Neck Dissection
163
Tyson J. Nielsen and Audrey B. Erman
Indications
• Elective in setting of clinically occult
metastases
–– Selective neck dissection: N0 (no clinical
evidence of nodal metastases) or for very
limited cervical metastases
• Therapeutic in setting of clinical metastases
–– Modified radical neck dissection: cervical
clearance of levels I–V with preservation
of one or more of the following struc-
tures – sternocleidomastoid muscle, spinal
accessory nerve (CN XI), and internal jug-
ular vein
–– Radical neck dissection: extensive cervical
lymph node involvement with extracapsu-
lar spread involving sternocleidomastoid
muscle and/or internal jugular vein and/or
spinal accessory nerve (CN XI)
–– Extended neck dissection: resection of
additional lymphatic groups or nonlym-
phatic structures not included in a modi-
fied/radical neck dissection
T.J. Nielsen, MD • A.B. Erman, MD (*)
Department of Otolaryngology–Head and Neck
Surgery, University of Arizona College of Medicine,
Tucson, AZ, USA
e-mail: aerman@oto.arizona.edu
© Springer Science+Business Media, LLC 2017
J.J. Hoballah et al. (eds.), Operative Dictations in General and Vascular Surgery,
DOI 10.1007/978-3-319-44797-1_163
Nodal Levels
• Level I
–– Level Ia (submental triangle) – bounded by
anterior bellies of the bilateral digastric mus-
cles and deeply by the mylohyoid between
the hyoid bone and body of the mandible
–– Level Ib (submandibular triangle) –
bounded by anterior and posterior bellies
of the digastric muscle between the hyoid
bone and body of the mandible
• Level II – bounded by the skull base and hyoid
bone, between the posterior edge of sterno-
cleidomastoid muscle (SCM) and stylohyoid
muscle
–– Transected obliquely by spinal accessory
nerve (CN XI) subdividing into level IIa
(anterior to CN XI) and level IIb (posterior
to CN XI)
• Level III – bounded by hyoid bone and infe-
rior border of cricoid cartilage between ster-
nohyoid muscle and posterior border of SCM
• Level IV – bounded by inferior border of cri-
coid cartilage and clavicle, between sternohy-
oid muscle and posterior border of SCM
• Level V – bounded by posterior border of
SCM and anterior border of trapezius, between
mastoid and clavicle
–– Can be subdivided along a horizontal line
extending from level of cricoid cartilage
into level Va superiorly and level Vb
inferiorly
541
542
• Level VI – bounded laterally by the carotid
arteries, superiorly by the hyoid bone, and
inferiorly by the suprasternal notch
Essential Steps
1. Incision and development of subplatysmal flaps.
2. Identify external jugular vein and greater
auricular nerve (+/− transection).
3. Superior flap is elevated to identify subman-
dibular salivary gland.
4. Submandibular gland fascia incised inferi-
orly to marginal mandibular nerve.
5. Submental triangle (level IA) lymph nodes
resected.
6. Hypoglossal nerve (CN XII) and lingual
nerve identified and preserved.
7. Submandibular duct and vessels ligated (+/−
ligation of facial artery/vein).
8. Submandibular triangle (Level IB) lymph
nodes and gland resected.
9. External jugular vein ligated.
10. Identify and preserve spinal accessory nerve
(CN XI).
11. Level IIa/IIb lymph nodes resected.
12. Carotid sheath identified and preserved.
13. Level III lymph nodes resected.
14. Level IV lymph nodes resected.
15. Closure.
Note These Variations
• A variety of incisions have been described –
the skin crease incision described here is the
most common.
• Resection of sternocleidomastoid, internal
jugular vein, and spinal accessory nerve.
• Drain placement.
• Repeat steps 6–14 on opposite side for bilat-
eral neck dissection (avoid bilateral internal
jugular vein ligation).
Complications
• Failure of incision to heal properly resulting in
exposure of carotid artery
T.J. Nielsen and A.B. Erman
• Post-op bleeding, resulting in tracheal com-
pression and airway obstruction
• Marginal mandibular, spinal accessory, hypo-
glossal, and/or lingual nerve injury
• Loss of cutaneous sensation in distribution of
cervical plexus
• Injury to thoracic duct or other lymphatic
structures and subsequent chyle leak
Template of Operative Dictation
Preoperative Diagnosis  Metastatic squamous
cell carcinoma/malignant melanoma/thyroid
cancer
Procedure  Anterolateral neck dissection
(selective)
Postoperative Diagnosis  Same
Indications  This ___-year-old male/female was
noted to have cervical lymphadenopathy in the
setting of squamous cell carcinoma/malignant
melanoma/thyroid cancer on work-up. Selective
anterolateral neck dissection is indicated.
Description of Procedure  Time-outs were per-
formed using both preinduction and pre-incision
safety checklists to verify correct patient, proce-
dure, site, and additional critical information prior
to beginning the procedure. Following induction
of general anesthesia, both arms were tucked at the
sides and all bony prominences were padded. A
roll was placed under the shoulders and the patient
was positioned with the neck extended. The neck
was prepped and draped in a sterile fashion.
A ___-cm incision was made in a skin crease
positioned approximately at the level of the hyoid
bone. The subcutaneous tissues and platysma
were divided with identification of the external
jugular vein and greater auricular nerve (+/−
transection). Superiorly, subplatysmal flaps were
then raised to the level of the submandibular
glands with the fascia overlying the gland incised
on the inferior portion of the gland to preserve the
marginal mandibular branch of the facial nerve
within the elevated flap. Inferiorly, subplatysmal
163  Neck Dissection
flaps were elevated to expose the superior border
of the clavicle.
Level Ia (submental triangle) was then
resected using electrocautery from between the
body of the mandible and the level of the hyoid
bone beginning at the contralateral anterior
belly of the digastric muscle and proceeding to
the ipsilateral anterior belly of the digastric
muscle with the mylohyoid muscle serving as
the deep boundary. After elevating the fascia
covering the submandibular gland to preserve
the marginal mandibular branch of the facial
nerve and identifying the facial artery and vein
with blunt dissection, the submandibular trian-
gle (level Ib) was resected from between the
anterior and posterior bellies of the digastric
muscle with the mylohyoid muscle again serv-
ing as the deep boundary. The mylohyoid mus-
cle was then retracted anteriorly, and the lingual
nerve, submandibular duct, and hypoglossal
nerve (CN XII) were then identified. The sub-
mandibular duct was then clamped and ligated
taking care to preserve the lingual nerve.
Next the external jugular vein was divided and
ligated with 3-0 silk suture. The fascia overlying
the posterior belly of the digastric muscle was
divided up to the anterior border of the SCM. The
fascia surrounding the SCM was then dissected
with identification and preservation of the spinal
accessory nerve (CN XI). Levels IIa and IIb were
then resected away from posterior edge of the
SCM with the scalene muscles of the neck serv-
ing as the deep boundary.
Dissection continued along posterior edge of
sternocleidomastoid muscle into level III and
subsequently into level IV. The carotid sheath
was then identified and preserved with anterior
traction placed on level II/III/IV specimen with
lymph node contents from level II/III/IV care-
fully dissected en bloc off of carotid sheath using
a scalpel with the superior border of the clavicle
serving as the inferior border for completion of
level IV dissection.
If bilateral neck dissection is indicated:
Process repeated on opposite side of the neck
beginning with resection of submandibular trian-
543
gle (level IB) contents and proceeding to remove
lymph nodes from levels II, III, and IV.
If a modified radical neck dissection is per-
formed: A modified type __ (I/II/III) neck dissection
was performed by removing the lymphatic tissue
from levels I–V including resection/preservation of
the__(sternocleidomastoid/spinal  accessory
nerve/internal jugular vein), extending laterally to
the anterior border of the trapezius, inferiorly to the
clavicle, and superiorly to the body of the
mandible/mastoid tip.
If a radical neck dissection is performed: A
radical neck dissection was performed by remov-
ing the lymphatic tissue from levels I–V including
resection of the __ (sternocleidomastoid/spinal
accessory nerve/internal jugular vein), extending
laterally to the anterior border of the trapezius,
inferiorly to the clavicle, and superiorly to the
body of the mandible/mastoid tip.
If an extended neck dissection is performed:
A modified/radical neck dissection was per-
formed removing the lymphatic tissue from levels
I–V including resection/preservation of the __
(sternocleidomastoid/spinal accessory nerve/
internal jugular vein), extending laterally to the
anterior border of the trapezius, inferiorly to the
clavicle, and superiorly to the body of the
mandible/mastoid tip along with resection of __
(additional lymphatic groups or nonlymphatic
structures).
All specimens were submitted to pathology.
A Valsalva maneuver was performed with no
evidence of chyle leak. A drain was placed deep
to the SCM exiting the neck laterally and a sec-
ond drain was placed medially deep to platysmal
flaps. The wound was copiously irrigated and
hemostasis was achieved. The platysma and der-
mis were re-approximated with interrupted 3-0
Vicryl sutures. The skin was re-approximated
with staples/sutures. Bacitracin was placed over
the length of the incision. A debriefing checklist
was completed to share information critical to
postoperative care of the patient. The patient tol-
erated the procedure well, was extubated, and
was taken to the postanesthesia care unit in sta-
ble condition.