silk ties Care must be taken not to saw through the vein with these ties 4) Dissection of supraclavicular tissue (Levels IV & V) CRetraction with sponge and incision in sequential layers after incision of fascia superficial to clavicle CControl of EJV CDivision of omohyoid m. CExtend from IJV to anterior border of trapezius muscle 3) Internal jugular vein (IJV) C Blunt dissection with blunt Kelly clamps C Avoiding undue forces on IJV preventing severe hemorrhage or air embolism C Exposure of adequate length of IJV to allow easy passage of the clamps C Visual identification of vagus nerve and CCA * Fascial carpet CDissection down to deep layer of deep cervical fascia overlying phrenic nerve, brachial plexus & posterior branches of cervical plexus Continued cephalad traction CPreservation of this fascia prevents injury to the above structures * Thoracic duct on the left neck If injured, clear identification and ligation needed to prevent chylous fistula 1 Tissue pedicle in IJV stump area between phrenic and vagus nerves should always be divided between clamps and tied Thoracic duct 8 C Upward and medially to the level of cervical plexus C Division & ligation of anterior (sensory) branches of cervical plexus : transition from level V to levels II, III, IV C Posterior approach to the carotid sheath - Separating IJV from vagus and carotid - Care not to dissect deep to carotid (cervical sympathetic trunk) Completion of Levels II~V Level II -Roll the specimen forward, clear separation of vagus nerve and carotids (together with Levels III & IV) -Identification of hypoglossal nerve above carotid bifurcation - Control of veins Venae commitantes nervi hypoglossi Lingual vein Veins draining pharyngeal plexus -Division of ansa hypoglossi 3. Anterior dissection - along the undersurface of omohyoid - Up to the level of hyoid bone, at which point anterior belly of omohyoid is divided F. Closure C Meticulous hemostasis C Wound irrigation with sterile saline C Place suction drains through separate stab incisions in the lower flap below clavicle, considering last functioning hole of the catheter C Secure the drains away from the carotid, cranial nerves, and mucosal suture lines C Closure of skin incisions in layers Airtight closure of platysma with absorbable sutures Placement of Suction Drain