A surgical procedure called elective neck dissection (END) is performed to remove lymph nodes from patients with head and neck cancer to stop or treat the spread of the disease.
It is most used to improve regional control and to increase survival when there is a high probability of microscopic metastasis but no clinical evidence of lymph node involvement.
Indications
Primary Tumor stage and location
Head and Neck Squamous Cell Carcinoma (HNSCC): Its application is most often considered for patients with clinically nonapparent nodal disease (pN0) and primary tumors in which evidence exists that the risk of malignant lymph node involvement is about 15-20%.
Oral Cavity Cancers: END is recommended in T1-T2 N0 oral cancer particularly when the cancer is arising from anatomical sites of higher prevalence of subclinical disease as in tongue and floor of mouth.
Probability of Occult Metastasis: END is suggested when the ultimate risk of occult malignant spread is 20% or more. This threshold defines whether neck dissection will be done especially if clinical evidence of nodal metastases is not seen.
Tumor Characteristics:
Poorly Differentiated Tumors: END may also be associated with higher grade or poorly differentiated tumors due to the higher possibility of nodal spread.
Perineural or Lymphovascular Invasion: Some tumors such as those that exhibit perineural invasion PNI and lymphovascular invasion LVI are more likely to have occult metastasis and hence may require END even in clinically N0 necks.
Anatomic Considerations: Tumours in preferential sites of regional metastasis are likely to require END especially those in lateral tongue and floor of mouth. The lymph node levels involved in END depends on the primary tumor site for instance levels I-III for oral cavity tumors.
Contraindications
Advanced Age or Poor Functional Status: If the patient has a poor performance status or severe comorbidities, the risks of surgery may outweigh the benefits.
Comorbidities: This including hypertension or diabetes or stroke, or other severe illnesses. In one’s poor performance status or severe co morbidities, there are higher risks associated with surgery than its benefits.
Significant Comorbidities: Specific situations when they can be contraindicated include diseases of severe cardiac or pulmonary origin, uncontrolled diabetes and any other disease that poses risks during or after procedure.
Distant Metastasis: Thus, if distal metastasis has already occurred the use of END is sometimes not very effective and is not employed.
Neck infection or severe inflammation of the neck tissue: Elective surgery shouldn’t be performed if the individual has any active infection or inflammation because they raise the risk of adverse effects.
Non-Surgical Treatment Plan: Patients who will receive other curative local non-surgical therapies like chemoradiotherapy may not get any benefit out of END and therefore should not be subjected to it.
Outcomes
Periprocedural care
EquipmentÂ
Surgical Instruments
Scalpel and blades
Hemostats and clamps
Needle holders and forceps
Dissection scissors
Tissue retractors
Energy Devices
Electrocautery unit
Harmonic scalpel
Suction Equipment
Yankauer suction and Frazier suction tips
Smoke evacuator
Visualization Tools
Surgical loupes or magnifying glasses
Ultrasound probe or nerve stimulator
Hemostasis Aids
Sutures and clips
Hemostatic agents
Anesthesia Equipment
Intubation and ventilation equipment
Monitoring equipment
Postoperative Equipment
Drains (e.g., Jackson-Pratt or Hemovac)
Dressings and bandages
Patient preparation
Medical Evaluation: A preoperative history and examination, and appropriate investigations should be done. It should be ascertained to the patient that there are certain medical conditions may delay or cause the surgery not to be conducted.
Imaging Studies: CT, MRI scans or PET scans are generally required prior to surgery, to determine the spread of the disease.
Consent and Discussion: The patient should have been well explained the pros and cons of neck dissection, for example, adverse effects such as nerve damage, bleeding, infection and cosmetic effects.
Nutritional Assessment: Most of the patients of the head and neck cancers had malnutrition. A nutritionist may need to be involved to optimize their preoperative nutritional status.
Smoking and Alcohol Cessation: Smokers and drinker should avoid smoking and consuming alcohol before at least three weeks to the date of surgery to better their results and improve the healing process. Support cessation as required among the patients on the need to quit smoking.
Patient position
Supine Position with Head Extension: The position of the patient is supine, the head in extension and turned to one side away from the neck is being operated on. This gives improved exposure to the operating site.
Head Support: A head ring, also known as a gel donut pad, is used to immobilize the head and the neck or to minimize pressure on the cervical region.
Shoulder Roll: There is a shoulder roll or bolster placed at the level of the scapula such that the shoulders are elevated slightly forward, head and neck flexed to maximize vision on the surgical field.
Imaging and Preoperative Planning
This level of disease and the LN involvement can be determined using images such as CT, MRI or PET scans.
To reduce the functional impact, careful planning ensures the accurate removal of lymph nodes while protecting vital components (such as muscles, blood arteries, and nerves).
Incision and Exposure
It is made at the neck, around skin fold so that people cannot see the scar easily.
Standard surgical incisions range from Y-shaped incision which has been slightly altered from a more familiar Y shape to allow for adequate visualization of the levels I-V of the neck.
Inclination in the natural line alba of the neck.
Subplatysmal flaps are turned up to this area to expose neck levels which may include from the hyoid bone down to the clavicle to access different Lymph node groups.
In selective neck dissection, structures including the carotid artery, the spinal accessory nerve, the internal jugular vein and the sternomastoid muscle and the hypoglossal nerve are identified and preserved.
Starting from separating lymph nodes level by level, all groupings of lymph nodes are excluded taking into consideration the primary location and risk zone areas of malignancy.
The most common dissections are:
Level I: Submental and submandibular nodes
Level II: Upper jugular nodes
Level III: Mid-jugular nodes
Level IV: Lower jugular nodes
Level V: Posterior triangle nodes
Whereas an SND involves removal of only certain nodal levels (e.g., I-III for oral cavity site) based on the tumor spread pattern for the specific site, the comprehensive dissection might remove all the neck levels (I-V).
Hemostasis and Closure
Prolonged postoperative bleeding should be prevented and surgeries admitting special attention during haemostasis.
Usually, the drain is placed to prevent seroma or hematoma.
The wound is finally sutured or stapled in layers by using the best and preferred procedures for subcutaneous tissues and skin.
Postoperative Care and Monitoring
Complications such as nerve injury, shoulder dysfunction (caused by auxiliary nerve sacrifice), and problems with wound healing are observed in patients.
Drains are also evacuated once there is low output level.
They need assessment of pathology from dissected nodes to determine whether other treatment (such as radiotherapy) is necessary.
Complications
Nerve Injury: Some of the effects of spinal cord injuries are shoulder dysfunction, and limited joint mobility. Also, the hypoglossal nerve may also cause speech problems and the weakening of the tongue in a patient. Infection can occur and is likely to show symptoms such as fever, discharge, swelling or redness, depending on the location of the infection. In most cases, the use of antibiotics helps to treat or prevent those problems.
Vascular Injury: Injury to large structures, including the internal jugular vein, the common carotid artery, may cause bleeding, hematoma or, rarely, death.
Chyle Leak (Chylous Fistula):
There are major complications due to thoracic duct damage, common being chyle leakage in the left side neck region resulting to swelling and likely infection. This must be well monitored to avoid undernutrition.
Infection:
Wound infection or formation of abscess is one of the post-surgical complications expected after the procedure. In neck dissection, it may cause delayed wound healing and may be necessitate antibiotic treatment or wound drainage.
A surgical procedure called elective neck dissection (END) is performed to remove lymph nodes from patients with head and neck cancer to stop or treat the spread of the disease.
It is most used to improve regional control and to increase survival when there is a high probability of microscopic metastasis but no clinical evidence of lymph node involvement.
Primary Tumor stage and location
Head and Neck Squamous Cell Carcinoma (HNSCC): Its application is most often considered for patients with clinically nonapparent nodal disease (pN0) and primary tumors in which evidence exists that the risk of malignant lymph node involvement is about 15-20%.
Oral Cavity Cancers: END is recommended in T1-T2 N0 oral cancer particularly when the cancer is arising from anatomical sites of higher prevalence of subclinical disease as in tongue and floor of mouth.
Probability of Occult Metastasis: END is suggested when the ultimate risk of occult malignant spread is 20% or more. This threshold defines whether neck dissection will be done especially if clinical evidence of nodal metastases is not seen.
Tumor Characteristics:
Poorly Differentiated Tumors: END may also be associated with higher grade or poorly differentiated tumors due to the higher possibility of nodal spread.
Perineural or Lymphovascular Invasion: Some tumors such as those that exhibit perineural invasion PNI and lymphovascular invasion LVI are more likely to have occult metastasis and hence may require END even in clinically N0 necks.
Anatomic Considerations: Tumours in preferential sites of regional metastasis are likely to require END especially those in lateral tongue and floor of mouth. The lymph node levels involved in END depends on the primary tumor site for instance levels I-III for oral cavity tumors.
Advanced Age or Poor Functional Status: If the patient has a poor performance status or severe comorbidities, the risks of surgery may outweigh the benefits.
Comorbidities: This including hypertension or diabetes or stroke, or other severe illnesses. In one’s poor performance status or severe co morbidities, there are higher risks associated with surgery than its benefits.
Significant Comorbidities: Specific situations when they can be contraindicated include diseases of severe cardiac or pulmonary origin, uncontrolled diabetes and any other disease that poses risks during or after procedure.
Distant Metastasis: Thus, if distal metastasis has already occurred the use of END is sometimes not very effective and is not employed.
Neck infection or severe inflammation of the neck tissue: Elective surgery shouldn’t be performed if the individual has any active infection or inflammation because they raise the risk of adverse effects.
Non-Surgical Treatment Plan: Patients who will receive other curative local non-surgical therapies like chemoradiotherapy may not get any benefit out of END and therefore should not be subjected to it.
EquipmentÂ
Surgical Instruments
Scalpel and blades
Hemostats and clamps
Needle holders and forceps
Dissection scissors
Tissue retractors
Energy Devices
Electrocautery unit
Harmonic scalpel
Suction Equipment
Yankauer suction and Frazier suction tips
Smoke evacuator
Visualization Tools
Surgical loupes or magnifying glasses
Ultrasound probe or nerve stimulator
Hemostasis Aids
Sutures and clips
Hemostatic agents
Anesthesia Equipment
Intubation and ventilation equipment
Monitoring equipment
Postoperative Equipment
Drains (e.g., Jackson-Pratt or Hemovac)
Dressings and bandages
Patient preparation
Medical Evaluation: A preoperative history and examination, and appropriate investigations should be done. It should be ascertained to the patient that there are certain medical conditions may delay or cause the surgery not to be conducted.
Imaging Studies: CT, MRI scans or PET scans are generally required prior to surgery, to determine the spread of the disease.
Consent and Discussion: The patient should have been well explained the pros and cons of neck dissection, for example, adverse effects such as nerve damage, bleeding, infection and cosmetic effects.
Nutritional Assessment: Most of the patients of the head and neck cancers had malnutrition. A nutritionist may need to be involved to optimize their preoperative nutritional status.
Smoking and Alcohol Cessation: Smokers and drinker should avoid smoking and consuming alcohol before at least three weeks to the date of surgery to better their results and improve the healing process. Support cessation as required among the patients on the need to quit smoking.
Patient position
Supine Position with Head Extension: The position of the patient is supine, the head in extension and turned to one side away from the neck is being operated on. This gives improved exposure to the operating site.
Head Support: A head ring, also known as a gel donut pad, is used to immobilize the head and the neck or to minimize pressure on the cervical region.
Shoulder Roll: There is a shoulder roll or bolster placed at the level of the scapula such that the shoulders are elevated slightly forward, head and neck flexed to maximize vision on the surgical field.
This level of disease and the LN involvement can be determined using images such as CT, MRI or PET scans.
To reduce the functional impact, careful planning ensures the accurate removal of lymph nodes while protecting vital components (such as muscles, blood arteries, and nerves).
It is made at the neck, around skin fold so that people cannot see the scar easily.
Standard surgical incisions range from Y-shaped incision which has been slightly altered from a more familiar Y shape to allow for adequate visualization of the levels I-V of the neck.
Inclination in the natural line alba of the neck.
Subplatysmal flaps are turned up to this area to expose neck levels which may include from the hyoid bone down to the clavicle to access different Lymph node groups.
In selective neck dissection, structures including the carotid artery, the spinal accessory nerve, the internal jugular vein and the sternomastoid muscle and the hypoglossal nerve are identified and preserved.
Starting from separating lymph nodes level by level, all groupings of lymph nodes are excluded taking into consideration the primary location and risk zone areas of malignancy.
The most common dissections are:
Level I: Submental and submandibular nodes
Level II: Upper jugular nodes
Level III: Mid-jugular nodes
Level IV: Lower jugular nodes
Level V: Posterior triangle nodes
Whereas an SND involves removal of only certain nodal levels (e.g., I-III for oral cavity site) based on the tumor spread pattern for the specific site, the comprehensive dissection might remove all the neck levels (I-V).
Prolonged postoperative bleeding should be prevented and surgeries admitting special attention during haemostasis.
Usually, the drain is placed to prevent seroma or hematoma.
The wound is finally sutured or stapled in layers by using the best and preferred procedures for subcutaneous tissues and skin.
Complications such as nerve injury, shoulder dysfunction (caused by auxiliary nerve sacrifice), and problems with wound healing are observed in patients.
Drains are also evacuated once there is low output level.
They need assessment of pathology from dissected nodes to determine whether other treatment (such as radiotherapy) is necessary.
Complications
Nerve Injury: Some of the effects of spinal cord injuries are shoulder dysfunction, and limited joint mobility. Also, the hypoglossal nerve may also cause speech problems and the weakening of the tongue in a patient. Infection can occur and is likely to show symptoms such as fever, discharge, swelling or redness, depending on the location of the infection. In most cases, the use of antibiotics helps to treat or prevent those problems.
Vascular Injury: Injury to large structures, including the internal jugular vein, the common carotid artery, may cause bleeding, hematoma or, rarely, death.
Chyle Leak (Chylous Fistula):
There are major complications due to thoracic duct damage, common being chyle leakage in the left side neck region resulting to swelling and likely infection. This must be well monitored to avoid undernutrition.
Infection:
Wound infection or formation of abscess is one of the post-surgical complications expected after the procedure. In neck dissection, it may cause delayed wound healing and may be necessitate antibiotic treatment or wound drainage.
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