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Neck Dissection (Level I-IV)

Neck Dissection (Level I-IV)

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Preoperative Considerations

Consent:

  • Bleeding: possible transfusion
  • Infection
  • Sensory & motor nerve damage
  • Difficulty Swallowing
  • Hoarseness & difficulty speaking
  • Shoulder Dysfunction: frozen shoulder, limited range
  • Lymphedema:
  • Cosmetic Changes

Anesthesia/Positioning:

  • Supine
  • Shoulder roll with adequate neck extension
  • Paralysis per surgeon preference

Other:

  • Type & screen
  • Communicate with ICU PRN

Armamentarium:

  • Scalpel Handle
  • Metzenbaum Scissors
  • Dissecting Forceps (e.g., Adson Forceps)
  • Hemostatic Forceps (e.g., Kelly Forceps)
  • Bipolar Cautery or LigaSure Vessel Sealing Device
  • Suction Apparatus
  • Weitlaner Retractor
  • Richardson Retractor
  • Senn Retractor
  • Electrocautery or Harmonic Scalpel
  • Suture Material (e.g., Vicryl, Nylon)
  • Specimen Containers
  • Anesthesia Equipment
  • Sterile Draping Materials
  • Sterile Gauze and Sponges
  • Topical Hemostatic Agents (e.g., Surgicel, Floseal)
  • Optional Imaging Equipment (e.g., intraoperative ultrasound, nerve monitoring devices)

Technique

  • ​Intubation and standard headwrap ensuring exposure below clavicles (if large reconstruction is planned, prudent to prep till xiphoid in case pectoralis salvage flap is needed
  • Mark skin incision ​in skin crease. Various designs per surgeon preference
Skin incision is marked
  • Skin incision with blade or monopolar
  • Keep incision 2 cm away from tracheostomy if present
  • Dissect through skin and subcutaneous tissue until platysma is encountered
skin incision
dissection through subcutaneous tissue
platysma is encountered
  • Begin elevating subplatysmal flap using traction and countertraction. This can be done by retracting with the skin hooks towards the ceiling
  • Take care to avoid perforating skin
platysma
  • External jugular is identified and dissected to be as long cephalad as possible for use as venous graft or coupling for reconstruction
  • Take care to avoid indiscriminate diathermy to avoid damage.
external jugular is identified and skeletonized
great auricular nerve is identified and protected
subplatysmal flap is elevated
subplatysmal flap elevationis continued
subplatysmal flap
SCM dissected away from the fascia
subplatysmal flap is elevated inferiorly
  • Subplatysmal flap should be elevated inferiorly to the clavicle, avoid EJ injury with traction & countertraction
continuation of subplatysmal flap inferiorly
  • SCM is identified and retracted laterally
scm is retracted laterally and dissected away from the deeper tissue
  • Ligate any small veins between the SCM and the lymphofatty tissue
  • Expose and free spinal accessory nerve (XI)
spinal accessory nerve is identified
vessel loop placed around CN XI
  • Continue exposing the lymphofatty tissue underneath the SCM until the cervical nerve rootlets are encountered
  • Start elevating the lymphofatty tissue from posterior to anterior
lymphofatty packet is grasped and carefully dissected away from underlying great vessels
  • Start exposing the IJ f
  • rom caudad to cephalad
internal jugular is exposed
  • During level IV dissection, the lymphatic duct may be encountered and ligated
IJ is retracted medially and level IV lymph nodes are exposed for removal
Level IV dissection
  • Lymphofatty tissue is harvested from posterior to anterior
Dissection is carried superiorly into level iii
  • IJ is retracted with a venous retractor and the lymphofatty tissue of level IV is elevated from caudad to cephalad (towards level III)
Lymphofatty packet is dissected away from the IJ
  • After finishing elevation of levels III & IV, attention is directed towards level II
futher superior dissection towards level II
level 2b nodes are removed taking care to preserve CN XI
Level IIB is pulled underneath XI towards level IIA
level IIA dissections
  • Levels Ia and Ib are then harvested and elevated superiorly along with levels II, III, IV
lymphofatty tissue is released from the strap muscles
  • Carotid fascia is then carefully incised
  • Dissection is carried deeply to identify the carotid
careful dissection of packet away from underlying carotid
carotid exposed (medial to suction)
carotid is dissected
exposure of carotid
spreading dissection is used to skeletonize great vessels
external carotid is skeletonized to identify vessels
continued superior elevation of the lymphofatty packet
junction of common facial vein and internal jugular vein
packet elevated off of digastric muscle
specimen is removed
primary tumor is visualized
specimen removed
completed neck dissection

Postoperative Considerations

Immediate:

  • Elevate HOB
  • Monitor drain output
  • Maintain normotension
  • CXR if concomitant trach

Follow Up:

  • Remove skin sutures POD7
  • Remove skin staples POD10

Operative Note

Surgeon(s): ***

Assistant Surgeon(s):  ***

Preoperative Diagnosis: ***

Postoperative Diagnosis: Same

Procedure(s): ***

Anesthesia: General

Implants: None

Specimen:***

Drains: None

Fluids: See anesthesia record

EBL: Minimal

Complications: None

Counts:  Correct x2

Indications: ​***

Findings: As expected

Procedure in Detail:

The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

A curvilinear utility incision was made in a natural skin crease extending from the mastoid process crossing to the midline at the level of the cricothyroid membrane.  Superior and inferior subplatysmal skin flaps were elevated and secured with silk ties.  Level 1A was then cleared from the symphysis of the mandible to the hyoid bone inferiorly.  This was then carried to level 1B.  Care was taken to identify the marginal mandibular nerve and protected via Hayes-Martin maneuver after identifying the facial vein and facial artery which were tied and elevated superiorly.  Perifacial lymph nodes were harvested and submitted for permanent pathology.  Submandibular gland was then incised and removed out of its fossa after identifying the posterior edge of the mylohyoid and then identifying the lingual nerve.  Care was taken to preserve this as it was dissected posteriorly up towards the jugular vein.  Once the jugular vein was encountered, attention was then turned posteriorly to the SCM where the superficial layer of the deep cervical fascia was then elevated and dissected posteriorly up toward the contents of level 5.  Spinal accessory nerve was identified superiorly as well as the omohyoid inferiorly and in an inferior to superior direction, the fibrofatty contents of levels 1, 2, 3 and 4 were elevated and submitted for permanent pathology.  Hemostasis was achieved.  A 19 French Blake drain was then placed into the gutter and secured to the skin with a 3-0 nylon.  The wound was closed in layers with 3-0 Vicryl suture and a 5-0 Prolene superficially.  Confirmation of hemostasis was achieved with Valsalva maneuver by the anesthesia service.

The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

Coding

  • 21244 Reconstruction of mandible - extraoral approach, with plate application
  • 35701 Exploration of Neck / Carotid vessels
  • 41155 Composite procedure with resection of floor of mouth, mandibular resection, and neck dissection
  • 20969 Fibula free Flap, osteocutaneous
  • 20245: Deep bone open biopsy (bone deep to muscular tissue)
  • 31600 Tracheotomy
  • 21209 Osteoplasty of facial bone with reduction Incision and repair of bony defect of cheek bone including bony segment reduction
  • 69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
  • 88331, Pathology consultation during surgery
  • 14041  Local tissue rearrangement
  • 97605 Wound vac application < 50cm SQ
  • 64400 - Local anesthesia block
  • 76377 - 3D post-processing images are reconstructed on an independent workstation with concurrent physician supervision.
  • Surgical Dental extraction

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