Radical Neck Dissection

Ashok R. Shaha, MD, FACS

T
he most important prognostic factor in the manage-
ment of head and neck cancer is the presence or
absence of cervical node metastasis.
1,2
The presence of
nodal metastasis reduces the survival rate by almost 50%.
Chelius in the mid-19th century said, Once a tumor
metastasizes to the submaxillary gland area the cure is
almost impossible. Appropriate management of cervical
node metastasis is extremely crucial in the overall plan-
ning and treatment of squamous cell carcinoma of the
upper aerodigestive tract. Elective or therapeutic manage-
ment of cervical node metastasis is an integral part in the
care of patients with head and neck cancers, whether the
lymph node metastases are clinically palpable or not. The
overall incidence of microscopic disease in the N0 neck is
20%to 25%, and appropriate consideration must be given
in managing head and neck cancer to the possibility of the
patient having microscopic disease to the lymph nodes in
the neck.
3,4
The standard practice for management of
lymph node metastasis in the neck has been radical neck
dissection for almost 75 years. Interestingly, since 1980
there appears to have been an enormous interest in mod-
ication of radical neck dissection in an effort to preserve
both the vital structures in the neck and to achieve better
functional results.
5-7
It is also important to remember
that, during this period, there was an increasing interest
in routine postoperative radiation therapy in patients
with positive cervical nodes. This article will discuss the
indications, contraindications, and the technique of rad-
ical neck dissection.
HISTORY OF RADICAL NECK
DISSECTION
Even though Chelius approached neck node metastasis as
an incurable situation, in 1880 Theodore Kocher de-
scribed the submandibular triangle dissection along with
removal of tongue cancer and removal of the upper cer-
vical lymph nodes. The classical double trifurcate inci-
sion bears Kochers name (ie, Kocher incision). Butlin in
1900 suggested elective removal of the cervical lymph
nodes; however, it was George Crile who systematically
described the technique of radical neck dissection in
1906. His article is still considered to be one of the land-
mark works in the head and neck literature.
8
He de-
scribed his experience with 132 operations, and advised
removal of the lymph nodes in the neck along with the
sternomastoid muscle, internal jugular vein, and spinal
accessory nerve, and he essentially standardized the tech-
nique of radical neck dissection. Interestingly, in his arti-
cle he mentioned that if the accessory nerve is not directly
involved by the tumor, it might be preserved. Clearly, he
must have given thought to modied neck dissection.
However, truly modied neck dissection was not popu-
larized until Suarez from Argentina and Bocca from Italy
popularized this operation in the mid-1960s and early
1970s.
9,10
Even though several articles have been pub-
lished on the subject of radical neck dissection, the credit
goes to Hayes Martin for describing in detail in 1951 the
step-wise procedure of neck dissection.
11
Later, Oliver
Beahrs from the Mayo Clinic again described in detail the
technique of radical neck dissection. Even though radical
neck dissection was quite popular, head and neck sur-
geons appeared to be quite concerned about the compli-
cations of radical neck dissection, mainly involving
shoulder dysfunction, frozen shoulder syndrome, and
winging of the scapula and massive facial edema with
bilateral neck dissections. Practically, this led to the phi-
losophy of modied neck dissection, along with an un-
derstanding of the patterns of nodal metastasis and com-
partmentalized neck dissection. Oswaldo Suarez was the
rst to describe modied neck dissection.
9
Unfortu-
nately, Suarezs publications were in Spanish; however,
Ettore Bocca, who learned the technique from Suarez,
popularized modied neck dissection in the English lit-
erature. Since then, modied neck dissection has been
essentially the operation of choice for most patients with
metastatic disease in the neck. This clearly is an important
development, which addresses both local control of the
disease in the neck and better functional outcome, espe-
cially the cosmetic and functional outcome related to
shoulder dysfunction.
12-16
Unfortunately, the terms
modied neck dissection and functional neck dissec-
tion led to considerable confusion in the minds of vari-
ous head and neck surgeons. In an effort to standardize
the nomenclature, the American Academy of Otolaryn-
gology Head and Neck Surgery published an article in
Archives of Otolaryngology dividing neck dissection into
the categories of comprehensive and selective.
17
Re-
From the Memorial Sloan-Kettering Cancer Center, New York, NY.
Address reprint requests to Ashok R. Shaha, MD, FACS, Memorial Sloan-
Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.
2004 Elsevier Inc. All rights reserved.
1524-153X/04/0602-0003$30.00/0
doi:10.1053/j.optechgensurg.2004.05.008
72 Operative Techniques in General Surgery, Vol 6, No 2 (June), 2004: pp 72-82
cently, the committee revisited the issues of both nomen-
clature and the levels of lymph node metastasis in the
neck.
18
ANATOMY OF CERVICAL LYMPHATICS
AND PATTERNS OF NODAL METASTASIS
The cervical lymph nodes have been grouped into 5 lev-
els, as described below. Interestingly, this information
came from the Memorial Sloan-Kettering Cancer Center
as early as the 1940s and has been used worldwide. Level
I contains lymph nodes in the submandibular and sub-
mental triangle. The boundaries of level I include the
lower border of the mandible superiorly, the posterior
belly of the digastric muscle posteriorly, and the hyoid
bone inferiorly. Levels II, III, and IV contain upper, mid,
and lower jugular lymph nodes, respectively. Level II
extends from the skull base to the posterior belly of the
digastric muscle and the hyoid bone inferiorly, whereas
level III includes mid jugular lymph nodes with the infe-
rior border being the cricoid cartilage. The lymph nodes
in level IV are essentially supraclavicular lymph nodes
along the jugular vein. These are the lymph nodes that
include the scalene group of lymph nodes popularly
called Virchow nodes. The level V group includes the
posterior triangle lymph nodes behind the sternocleido-
mastoid muscle. Recently, level I, II, and V nodes have
been subclassied into level IA and IB, IIA and IIB, and
VA and VB. Level IA includes submental lymph nodes,
whereas level IB includes submandibular lymph nodes.
Level IIA includes lymph nodes below the accessory
nerve, whereas IIB includes lymph nodes above the acces-
sory nerve. The posterior triangle has been subdivided
into VAand VB, with the dividing line being the accessory
nerve in the posterior triangle. This subdivision is based
on patterns of lymph node metastasis from various pri-
maries in the upper aerodigestive tract and helps deter-
mine the high and low incidence of nodal metastasis; it
may tailor the surgical procedure accordingly. For exam-
ple, IA lymph node metastasis is very rare except for
tumors of the lower lip and anterior oor of the mouth; a
recent review of prospective studies showed that level IIB
metastatic nodes are quite rare. Similarly, lymph node
metastases at level VA are quite rare in thyroid cancer.
Similarly, lymph node metastasis at level I is also rare in
thyroid cancer. Based on this leveling systemand subclas-
sication, one can determine the extent of selective node
dissection based on the site of the primary tumor and
patterns of nodal metastasis. Location of the metastasis is
mainly based on the primary site. The oral cavity gener-
ally metastasizes to levels I, II, and III whereas the tumors
of the oropharynx, larynx, and hypopharynx commonly
metastasize to levels II, III, and IV. Lymph node metasta-
sis at level Vis quite rare. The patterns of nodal metastasis
have been extremely well described by Lindberg from the
MD Anderson Cancer Center
19
and Shah from Memorial
Sloan-Kettering Cancer Center.
20
Generally, cervical
lymph node metastases progress in an orderly fashion;
rarely, the metastatic disease may skip one area and go to
the next level of nodes. As there is a progression of disease
from level I to level V, there is decreasing survival and
worsening outcome. Lymph node metastases at level IV
and V are generally considered to have the worst progno-
sis, a high incidence of local recurrence, and a high inci-
dence of distant metastasis. The incidence of nodal me-
tastasis to the neck depends on the characteristics of the
primary tumor, the location of the primary tumor, the
size, the T stage, and histological differentiation. The
depth of the primary tumor is considered to be the most
important prognostic factor. As one moves from the an-
terior to the posterior sites of the oral cavity and orophar-
ynx, there is an increasing incidence of metastasis to the
neck nodes. Lesions of the tonsil and base of the tongue
have a very high incidence of nodal metastasis, whereas
tumors of the hypopharynx universally have metastatic
disease in the neck nodes. Interestingly, the free border of
the vocal cord has sparse lymphatics, and generally early-
stage laryngeal cancer has no neck node metastasis. In the
oral cavity, the tongue has the highest incidence of nodal
metastasis, whereas the hard palate and the lip rarely
present primarily with metastatic disease. The T stage is
very important; T1, T2, and T3 tongue cancers have an
incidence of metastatic disease to the neck in the range of
30%, 50%, and 70%, respectively. A patient presenting
with advanced-stage tongue cancer generally requires at-
tention to the possibility of cervical node metastasis. His-
tological characteristics of the primary tumor, such as
depth of the tumor, endophytic versus exophytic differ-
entiation, and pushing margins, are also predictors of
lymph node metastasis.
CLASSIFICATION OF NECK DISSECTION
The various types of neck dissections have been divided
into the categories of comprehensive and selective. Com-
prehensive neck dissections include classical radical neck
dissection, wherein all neck nodes and three vital struc-
tures, such as the accessory nerve, sternomastoid muscle,
and jugular vein, are universally removed. Extended rad-
ical neck dissection includes removal of the above vital
structures along with additional structures such as the
skin, platysma, hypoglossal nerve, posterior belly of the
digastric muscle, external or common carotid artery, and
the vagus nerve. Modied neck dissection is divided into
types I, II, and III, wherein the accessory nerve, the ster-
nomastoid muscle, and the internal jugular vein are pre-
served, respectively. Selective neck dissections, which in-
clude removal of a select group of neck nodes, have been
divided into classical supraomohyoid neck dissection, an-
terolateral neck dissection, jugular neck dissection, pos-
terolateral neck dissection, and central compartment dis-
section. Supraomohyoid neck dissection includes
73 Radical Neck Dissection
removal of the lymph nodes at level I, II, and III; it is
considered a standard staging procedure for cancer of the
oral cavity. Anterolateral or deep jugular neck dissection
is commonly used for tumors of the oropharynx, hypo-
pharynx, or advanced tumors of the larynx. Posterolateral
neck dissection includes removal of the lymph nodes at
level V. This operation is generally reserved for tumors of
the suboccipital area or melanoma of the posterior neck.
Central compartment dissection is generally reserved for
tumors of the thyroid gland, especially in patients with
paratracheal or tracheoesophageal groove lymph node
metastasis. It is a standard operation for most of the pa-
tients with medullary carcinoma of the thyroid. Level VI
lymph nodes include the tracheoesophageal and superior
mediastinal nodes, which are generally cleared in patients
with thyroid cancer. The incidence of level VI nodal me-
tastasis is also high in patients with advanced carcinoma
of the hypopharynx or cervical esophagus. Patients pre-
senting with metastatic disease at level IV may have a
sheet-like disease in the paratracheal area extending into
level VI, and appropriate attention must be paid to in-
clude this area in postoperative radiation therapy for
squamous cell carcinoma. Selective neck dissections are
commonly reserved for microscopic metastatic disease in
the neck or N0 patients, whereas patients with clinically
palpable disease or therapeutic neck dissections are gen-
erally considered for comprehensive neck dissection.
However, recently there appears to be increasing use of
selective neck dissection, even for clinically palpable
nodal disease, with routine use of postoperative radiation
therapy. Whether this has any long-term impact on local
recurrence and survival rates remains to be studied.
STAGING OF THE NECK NODE
METASTASIS AND PROGNOSTIC
FACTORS
The staging systemdescribed by the American Joint Com-
mittee on Cancer (AJCC)
5
is shown in Table 1. The prog-
nostic factors affecting lymph node metastasis also in-
clude the location of the neck node metastasis, presence
of tumor emboli, perivascular and perineural inltration
of the tumor, and the presence of extranodal spread, com-
monly called extracapsular extension of the disease.
Among all the prognostic factors in neck node metastasis,
the presence of extranodal spread has the worst outcome.
Patients with extranodal spread have a high incidence of
both local recurrence in the neck and distant metastasis.
Interestingly, even in patients with N1 disease, there is a
30% incidence of extranodal spread, whereas in pa-
tients with N2 and N3 disease, the presence of extranodal
spread occurs in 50%to 70%of patients. This is also more
common in certain tumors (eg, the hypopharynx and base
of the tongue). Metastatic disease in the neck that inl-
trates into the subdermal area or platysma is considered
to be another important prognostic factor. Subdermal ex-
tension of the disease is generally considered to have a
very high incidence of local recurrence or further subder-
mal metastasis.
21
INDICATIONS FOR RADICAL NECK
DISSECTION
Classical radical neck dissection, with comprehensive re-
moval of all lymph nodes in the neck, the sternomastoid
muscle, internal jugular vein, and accessory nerve as well
as the submandibular salivary gland, although not prac-
ticed commonly today, has the following important indi-
cations:
1. N3 neck disease, especially in the upper neck
2. Bulky metastatic disease near the accessory nerve
3. Tumor directly involving the accessory nerve
4. Clinically palpable multiple nodes, especially near
the accessory nerve (N2b, N2c)
5. Recurrent metastatic tumor after previous radiation
therapy
6. Recurrent disease in the neck after previous neck
dissection
7. Salvage surgery in patients with chemoradiation
therapy, especially in those who presented with bulky or
level II nodal disease
8. Involvement of the platysma or skin, requiring sac-
rice of a portion of skin in the upper neck
9. Clinical signs of obvious extranodal disease
CONTRAINDICATIONS
Although there are generally no major contraindications
for classical radical neck dissection, tumors that involve
the skull base or those with massive extension of the
disease in the parapharyngeal area or prevertebral mus-
culature, including the levator scapulae or scaleni, or
extension of the disease into the deep portion of the pa-
rotid gland may be considered to be inoperable. Bulky,
xed disease to the deeper structures in the neck is also
considered to be an inoperable condition, whereas tumor
involving the common carotid artery remains controver-
sial vis-a`-vis sacrice of the carotid artery. Generally, sac-
rice of the carotid artery along with neck dissection is
not considered to be a potentially curable situation be-
cause most of these patients have disease limited not only
Table 1. Staging of the Regional Lymph Nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm in
greatest dimension
N2a Metastasis in a single ipsilateral lymph node 3 cm but
not 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none 6 cm
in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none
6 cm in greatest dimension
N3 Metastasis in a lymph node 6 cm in greatest dimension
74 Ashok R. Shaha
to the carotid artery but also involving surrounding struc-
tures such as the vagus nerve, the scaleni muscles, and
parapharyngeal musculature. Even with sacrice of the
common carotid artery and appropriate reconstruction
either with a Gortex graft or saphenous vein graft, the
recurrence rate is extremely high; average survival in
these patients is measured in months, with rare long-term
survival.
TECHNIQUE OF RADICAL NECK
DISSECTION
Anesthesia
Radical neck dissection is performed under general anes-
thesia with an endotracheal tube in place. The patient is
placed supine and positioned with 20 reverse Tren-
delenburg tilt, with the head of the patient on the head
plate of the operating table so that the neck can be ex-
tended as necessary. Generally, the neck is extended with
a lateral tilt of the neck on the contralateral side of the
neck dissection. A transparent drape on the face and the
head is quite helpful to viewmovements of the face, func-
tional aspects of the lip, and the endotracheal tube as well
as to avoid any inadvertent disconnection of the endotra-
cheal tube.
Incision
A variety of different incisions have been popularized
over the last century. The standard incision until the
middle of last century was a double trifurcate, or Kocher,
incision. Unfortunately, both the trifurcation angles were
invariably on the carotid artery; especially, the upper tri-
furcation was on the carotid bulb. This incision is rarely
used today in lieu of a modied Schobinger or modied
Conley incision. The horizontal double-parallel McFee
incision is also rarely used today except in young women
and especially those with thyroid cancer. The J-shaped, or
apron, incision once again is rarely used today. The J-
shaped incision is used mainly for thyroid cancer; how-
ever, even for patients with thyroid cancer and neck dis-
section, an extended necklace incision is commonly used
in place of the J extension. The standard incision used
today begins at the tip of the mastoid process in a curvi-
linear fashion two nger breadths below the angle of the
mandible and extends onto the tip of the hyoid bone and
medially to the midline of the chin area (Fig 1). This
incision can be extended through the midline of the chin
and lip for exposure of tumors of the oral cavity or for a
cheek ap for composite resections. This incision can be
extended to the opposite neck along the hyoid should
contralateral neck dissection be necessary at that time or
1 Classical incision used for radical neck dis-
section. The incision begins fromthe mastoid pro-
cess in a curvilinear fashion up to the tip of the
hyoid, extending superiorly to the submental
area. The vertical limb starts behind the carotid
artery and goes down to the middle portion of the
clavicle in a lazy S fashion.
75 Radical Neck Dissection
in the future. Avertical limb is dropped fromthe posterior
aspect of this incision behind the carotid artery and ex-
tending inferiorly to the clavicle in a lazy S fashion. A
straight vertical incision is likely to lead to scarring and
contracture, thus a lazy S incision is used, essentially ac-
complishing a Z plasty at the initial surgical procedure. The
vertical limb of the incision is generally dropped at 90, and
acute angulation of this incision is avoided; otherwise, the
tip of the acute angle may result in local skin necrosis and
exposure of the deeper structures. This is more crucial in
patients who have undergone previous radiation therapy,
because radiationtherapy is likely to hamper woundhealing
due to a lack of blood supply to the skin and subcutaneous
tissue.
The skin is generally inltrated with 1% lidocaine and
epinephrine to avoid excess bleeding from the skin. Ini-
tially, the incision is made in the posterior limb of the
horizontal incision and extends almost to the carotid ar-
tery. The submandibular incision is not made initially to
avoid excessive bleeding from the skin. The vertical inci-
sion is also extended to the clavicle. The skin and subcu-
taneous tissue are incised. The platysma is incised while
keeping in mind that there is no platysma in the posterior
portion of the neck. Injury to the external jugular vein,
which lies immediately under the platysma, is avoided.
Dissection is now performed between the platysma and
the deeper structures. There is essentially an avascular
plane beneath the platysma. The posterior aps are raised
with skin hooks just under the platysma. The dissection is
performed posteriorly up to and behind the trapezius
muscle, with good exposure of the sternocleidomastoid
muscle (Fig 2).The greater auricular nerve is identied
posteriorly at Erbs point. The greater auricular nerve is
routinely sacriced in this operation. The accessory nerve
can be located 1 cm above Erbs point behind the ster-
nocleidomastoid muscle in the posterior triangle. How-
ever, in a standard radical neck dissection, no effort is
made to identify the accessory nerve. However, if there is
any question about radical or modied neck dissection,
every effort should be made to nd the accessory nerve
and preserve it in selected patients if there is no obvious
gross disease near the nerve. Dissection is performed up
to the anterior border of the trapezius muscle, and the
contents of the posterior triangle are held with multiple
clamps. Dissection begins near the mastoid area with
transection of the origin of the sternomastoid muscle and
exposure of the splenius capitis muscle. The dissection is
performed on the surface of the splenius muscle, avoiding
injury to the occipital vessels (Fig 3). Inferiorly, the dis-
section is extended from the anterior border of the trape-
zius muscle. It is important to avoid deep dissection be-
hind the trapezius muscle because there is a network of
veins that may cause excessive bleeding. Inferiorly, the
dissection is extended along the trapezius muscle up to
the clavicle. The posterior triangle contents are held with
multiple clamps, and dissection is performed on the sur-
face of the levator scapulae muscle to avoid injury to the
nerve supply to the levator scapulae muscle. The trans-
verse cervical vessels may be clamped; however, if there is
no gross disease in the posterior triangle, these vessels
may be preserved if they are necessary for microvascular
reconstruction. The inferior belly of the omohyoid is cut
near the clavicle (Fig 4). This is a good landmark to avoid
injury to the brachial plexus. The brachial plexus lies
behind the inferior belly of the omohyoid muscle. The
dissection is now performed on the under aspect of the
2 The procedure begins in the posterior
triangle by raising the posterior ap and dis-
secting in the supraclavicular fossa by
transecting the inferior belly of the omo-
hyoid and retracting the contents of the pos-
terior triangle medially along with dissec-
tion in the superior portion of the posterior
triangle.
76 Ashok R. Shaha
inferior belly of the omohyoid muscle, extending anteri-
orly behind the sternomastoid muscle. As the dissection is
continued anteriorly, every effort is made to avoid injury
both to the brachial plexus and to the phrenic nerve. The
dissection is carried medially up to the phrenic nerve on
the surface of the scaleni muscles. The jugular vein is
identied in the inferior portion. The external jugular
vein invariably enters deep to the clavicle into the subcla-
vian system. It is important to identify this vein and care-
fully ligate it. A double ligation may be necessary if the
external jugular vein is either distended or large.
As the dissection continues medially, the remaining
incision of the skin is completed to extend the incision up
to the submental area. The anterior ap is raised up to the
midline, and the superior ap is raised up to the free
border of the mandible, avoiding any injury to the ramus
3 The dissection is performed by
transecting the upper portion of the
sternomastoid muscle; the accessory
nerve is transected anterior to the trape-
zius muscle and the entire contents of the
posterior triangle are pulled medially.
The dissection continues under the infe-
rior belly of the omohyoid muscle, care-
fully avoiding any injury to the brachial
plexus.
4 The posterior triangle dissection is
completed, exposing the levator scapu-
lae and scaleni muscles. Inferiorly, the
stump of the external jugular vein is seen;
posteriorly, the transverse cervical ves-
sels may be ligated.
77 Radical Neck Dissection
mandibularis. If the dissection is performed under the
platysma, the ramus mandibularis can be identied on the
surface of the fascia covering the submandibular salivary
gland. Injury to the ramus mandibularis is avoided by
careful identication of this nerve and by ligating the
facial vessels below the ramus mandibularis on the sur-
face of the submandibular salivary gland and retracting
the ligated vessels superiorly along with the ramus man-
dibularis. At this time, the dissection can be performed in
the submandibular area or inferiorly. We generally prefer
to continue the dissection inferiorly, exposing the inter-
nal jugular vein by transecting the entire sternomastoid
muscle (Fig 5). A cuff of at least 1 cm of sternomastoid
muscle should be left attached to the clavicle to avoid any
excessive bleeding from the sternomastoid muscle and to
avoid injury to the periosteum of the clavicle. As the
entire sternomastoid is cut, it will be noted that the lateral
border of the sternomastoid muscle is at and muscular
whereas the medial aspect is more bulky and tendinous.
After transecting the entire sternomastoid muscle inferi-
orly, the internal jugular vein is exposed and dissected
from the carotid sheath. While dissecting the lower por-
tion of the internal jugular vein, it is vitally important to
identify the vagus nerve and carefully preserve it. There
are also small tributaries entering the posterior portion of
the internal jugular vein, and it is important to avoid
injury to these veins. Any injury to this vein may lead to
excessive bleeding. The internal jugular vein is clamped,
divided, and doubly ligated. Inferiorly, a transxion su-
ture is generally used to avoid any distention of the vein
and slipping of the ligature. If the internal jugular vein is
inadvertently transected during the dissection, it may
lead to excessive bleeding in the neck, retraction of the
internal jugular vein into the chest, or even an air embo-
lism. It is also important to ligate the proximal end of the
internal jugular vein, which invariably gets distended; the
ligature may slip during the operation, leading to short-
term profuse bleeding from the open end of the internal
jugular vein. As the dissection is continued superiorly
behind the internal jugular vein and medial to the sterno-
mastoid muscle, the middle thyroid vein may be identi-
ed and should be clamped and ligated. Meticulous dis-
section in this area is very crucial, especially in the left
side of the neck, where there may be multiple channels of
lymphatics or even the thoracic duct. It is important to
avoid any injury to the thoracic duct. The lymphatics in
this area are best ligated with silk ties rather than chromic
catgut. It is also important to have the anesthesiologist
perform a Valsalva maneuver to see if there is any exces-
sive bleeding in this area or a chyle leak. If an unidenti-
able lymphatic leak is noticed in this region, a transxion
suture with silk in the soft tissues of the neck may be
undertaken to control the chyle leak. The dissection is
nowcontinued superiorly behind the sternomastoid mus-
cle and the jugular vein. The superior belly of the omo-
hyoid is transected near the hyoid; bone and multiple
small parapharyngeal veins need to be ligated. As the
dissection is continued superiorly, the dissection is per-
formed near the carotid bulb. When the dissection is
performed near the carotid bulb and there is manipula-
tion of the carotid bulb, it is important to inform the
anesthesiologist to check the blood pressure and the pulse
5 The dissection performed
behind the inferior border of the
sternomastoid muscle, ligating
the internal jugular vein and
dissecting between the carotid
artery and the internal jugular
vein.
78 Ashok R. Shaha
rate. If there is any bradycardia or hypotension, this area
is best left undisturbed; if necessary, inltrate lidocaine in
the subadventitial plane near the carotid bulb to avoid
carotid body stimulation. The dissection is now contin-
ued superiorly; occasionally one may have to ligate the
superior thyroid artery. The hypoglossal nerve is identi-
ed 1.5 cm above the carotid bifurcation just under the
posterior belly of the digastric muscle. Now the entire
sternomastoid is transected superiorly, and the dissection
is performed medial to the sternomastoid muscle (Fig 6).
At this time, the dissection is generally extended to the
submental area. The submental area is cleared, exposing
the contralateral anterior belly of the digastric muscle.
The entire contents of the submental triangle are pulled
laterally, avoiding any injury to the small vessels on the
surface of the geniohyoid muscle. The dissection is now
continued on the surface of the anterior belly of the di-
gastric, and the mylohyoid muscle is exposed medial to
7 The submandibular dissection is per-
formed by retracting the mylohyoid muscle
and exposing the submandibular salivary
gland, with careful preservation of the hypo-
glossal and lingual nerves.
6 The dissection completed in the poste-
rior triangle, inferior triangle, and the supe-
rior area near the angle of the mandible by
exposing the posterior belly of the digastric
muscle.
79 Radical Neck Dissection
the digastric. There is always a small vessel on the surface
of the mylohyoid that supplies this muscle. This needs to
be ligated or cauterized. The mylohyoid muscle is pulled
medially, exposing the deeper portion of the submandib-
ular salivary gland (Fig 7). At this time, the dissection is
extended along the free border of the mandible, expos-
ing the submandibular salivary gland. There are many
small branches of the facial artery in this region that
need to be carefully ligated. If not, they will retract
under the mandible causing excessive bleeding in this
area. The deeper portion of the submandibular salivary
gland is exposed and ligated, transecting Whartons
duct and pulling the entire submandibular salivary
gland laterally. The lingual nerve is exposed above the
submandibular salivary gland, and the hypoglossal
nerve is exposed inferiorly. These two nerves come
very close to each other under the mylohyoid muscle.
The branch of the lingual nerve supplying the parasym-
pathetic bers to the submandibular salivary gland is
transected, and the submandibular salivary gland is
retracted posteriorly. If the facial artery was not previ-
ously ligated, it is now ligated and pulled superiorly. As
the dissection continues on the surface of the digastric
muscle, it is important to avoid any injury to small
veins that run parallel to the hypoglossal nerve. The
dissection is now performed on the hyoglossus muscle,
retracting the entire submandibular salivary gland.
There may be a group of facial lymph nodes in this area
that may be removed; however, it is very important in
this area to avoid any injury to the ramus mandibularis
while the facial lymph nodes are being removed. Ex-
tensive dissection in this area is likely to lead to injury
to the ramus mandibularis, with subsequent weakness
of the lower lip. As the dissection proceeds posteriorly,
the facial artery is identied in front of the posterior
belly of the digastric. This needs to be clamped and
ligated carefully. A double ligature is always helpful to
avoid any unexpected slipping of the ligature. At this
time, the dissection proceeds again from the inferior
aspect, exposing the hypoglossal nerve and sectioning
the ansa hypoglossi nerve. As the dissection proceeds
from the posterior aspect, particularly if there is bulky
metastatic disease in this region, it is important not to
expose the tumor and to stay away from the metastatic
disease. The sternomastoid muscle is pulled inferiorly,
and the dissection is now performed medial to the
sternomastoid muscle on the surface of the posterior
belly of the digastric. If the tumor is adherent to the
posterior belly of the digastric, a portion or the entire
posterior belly of the digastric may have to be sacriced
along with other muscles such as the stylohyoid and
styloglossus. The tail of the parotid gland also may
have to be resected in this region, especially if the
tumor extends high at level II. However, as the dissec-
tion continues in the parotid gland, there invariably is
excessive bleeding that needs to be carefully cauter-
ized. Once again, it is very important to avoid injury to
the ramus mandibularis in this region. The superior
portion of the internal jugular vein is exposed just
behind the posterior belly of the digastric. A right-
angle retractor is very helpful to pull the posterior belly
of the digastric superiorly and expose the internal jug-
ular vein. Once again, there may be tiny tributaries to
the internal jugular vein in this area from the parapha-
ryngeal veins that need to be carefully ligated. Any
injury to the veins in this region may lead to excessive
bleeding and inadvertent injury to the hypoglossal or
vagus nerves. The internal jugular vein is exposed,
separating the vagus and the hypoglossal nerve. It is
clamped and ligated. As the internal jugular vein is
ligated, one may see the occipital artery, which runs
supercial to the internal jugular vein. The hypoglossal
nerve is medial to this area, and the accessory nerve is
in the posterolateral region. In a standard radical neck
dissection, the accessory nerve is transected in this area
along with the branch entering the sternomastoid mus-
cle. As the internal jugular vein is clamped and ligated,
the entire neck specimen is mobilized and separated
from the remaining portion of the levator scapulae
muscle.
The surgeon may consider bringing the specimen
personally to the pathology department and identifying
various levels of the lymph nodes to the prosector, or
the specimen may be pinned to cardboard or a template
for better localization of the various levels of the neck
lymph nodes. After removal of the entire neck speci-
men, the wound is irrigated and any bleeding spots on
the surface of the muscles are ligated or cauterized. The
wound is irrigated copiously, and the supraclavicular
area is once again visualized for any lymphatic leak.
Two Reliavac drains are commonly insertedone in
the anterior portion and another in the posterior por-
tion extending superiorly up to the skull base. It is
important to avoid placing the suction drains across
the carotid vessels. The suction drains are secured with
a silk suture. The drains are attached to suction and the
wound is approximated. The platysma is closed with
either chromic catgut or Vicryl sutures, and the skin is
approximated generally with staples or nylon sutures.
The central portion of the trifurcation should be ap-
proximated with nylon sutures rather than with sta-
ples. It is important to make sure that the drains are
attached to wall suction when the patient is in the
recovery room. If the drains do not function properly
or the suction does not work, it is important to identify
the defect and correct it promptly; otherwise, the pa-
tient will end up with a uid collection in the neck,
leading to a subcutaneous hematoma requiring re-ex-
ploration. Most often, the patient is extubated in the
operating room. If there is any extension of the surgery
80 Ashok R. Shaha
into the oral cavity by midline lip incision or extensive
resection of the tumor in the oral cavity, a tracheos-
tomy may be necessary because there is a likelihood of
considerable edema of the oral cavity and structures
such as the oral tongue or base of the tongue. If there is
no contamination and neck dissection alone is per-
formed, there is generally no need for antibiotics. How-
ever, if there is any possibility of oral contamination or
pharyngeal surgery, preoperative antibiotics and 24
hours of perioperative antibiotics are generally consid-
ered. Broad-spectrum antibiotics such as cephalospo-
rins are used. However, if the patient is allergic to
penicillin, clindamycin may be considered.
COMPLICATIONS OF RADICAL NECK
DISSECTION
Major complications of radical neck dissection revolve
around sacrice of the accessory nerve, sternocleido-
mastoid muscle, and internal jugular vein, leading to
functional morbidity and cosmetic deformity related to
shoulder dysfunction and indentation in the neck. Cer-
tain other complications are also quite critical in the
surgical procedure of radical neck dissection. These
complications may be divided into intraoperative and
postoperative complications. The intraoperative com-
plications are mainly related to excessive bleeding, bra-
dycardia during dissection near the carotid body, chy-
lous leak, and slipping of the stump of the internal
jugular vein near the skull base. Excessive bleeding in
neck dissection may occur from slipping of the middle
thyroid vein in the supraclavicular fossa near the inter-
nal jugular vein, from small tributaries of the internal
jugular vein, or in the posterior triangle from slipping
of the transverse cervical vessels. Excessive bleeding
may occur near the mylohyoid muscle, where there are
small branches supplying the mylohyoid muscle.
Bleeding may also occur in the tail of the parotid during
transection of the tail of the parotid gland. However,
major bleeding can occur from both ends of the inter-
nal jugular veins. The superior portion of the internal
jugular vein may slip near the skull base, where it may
be difcult to place a clamp on the stump of the vein.
This can be a very difcult surgical situation. Gener-
ally, packing will minimize the bleeding, and one may
be able to identify the stump of the jugular vein and
carefully ligate it. If this is impossible and the jugular
vein is retracted near the jugular bulb, it may be more
appropriate to use hemostatic agents such as Avitene or
Gel foam and suture the portion of the sternomastoid
or digastric muscle against the jugular vein and transx
this tissue around other muscular structures near the
skull base. Slipping of the jugular vein in the inferior
portion may lead to air embolism. Air embolism may be
related to inadvertent suction of air into the venous
system; effectively, air enters the cardiac system. The
clinical signs of air embolism include a sudden drop in
blood pressure, cardiac output, and oxygen saturation.
There may be an audible cardiac murmur. This can be a
very serious situation in the operating room. The fol-
lowing measures are generally useful. Nitrous oxide
anesthesia should be stopped and the patient ventilated
with 100% oxygen. The patient should be positioned in
the left lateral decubitus position so that the air can be
trapped in the right atrium. Aspiration of the air embo-
lus can be performed through cardiac puncture or as-
pirating through the central venous catheter. It is ex-
tremely important to avoid this major complication
intraoperatively. Chyle stula and chyle leak are other
critical complications of radical neck dissection. Me-
ticulous identication and ligation of the branches of
the thoracic duct are important in the conduct of rad-
ical neck dissection. Intraoperative chylous leak may
be recognized with identication of chyle leak or by a
Valsalva maneuver. The chyle leak should be suture-
ligated or controlled with hemo clips. Postoperative
chyle stula will be manifested by increasing output of
milky uid. Conservative management of postopera-
tive chyle stula includes a medium-chain triglyceride
diet, low-fat diet, pressure dressings, and suction of the
drains. Total parenteral nutrition may be considered in
select patients. Rarely, a failure in conservative man-
agement may necessitate a return to the operating
room.
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