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Description of Operative Technique
Bocca, MD; Oreste Pignataro, MD; Clarence T. Sasaki, MD
\s=b\ The operative technique involved in functional neck dissection is described to clarify its stepwise execution. Recent interest in functional preservation demands therapeutic techniques that are oncologically reliable but not mutilating. The functional neck dissection seems to be a reasonable alternative to radical radiotherapy and a preferred alternative to traditional neck dissection in the control of regional metastasis when disease in the neck is either occult or still confined to mobile lymph nodes.
routine, radical removal of struc¬ by nodal disease remained largely unchallenged for
(Arch Otolaryngol 106:524-527, 1980)
neck dissection, first described by Crile1 in 1906, is a destructive procedure designed to remove tumor-bearing lymph nodes of the neck. In an attempt to remove the lymphatics as completely as possi¬ ble, traditional neck dissection in¬ cluded removal of the submaxillary salivary gland, internal jugular vein, greater auricular and spinal accessory nerves, as well as digastric, stylohyoid, and sternomastoid muscles.
for publication Oct 16, 1979. From the Otorhinolaryngology Clinic, Univerof Milan, Milan, Italy (Drs Bocca and Pignasity taro), and the Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Conn (Dr Sasaki). Reprint requests to Department of Surgery, 333 Cedar St, New Haven, CT 06510 (Dr Sasa-
despite the anatomic and func¬ tional deformities it produced. In 1953, Pietrantoni,2 a strong advo¬ cate of bilateral elective neck dissec¬ tion, recommended sparing the spinal accessory nerves and at least one internal jugular vein. This break with surgical tradition was first limited to elective neck dissections, but was later extended to therapeutic dissections when lymph nodes were enlarged but still mobile. On the basis of the anatomic and surgical contributions of Suarez,1 Boc¬ ca,4 in 1966, modified the traditional neck dissection, radically revising those concepts historically identified with the surgical treatment of region¬ al metastasis. A staunch opponent of conservative nodal stripping, Bocca5 indicated the complete effectiveness of his surgical technique, which he described in the Semon Lecture to the Royal Society of Medicine in 1975. He called this technique the functional neck dissection, a procedure that made no concession to oncologie radicality and that was based on sound anatomic and surgical concepts. The anatomic basis for functional neck dissection has been described in great detail by others and therefore will not be repeated. The purpose of
clarify the operative technique concerning the procedure, which originated with Boc¬ ca in Europe and which promises to become a preferred alternative to the
classical neck dissection or radical radiotherapy when regional metasta¬ sis is either strongly suspected or con¬ fined within palpable lymph nodes of the neck.
The total operative time for a unilateral neck dissection varies from one to two hours. 1. In bilateral neck dissection, a superi¬ orly based apron flap is preferred, whereas a hockey-stick skin incision may be used when neck dissection is unilateral. 2. By raising skin flaps that include the platysma muscle, generous exposure of the cervical structures is obtained (Fig 1). Care is taken to preserve the greater auricular and marginal mandibular nerves. The point at which the greater auricular nerve emerges from behind the sternomastoid muscle (Erb's point) is an important land¬ mark (arrow in Fig 1) because it indicates the superior extent of the supraclavicular dissection to be accomplished later. The external jugular vein is temporarily pre¬ served along its entire course, as is the superficial cervical fascia enveloping the sternomastoid muscle. 3. The external jugular vein is ligated and divided superiorly (Fig 2). The superfi¬ cial cervical fascia is now cut along the posterior border of the sternomastoid mus-
this communication is to
Downloaded from www.archoto.com at Washington University - St Louis, on July 5, 2010
Inspection of the space medial to the sary to avoid venous trifurcation is neces¬ venous missing disease. exposing the spinal accessory nerve as it crosses the lateral cervical space to enter the sternomastoid muscle (Fig 4). best accomplished with a needle-tipped electrocautery." External jugular vein is divided superiorly and left attached to contents of supraclavicular fossa. The occipital artery. 5. is dissected anteriorly as muscle is "unwrapped. care should be taken to identify and avoid injuring the internal jugular vein at this level. External jugular vein (EJ) and superfi¬ cial cervical fascia overlying sternomastoid muscle (SM) are temporarily preserved. including the exter¬ nal jugular vein. By upward retraction of the mandibu¬ lar angle and posterior retraction of the sternomastoid muscle superiorly. 8.com at Washington University . cervical fascia is cut along posterior border of sternomastoid muscle and. By forward retraction on the cut edge of the fascia. Superiorly in the neck. Note position of Erb's point (arrowhead). in close approximation to the acces¬ sory nerve. the sternomastoid is "un¬ wrapped. nodal tissue may be freed from the submaxillary gland and lower pole of the parotid. 15 blade. posteroinferiorly. The supraclavicular tissue. With the electrocau¬ tery turned to a low setting. Anterior and medial to the accessory nerve. which forms the deep or medial extent of this dissection. 6.—Superficial Downloaded from www. injury to the nerve has never occurred." Minor bleeding from the muscle belly is controlled by electrocoagulation.ele. By downward retrac¬ tion on this fascia.archoto. Attention is now turned to the superior limit of the operative field. limited posteriorly by the trapezius muscle and inferiorly by the clavicle. meticulous dis¬ section of potential node-bearing tissue is carefully accomplished from around the thyro-lingual-facial venous trunk (Fig 6. to protect this portion of the accessory nerve. 2010 . Dissection with the electrocautery needle minimizes bleeding and facilitates identification of the accessory nerve. black arrow). fascia is stripped from the digastric and stylohyoid muscles.St Louis. The superficial cervical fascia is cut along the lower border of the submaxillary fossa against the lateral surface of the submaxil¬ lary gland. The phrenic nerve and thoracic duct are care¬ fully preserved as the contents of the supraclavicular fossa. This dissection. Care must be taken to avoid injury to greater auricular (GA) and marginal mandibular (MM) nerves. with No. The superficial cervical fascia is now dissected from the posterior border of the sternomastoid muscle (Fig 5). should be avoided if possible. Potential node-bearing tissue and fascia surrounding the nerve is metic¬ ulously dissected from the nerve trunk and slipped under it. are delivered anteriorly under the belly of the sternomastoid mus¬ cle (Fig 5). Dissec¬ tion of the supraclavicular fossa is carried superiorly only as far as Erb's point. 7. preserving the marginal man¬ dibular nerve (Fig 3). 4. is carried medially to the levator scapulae muscle. is dissected medially up to the brachial plexus of nerves that rests on the prevertebral muscles. The Fig 1 —Skin flaps are raised deep to platysma muscle. Retracting this muscle anteriorly will expose the direc¬ tion of the accessory nerve as it enters the trapezius muscle. The divided external jugular vein will now form the apex of the supraclavicular fossa dissection to which it remains attached. tissue overly- ing it is incised longitudinally along its direction. Inadvertent injury to this artery causes unnecessary bleeding that may obscure identification of the nerve. To free the accessory nerve. on July 5. Fig 2.
St Louis. 9.archoto. Potential lymph-bearing tissue is dissected from submaxillary salivary gland (SG) and lower pole of parotid gland (PG). This dissected block of tissue. 2010 . of 367 Fig 3.5 the effective¬ ness of functional neck dissection is favorably compared to traditional neck dissection in a report from the to tional neck dissection. should be avoided. This fascia is now cut along lower border of submaxillary fossa against lateral surface of submaxil¬ lary gland. A good deal of importance is placed on meticulous dissection around this nerve. across clavicle inferiorly. nerve is identified by strong upward retraction on mandible and posterosuperior retraction of sterno¬ mastoid muscle. is delivered anteriorly deep to sternomastoid muscle. Contents of supraclavicular fossa are dissected from trapezius muscle posteriorly. lymph-bearing tissues from the lateral COMMENT Otorhinolaryngology Clinic of Milan. resulting in complete removal of all aspect of the neck (Fig 7). surrounding fascia and soft tissue is passed anteriorly beneath nerve trunk. Care must be taken to identify internal jugular vein.trifurcation may be resected if nodes medial to this venous trunk are suspected to contain metastatic tumor. on July 5. whereas 44% of those with Nl-2 dis¬ ease (mobile nodes) survived five years. marked superiorly by Erb's point. passing in close proximity to accessory nerve. Italy. care must be taken to preserve the phrenic nerve and thoracic duct low in the neck. located anterior to accessory Fig 4. 70% of those with NO disease survived five years.—Superficial cervical fascia is dissected from medial sur¬ face of sternomastoid muscle. in 1975. Of 403 patients with laryngeal cancer treated by tradi¬ According Bocca. Fig 5. Final dissection from these large vessels is easily accom¬ plished. Tissue overlying nerve is incised along its direction. As this dissection proceeds anteriorly. Occipital artery. The specimen. remains at¬ tached to the internal jugular vein and carotid artery (Fig 6). brachial plexus (BP) overlying prevertebral muscles.com at Washington University . and inferiorly. now freed superiorly.—Superficial cervical fascia is now dissected from posterior border of sternomastoid muscle. and deep to. such that the deep margin of this compartment is cleaned to the levator scapulae muscle.—Spinal accessory nerve. posteriorly. On the other hand. As nerve is freed. protecting marginal mandibular nerve. Downloaded from www. but not including.
Pietrantoni L: Il problema chirurgico delle metastasi linfoghiandolari del cancro della laringe. Bocca E: Supraglottic laryngectomy and functional neck dissection.—Careful dissection of fascia from internal jugular vein (IJ) and carotid artery (CA) is accomplished. No pa¬ tient received adjuvant radiotherapy. advantages: 1. therefore. 2. or space behind it is carefully inspected for possible nodal disease (black arrow).com at Washington University . 1953. Sternomastoid (SM) and omohyoid (OH) muscles remain intact. 1906. tion. and itself containing the major cervical lymphatics. paying specific attention to thyro-lingual-facial venous trifurcation high in neck. skel- opinion that N3 disease (fixed nodes) represents an absolute our It is Downloaded from www. it is a complete dissec¬ tion of the lateral cervical space. previous radia¬ tion to the neck is not considered a contraindication to this procedure. limitations of neck and limb motion. Indeed. and widespread cutaneous cranially. JAMA 47:1780-1786. vessels. It is hoped that the essential points of this technique have been adequate¬ ly described at a time when increasing interest in functional preservation is both demanded by the patient and required by the physician.archoto. However. 4. 2. This trifurcation is either divided and included in neck specimen. with¬ out resorting to the mutilation of tra¬ contraindication to functional neck dissection. 1966. when the preferred treatment of the primary tumor is surgical. Fig 7. suppl 14. Arch Ital Otol Rinol Laryngol 4:151-158. When the preferred treatment of the primary tumor requires combined surgery and radiation. Crile G: Excision of cancer of the head and neck. 3. References 1. 3. that functional neck dissection fulfilled the require¬ ments of oncologie safety while avoid¬ ing unnecessary mutilation. and muscle does not appear to compromise onco¬ logie safety. 2010 . carotid artery (CA). Suarez O: El problema de las metastasis linfaticas y alejadas del cancer de laringe e hipofaringe. Such a favorable comparison would indicate. patients treated by functional neck dissection. Bocca E: Critical analysis of the techniques and value of neck dissection. This study was supported by a grant to Dr Sasaki from the International Union Against Cancer. Functional preservation of the neck presents undeniable anesthesia. 1976. Bilateral dissection may be per¬ formed simultaneously without dan¬ ger of abrupt venous congestion intra- pain. Rather. 1963.St Louis. on July 5.Fig 6. it may alter the man¬ ner in which adjuvant radiation is delivered in patients with Nl-2 dis¬ ease.5 The preservation of major nerves. internal jugular vein (IJ). It should be apparent that function¬ al neck dissection has nothing in com¬ mon with the mere stripping of lymph nodes. It provides a reasonable alterna¬ tive to radical radiotherapy of the neck. Thus. Arch Ital Otol. 4. ana¬ tomically confined by a fasciai enve¬ lope. as well as phrenic nerve and brachial plexus (BP). vagus and sympa¬ thetic nerves. functional neck dissection may alter the decision for neck irradiation in patients with NO disease. It avoids unjustified conse¬ quences of the traditional neck dissec¬ ditional neck dissection. Rev Otorrinolaryngol Santiago 23:83-99. the untoward biologic consequences of radiation are avoided entirely. 5. including dropped shoulder. J Laryngol 80:831-838.—Completed neck dissection should now have preserved marginal mandibular (MM) and greater auricular (GA) nerves. 89% of patients with NO disease and 48% of patients with Nl-2 étal disease survived five years.