448 The Surgical Technologist OCTOBER 2010
Radical Neck Dissectionby Nydia Morales,DeborahD. Lamb,CSTCSTA radical neck dissection is performed when malignant lesionsare found in a patient’s head and/or neck, as well as in his or hercervical nodes. This metastasis happens through the lymphaticchannels via the bloodstream. The disease can affect the oral cavity, lips and the thyroid gland, which in turn can cause the cancerto spread slowly to the neck.HISTORYThe first radical neck dissection was described and performed byGeorge Washington Crile at the Cleveland Clinic in 1906. 1 Therevolutionary procedure marked a great step forward in the treatment of metastatic neck diseases. At the time, Crile, a foundingmember of both the Cleveland Clinic and the American Collegeof Surgeons, was already well known for his work in thyroidectomies, of which he performed more than 25,000 in his career.1As performed by Dr Crile, the radical neck dissection calledfor the removal of all the lymph nodes on one side of the neck,as well as the spinal accessory nerve, internal jugular vein andsternocleidomastoid muscle. The main drawback to this procedure was shoulder dysfunction, which occurred due to the sacrificing of the accessory nerve.2 Future practitioners eventuallyestablished more conservative measures.It wasn’t until the 1940s that surgery began to take over as thetreatment of choice for the majority of cancers of the head andneck. It was in this time frame that advances in the field of anesthesiology allowed for more elaborate surgeries. Additionally, theintroduction of antibiotics during the second World War allowedLEARNING OBJECTIVES Review the relevant anatomy forthis procedure Examine the set-up and surgicalpositioning for this procedure Compare and contrast the modificationsof the radical neck dissection Assess the risks and benefits of skinand nerve grafts Evaluate the step-by-step procedure fora radical neck dissectionOCTOBER 2010 The Surgical Technologist 449
surgery to emerge as the primary choice for management ofcancers of the head and neck.3In the 1940s and 50s, Hayes Martin, MD, preformedradical neck dissections on a routine basis in order to manage neck metastasis. The main objective, as he saw it, was toremove and block the entire ipsilateral lymphatic structuresfrom the mandible to the clavicle and from the infrahyoidmuscles to the anterior border of the trapezius. His methodalso resected the spinal accessory nerve, the internal jugularvein, the sternocleidomastoid muscle and the submandibular gland. The remaining structures, including the carotidarteries, vagus nerve, hypoglossal nerve, brachial plexus andphrenic nerve were left intact.4In the early 1960s, an Argentinean surgeon, OswaldoSuarez, described the facial compartments in the neck andfacial envelope covering a selective group of lymph nodes.He proposed a modification of Crile and Martin’s radicalneck dissection, which he termed as a functional neck dissection. Suarez’s method was to remove a selected group oflymph nodes and preserve the vital structures, including theaccessory nerve, jugular vein and sternomastoid muscle thatCrile’s procedure had originally designated for extraction. 2This method was further popularized in Europe by EttoreBocca and Caesar Gavilan, and in the United States by Richard Jesse, Alando Ballantyne and Robert Byers.2The last four decades have made way for progressiveadvances to occur, giving an understanding of cervical fascial planes, lymphatic drainage patterns, preoperative staging and extracapsular spread. In 1991, a report was published by the American Academy of Otolaryngology-Headand Neck Surgery that standardized the terminology for thedifferent types of neck dissections. In 2001, the report wasupdated with very few changes. These changes dealt withthe application of various types of selective neck dissectionprocedures for oral cavity, pharyngeal and laryngeal,thyroidand cutaneous malignancies.Extended Radical Neck Dissection: The lymph node groupsand/or additional structures not included in the classicneck dissection are resected.PRE-SURGIC AL PREPAR ATIONThe patient is placed on the OR table in the supine position. The anesthesiologist administers general endotrachealanesthesia, after which the patient is positioned for surgery.The patient’s head is extended moderately with the affectedside of the face and neck facing upward. The shoulder onthe operative side is slightly rotated so that the surgicalfield from the posterior midline of the neck to the anteriormidline of the neck is accessible. The face and neck skinprep is extensive and starts at the hairline and goes downto the nipples, as well as down to the table both anteriorand posterior. If a skin graft is to be harvested, the thigh isalso prepped and draped using sterile towels that are placedover the sterile area for later use as the dermal skin graftbefore the neck wound is closed. This graft is used to protect the carotid artery due to the possibility that the patienthas undergone extensive previous or preoperative radiationtherapy.The patient is draped with a head drape, which consistsof a drape sheet and two towels under the head with theupper towel wrapped around the head and clamped. Theneck is draped with folded towels and secured with sterileplastic adhesive. Some surgeons’ preference is to suture orstaple the sterile towels to the skin. Once the sterile towels are in place, the fenestrated sheet, (diagram A), is thenplaced over the patient.Fenestrated Laparotomydrape with reinforcementaround the fenestrationThe modifications to the radical neck dissection are asfollows:Type I: The spinal accessory nerve is preserved.Type II: The spinal accessory nerve and the internal jugular vein are preserved.Type III: The spinal accessory nerve, internal jugular veinand the sternocleidomastoid muscle are preserved.450 The Surgical Technologist OCTOBER 2010Diagram A
Instrumentation setup for this surgical procedure varies, depending on the surgeon’s preference. The surgicaltechnologist should familiarize him or herself with the surgeon’s preference card, however, each setup does include thefollowing:50 Mosquito hemostats, curved8 Allis forceps8 Kelly hemostats8 Pean forceps4 Thyroid tenacula4 Babcock forceps2 Right angle clampsAssorted needle holders12 Towel clamps2 Tonsil suction tubes1 Trousseau tracheal dilator2 Rake retractors2 Army-Navy retractors2 Richardson retractors2 Vein retractors4 Skin hooks, 2 single and 2 double1 Gelpi retractor4 knife handles, no. 3, with no. 10 and no. 15 blades1 Tracheal hook2 Mayo scissors, straight and curved2 Metzenbaum scissors2 scissors, small, curved, sharp and blunt4 Tissue forceps, 2 with and 2 without teeth2 Adson tissue forceps2 Brown-Adson tissue forceps1 Periosteal elevators2 Freer elevators1 Bayonet forcepsBrown or Stryker dermatome (if a skin graft is anticipated)EQUIPMENT:SuctionElectrosurgical unit (ESU)Scales (to weigh sponges)SUPPLIES:Foley catheter and urimeterBasin setMarking penSuction tubingElectrosurgical pencilNeedle magnet or counterGraduateBulb syringes (2)Dissectors (peanut)Umbilical tapes, vessel loopsNerve stimulator (locator)Suction drainage unit (Hemovac)Lap sponges4x4 Raytech spongesAs with instruments, equipment and supplies varydepending on surgeon preference, so it is always a good ideato familiarize oneself with the surgeon’s preference card.The last four decades have made way forprogressive advances to occur, giving an understanding of cervical fascial planes, lymphatic drainage patterns, preoperative staging andextracapsular spread.THE SURGICAL PROCEDUREThe surgical incision is made starting at the lateral neckfrom beneath the jaw to the supraclavicular area (diagramB). Skin flaps are mobilized while hemostasis is achievedusing fine hemostats as well as ligatures on bleeding vessels.Once the skin flaps are freed, the surgeon places a tractionsuture in different areas of the skin flap and then places ahemostat on the end. This is done to retract the skin flapfor better exposure. Using curved scissors, the anteriortrapezius muscle is exposed, as well as the external jugular vein. The trapezius muscle and the external jugular veinare clamped, ligated and divided. The internal jugular veinis then found, isolated and divided. The omohyoid muscleis identified and transsected. The fatty tissue in the neckhouses lymph nodes. These lymph nodes are dissected awayfrom other structures and the common carotid artery andvagus nerve are identified (diagram C).The thyrocervical artery is then clamped, divided, andligated. The posterior triangle are dissected starting at theanterior of the trapezius muscle and continuing to the bra-OCTOBER 2010 The Surgical Technologist 451
LatyshevskyLatyshhevevskskyy andand FreundFreuFreundeunddFreundIncision used for unilateral supraomohyoid neck dissectionCrileIncision used for bilateral supraomohyoid neck dissectionDiagram Bchial plexus, the levator scapulae and the scalene muscles.Branches of the cervical and suprascapular arteries are identified then clamped, ligated, and divided. Once the anteriorportion dissection is complete, the omohyoid muscle is severed where it attaches to the hyoid bone. Once hemostasisis controlled, all hemostats are removed. The surgical fieldis then covered with warm, moist, sterile laparotomy packs.Next, the sternocleidomastoid muscle is cut and retractedout of the way. At this point the submental space is dissected from fatty tissue that houses lymph nodes, startingupward and working down. The fascia that is deep on thelower portion of the mandible is then incised and the facialvessels are then divided and ligated.Entering the submandibular triangle, the submandibular duct is divided and ligated. The submandibular glandsthat have fatty tissue and lymph nodes surrounding them452 The Surgical Technologist OCTOBER 2010are dissected going toward the digastrics muscle. The facialbranch of the external carotid artery is identified and divided. Parts of the digastrics, as well as the stylohyoid muscles,are then cut where they attach to the hyoid bone and mastoid. The top end of the internal jugular vein is elevated anddivided, and the mass is removed.The entire surgical site is checked for any bleeding andirrigated with warm saline solution. If a skin graft is needed,it is placed over the bifurcation of the carotid artery downward about four inches, then sutured using 4-0 absorbablesuture on a small cutting needle. Tubing for the Hemovacdrain, if that is the surgeon’s preference, is placed in thewound. The skin flaps are then approximated and closedwith interrupted, fine non-absorbable sutures or skin staples. A pressure dressing is applied to the neck, which alsodepends on the surgeon’s preference.
Submandibular GlandFacial Artery VeinExternal Carotid ArteryFacial NerveDigastric MuscleMandibular NerveInternal Juglular VeinCervical NerveHyoid BoneTrapezius MuscleThyroid CartilageExternal Carotid ArteryThyroid leidomastoidMuscleRECONSTRUCTIVE PROCEDURESWhen reconstructive procedures are performed, the methodused depends on the surgical defect. The surgical wound maybe closed primarily or with split-thickness skin grafts. Localflaps may be used. These skin grafts are used for facial orintraoral defects. For nasal and facial defects, full-thicknessskin grafts are used. The pectoralis major musculocutaneous flap is an example of a regional flap. The radial forearmflap, free jejunal flap and rectus abdominis flap are used formicrovascular tissue transfer. The iliac crest flap is used formicrovascular osteocutaneous flaps. All of these flaps areused to restore function and cover defects. The grafts andflaps listed above are performed when it is deemed necessary due to large defects that are created. When microvascular flaps are used, surgical and anesthesia time increasesignificantly. This is because veins and arteries are connectedReprinted with permission of WelleschikDiagram CRadical Neck DissectionOCTOBER 2010 The Surgical Technologist 453
microscopically. Nerve grafts and bone grafts may also be used, and must be connected by using plates and screws.In a 2000 study, published in The Laryngoscope, it was determined thatallograft, or cadaveric tissue, may be useful in this type of procedure. Benefitsof allograft include a reduction in the the surgical time, as well as the amountof time that a patient is under general anesthesia. AlloDerm is a dermal graftthat is derived from banked human tissue. Because it has been decellularized,AlloDerm does not induce an immune response in the body, reducing the probability that the graft will be rejected.5 The study concludes that a previouslyirradiated field does not adversely affect the integration of AlloDerm , making ita potentially viable alternative to an autograft option—or the harvesting of thepatient’s own tissue for reconstructive purposes. Originally developed for use inburn patients, it has recently made strides toward wider acceptance and utilization in different surgical settings.Doppler units are used intraoperatively as well as postoperatively. It is paramount to have thorough nursing assessment skills so that occlusions and/orspasms of the vessels can be spotted in order for the transplanted flap to survive.The patient’s average hospital stay is 13-15 days.SPECIAL NOTE:* Make sure the blood bank has blood available and ready for the patient asordered.* The surgical sponges must be weighed and the irrigation fluids measuredaccurately.ABOUT THE AUTHORDeborah D Lamb, CST, graduated from Hinds Community College in Jackson, Mississippi as a President’sScholar in 1997. She worked at a Level I trauma center inJackson until 1998, when she transferred to a small hospital in Athens, Alabama, where she worked until 2000.After spending six years as a vet tech, Ms Lamb decidedto retire, but she continues to maintain her certification.AlloDerm is a registered trademark of LifeCell Corp.References1. Kazi, RA. “The Life and Times of George Washington Crile: An Outstanding Surgeon.” The InternetJournal of Otorhinolarygology. 2003. Vol 2, No 2.Earn CE Credits at HomeYou will be awarded continuing education (CE) credits toward your recertification after reading the designated article and completing the test with a score of70% or better. If you do not pass the test, itwill be returned along with your payment.Send the original answer sheet from thejournal and make a copy for your records. Ifpossible use a credit card (debit or credit) forpayment. It is a faster option for processing ofcredits and offers more flexibility for correctpayment. When submitting multiple tests,you do not need to submit a separate checkfor each journal test. You may submit multiplejournal tests with one check or money order.Members this test is also available onlineat www.ast.org. No stamps or checks andpost to your record automatically!Members: 6 per credit(per credit not per test)Nonmembers: 10 per credit(per credit not per test plus the 400 nonmemberfee per submission)After your credits are processed, AST willsend you a letter acknowledging the numberof credits that were accepted. Members canalso check your CE credit status online withyour login information at www.ast.org.2. Shaha, A. 2007. “Editorial: Complications of Neck Dissection for Thyroid Cancer.” Annals of Surgical Oncology. Accessed: August 19, 2010. Available at: 7/.3 WAYS TO SUBMIT YOUR CE CREDITS3. American Head & Neck Society. 2005. “Hayes Martin Biography.” Accessed: August 19, 2010, Availableat: x CE credits to: 303 -694-91694. Martin, H. “The Treatment of Cervical Metastatic Cancer.” Annals of Surgery. 1941. Vol 114, No 6. Available online at: 5/pdf/annsurg00378-0016.pdf.5. Dubin, M; Feldman, M, et al. “Allograft Dermal Implant (AlloDerm) in a Previously Irradiated Field.”The Laryngoscope. Lippincott Williams & Wilkins, Inc. Philadelphia. 2000.454CE EXAM The Surgical Technologist OCTOBER 2010Mail to: AST, Member Services, 6 West DryCreek Circle Ste 200 Littleton, CO 80120-8031E-mail scanned CE credits in PDF format to:[email protected] questions please contact Member Services [email protected] or 800-637-7433, option 3.Business hours: Mon-Fri, 8:00a.m. - 4:30 p.m.,mountain time