Cervical Nodal Dissection - Tips and Techniques - Head & Neck Cancer Surgery скачать в хорошем качестве

Cervical Nodal Dissection - Tips and Techniques - Head & Neck Cancer Surgery

This video illustrates surgical tips and techniques on performing Cervical Nodal Dissection. The surgery was 1st described by the American surgeon George Washington Crile in 1906. The procedure underwent significant modifications during the 1950s & 1960s & is now accepted surgical practice for a selected group of head & neck cancers. Most texts describe 3 types of nodal dissections. Radical Lymphadenectomy means removal of the IJV, AN & the sternocleidomastoid muscle together with all macroscopic lymphatics on one side of the neck neck as a standard procedure. Modified Radical Dissections try to preserve any or all of the above 3 structures & selective nodal dissections target the 1st & 2nd tier nodal groups of a head & neck cancer. From our vast experience we can say that one can preserve all three structures in most cases & perform a macroscopically complete Nodal Dissection. However if there is any evidence of macroscopic invasion of any of the above 3 structures, we do not hesitate to excise the involved part of the structure en-bloc together with the lymphatics. So in our view there are only two types of block dissections. Comprehensive Nodal Dissection, which means a complete macroscopic nodal dissection usually excluding level 6 unless there is clinical evidence of level 6 lymphadenopathy or in the case of Thyroid & Laryngeal cancer. The other type is selective nodal dissection. In this lecture we will be talking about comprehensive nodal dissection since selective nodal dissection means removal of one or two levels from the six levels of nodes without clinical evidence of malignancy. Thyroidectomy incision can be extended laterally to perform a selective lateral or even a comprehensive neck dissection. Remember, if you do not raise the flaps in the proper plane, flap necrosis is very likely to happen. The fascia along the anterior border of the SM muscle is incised & the SM muscle is separated if there is any evidence of tumor attachment. In most cases we do not divide the muscle but use a rubber sling around the muscle at various levels to retract it. Once the SM muscle is retracted or divided the omohyoid muscle shown in number 5 with its tendon overlying the IJV comes into view. We always divide to reach the IJV. Try your best to preserve the IJV if uninvolved by the tumor, since division of the IJV leads to marked facial edema which may be worse in patients who have already received radiotherapy previously. Retract the lower most part of the IJV anteriorly & incise the thin membrane over the fat layer between it & the trapezius muscle. This will help you to scoop the lowermost; that is level 4 nodes, together with level 5 nodes. On the left side, be careful about the flimsy thoracic duct & avoid damaging it. Also try to preserve the supraclavicular nerves which traverse this fat to enter the pectoral region by running superficial to the clavicle. Clearing the level 4 cervical nodes reveal the lower prevertebral musculature & the surrounding structures. Carry out the nodal dissection upwards up to level 2 . Retract the IJV all around to see nodes hiding between the IJV & the carotid artery. During comprehensive nodal dissection, we always encounter 3 nerves, if damaged can lead to significant morbidity. Iatrogenic injury to hypoglossal nerve is disastrous. Therefore, always carefully expose this nerve which runs lateral to the ext & int. carotid arteries about 1cm above the carotid bifurcation. Final step is to perform level 1 dissection together with the submandibular gland. The facial vein running over the gland is divided & the fascia overlying the gland, which contains the marginal mandibular branch of the facial nerve is swept off of the gland superiorly. The digastric tendon is retracted inferiorly while maintaining upward traction on the gland to deliver the facial artery passing deep to the digastric muscle & the gland. The facial artery is divided both at this level & also at the level of the lower border of the mandible, since there is good blood supply from the contralateral facial artery. The gland is finally delivered by dividing the duct & the submandibular ganglion attached to the lingual nerve. This channel is dedicated to everyone who is interested in the field of Oncological surgery & is conducted by Dr. Anuruddha Thewarapperuma MBBS MS, a Consultant Cancer Surgeon from Sri Lanka. This includes a series of video classes & lectures on operative surgery with illustrations, valuable tips and advice. Please feel free to comment, give suggestions & ask questions in the comment section below. We hope this channel will be thought provoking and inspiring to all the surgeons, medical students, aspiring doctors, nurses and anyone in the surgical community who is interested in Cancer Surgery. We wish you all the best! Thank you! Contact us [email protected]