Special Surgical Procedures II
LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery
Section IV: THROAT, TONGUE, AND NECK SURGERY
1-45
1-45. RADICAL NECK DISSECTION
a. General. This operation involves the removal of a tumor, surrounding structures, and lymph nodes en massa, through a Y-shaped or trifurcate incision in the affected side of the neck. It is done to remove the tumor and metastatic cervical nodes present in malignant lesions and all nonvital structures of the neck. Metastasis occurs through the lymphatic channels via the bloodstream. Disease of the oral cavity, lips,
and thyroid gland may spread slowly to the neck. Radical neck surgery is done in the presence of cervical node metastasis from a cancer of the head and neck, which has a reasonable chance of being controlled. It may also be done in a slightly less radical form when there is cancer of the tongue and no firm evidence of metastasis.
b. Preparation of the Patient.
(1) The patient is placed on the table in a dorsal recumbent position, with the head in moderate extension and the entire affected side of the face and neck facing uppermost. During surgery, the face of the patient is turned away from the surgeon.
(2) The preoperative skin preparation is extensive. The patient is draped with sterile towels and sheets, leaving a wide operative field. Endotracheal anesthesia is used. The anesthetic is administered before the patient is positioned for surgery. During the operation, the anesthesiologist works behind the sterile barrier, away from the surgical team.
c. Operative Procedure.
(1) One of several types of incisions may be used, including the Y-shaped, H-shaped, or trifurcate incision.
(2) The upper curved incision is made through the skin and platysma, using a knife, tissue forceps, and fine hemostats and ligatures for bleeding vessels. The upper flap is retracted; then the vertical portion of the incision is made and the skin flaps retracted anteriorly and posteriorly with retractors. The anterior margin of the trapezius muscle is exposed by means of curved scissors. The flaps are retracted to expose the entire lateral aspect of the neck. Branches of the jugular veins are clamped, ligated, and divided.
(3) The sternal and clavicular attachments of the sternocleidomastoid muscle are clamped with curved Rochester-Mayo clamps and then divided with a knife. The superficial layer of deep fascia is then incised. The omohyoid muscle is severed between clamps just above its scapular attachment.
(4) The internal jugular vein is isolated by blunt dissection and then doubly clamped, ligated with medium silk, and divided with Metzenbaum scissors. A transfixion suture is placed on the lower end of the vein.
(5) The common carotid artery and vagus nerve are identified. The fatty areolar tissue and fascia are dissected away, using Metzenbaum scissors and fine tissue forceps. Branches of the thyrocervical artery are clamped, divided, and ligated.
(6) The tissue and fascia of the posterior triangle are dissected, beginning at the anterior margin of the trapezius muscle, continuing near the brachial plexus and the levator scapulae and the scalene muscles. During the dissection, branches of the cervical and suprascapular arteries are clamped, ligated, and divided.
(7) The anterior portion of the block dissection is completed. The omohyoid muscle is severed at its attachment to the hyoid bone. Bleeding is controlled. All hemostats are removed, and the operative site is covered with warm, moist laparotomy packs.
(8) The sternocleidomastoid muscle is severed and retracted. The submental space is dissected free of fatty areolar tissue and lymph nodes from above downward.
(9) The deep fascia on the lower free edge of the mandible is incised; the facial vessels are divided and ligated.
(10) The submaxillary triangle is entered. The submaxillary duct is divided and ligated. The glands with surrounding fatty areolar tissue and lymph nodes are dissected toward the digastric muscle. The facial branch of the external carotid artery is divided. Portions of the digastric and stylohyoid muscles are severed from their attachments to the hyoid bone and on the mastoid. The upper end of the internal jugular vein is elevated and divided. The surgical specimen is removed.
(11) The entire field is examined for bleeding and then irrigated with warm saline solution. Penrose drains are placed in the wound and brought out through a stab wound, and #12 Fr catheters may be used.
(12) The flaps are then approximated with interrupted fine silk sutures. A bulky pressure dressing is applied to the neck. Gauze dressings are applied to the wound edges and covered with sterile fluffed gauze to provide even pressure. A wide gauze roller bandage is wrapped snugly around the neck and in some cases encircles the head. The dressing may then be covered with elastic bandage that is wrapped around the neck and anchored to the chest wall.
