CASE STUDY

ON
RIGHT MODIFIED NECK DISSECTION
[MND]

DISEASE CONDITION

MODIFIED NECK DISSECTION (MND)

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Definition:

Modified neck dissection (MND) is defined as the excision of

all lymph nodes routinely removed in a radical neck dissection
with preservation of one or more non-lymphatic structures.

Classification of neck dissection:

A. Radical neck dissection (RND):

Removes I, II, III, IV and V level of lymph nodes,
sternocleidomastoid muscle, internal jugular vein, spinal
accessory nerve, submandibular salivary gland, tail of the
parotid and omohyoid muscle.

Modified radical neck dissection:

Type I: Preserves accessory cranial nerve (CNXI)-
Type II: Preserves CN XI and internal jugular vein (IJV)-
Type III: Preserves CN XI, IJV and sternocleidomastoid
muscle (SCM)

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Radical neck dissection

Modified radical neck

dissection with preservation
of SAN

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Modified radical neck
dissection with
preservation of SCM,
IJV and SAN

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B. Selective neck dissection:
Preserves CN XI, IJV and SCM.
▪ Supra omohyoid (or anterolateral): Removes level I, II and
III lymph nodes (cancer of oral cavity).
▪ Lateral: Removes level II, III and IV lymph nodes (cancer
of pharynx, hypopharynx and larynx)
▪ Posterolateral: Removes level II, III, IV, V and
suboccipital lymph nodes (cancer or melanoma of
posterior scalp or posterior upper neck)
▪ Anterior compartment: Removes level VI lymph nodes
(cancer thyroid, subglottic, cervical trachea,
hypopharynx).

C. Extended neck dissection:

Extended RND may include additional lymph node
groups (retropharyngeal, parotid or level VI nodes) and
non-lymphatic structures (external carotid artery,
hypoglossal nerve, parotid gland, mastoid tip).

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 ANATOMY AND PHYSIOLOGY
A. HEAD COMPONENTS:

The head is composed of a series of compartments, which are

formed by bone and soft tissues.

They are:

1. the cranial cavity,

2. two ears,
3. two orbits,
4. two nasal cavities,
5. an oral cavity

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1. Cranial cavity

The cranial cavity is the largest compartment and contains the

brain and associated membranes (meninges). Most of the ear
apparatus on each side is contained within one of the bones
forming the floor of the cranial cavity. The external parts of the
ears extend laterally from these regions. Simply, it Composed
of a roof and floor.

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2. Orbits

The two orbits contain the eyes. They are cone-shaped

chambers immediately inferior to the anterior aspect of the
cranial cavity, and the apex of each cone is directed
posteromedially. The walls of the orbits are bone, whereas the
base of each chamber can be opened and closed by the eyelids.

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3. Nasal cavity

The nasal cavities are the upper parts of the respiratory tract
and are between the orbits. They have walls, floors, and
ceilings, which are predominantly composed of bone and
cartilage. The anterior openings to the nasal cavities are nares
(nostrils), and the posterior openings are choanae (posterior
nasal apertures). Continuous with the nasal cavities are air-
filled extensions (paranasal sinuses) (arrowed), which project
laterally, superiorly, and posteriorly into surrounding bones
The largest, the maxillary sinuses, are inferior to the orbits.

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4. Oral cavity

The oral cavity is inferior to the nasal cavities, and separated

from them by the hard and soft palates. The floor of the oral
cavity is formed entirely of soft tissues. The anterior opening
to the oral cavity is the oral fissure (mouth), and the posterior
opening is the oropharyngeal isthmus. Unlike the nares and
choanae, which are continuously open, both the oral fissure and
oropharyngeal isthmus can be opened and closed by
surrounding soft tissues.

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Other compartments

In addition to these five compartments there is also four areas.

Two of them related to transitional areas which are:

1. infratemporal fossa
2. pterygopalatine fossa

The other two related to the surface anatomy of the head which
are:

3. The Face and Scalp

1. Infratemporal fossa

The infratemporal fossa is an area between the posterior aspect

(ramus) of the mandible and a flat region of bone (lateral plate
of the pterygoid process) just posterior to the upper jaw
(maxilla).

This fossa, bounded by bone and soft tissues, is a conduit for

one of the major cranial nerve-the mandibular nerve (the
mandibular division of the trigeminal nerve [V3]), which
passes between the cranial and oral cavities.

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12
2. Pterygopalatine fossa

The pterygopalatine fossa on each side is just posterior to the

upper jaw. This small fossa communicates with the cranial
cavity infratemporal fossa, the orbit, the nasal cavity, and the
oral cavity. A major structure passing through the
pterygopalatine fossa is the maxillary nerve (the maxillary
division of the trigeminal nerve [V2]).

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3. Face and scalp

The face is the anterior aspect of the head and contains a unique
group of muscles that move the skin relative to underlying bone
and control the anterior openings to the orbits and oral cavity.
The scalp covers the superior, posterior, and lateral regions of
the head.

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B. THE NECK

Its superior boundary is along the inferior margins of the

mandible and bone features on the posterior aspect of the skull.
The posterior neck is higher than the anterior neck to connect
cervical viscera with the posterior openings of the nasal and
oral cavities. The inferior boundary of the neck extends from
the top of the sternum, along the clavicle, and onto the adjacent
acromion, a bony projection of the scapula. Posteriorly, the
inferior limit of the neck is less well defined, but can be
approximated by a line between the acromion and the spinous
process of vertebra C7, which is prominent and easily palpable.
The inferior border of the neck encloses the base of the neck.

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Neck compartments

The vertebral compartment contains the cervical vertebrae and

associated postural muscles. The visceral compartment
contains important glands (thyroid, parathyroid, and thymus)
and parts of the respiratory and digestive tracts that pass
between the head and thorax. The two vascular compartments,
one on each side, contain the major blood vessels and the vagus
nerve. These four compartments are enclosed by
musculofascial collar.

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➢ Carotid sheaths
Common carotid artery (bifurcates within the carotid
sheath into the external and internal carotid arteries)
➢ Internal jugular vein
➢ Vagus nerve
➢ Cervical lymph nodes
➢ Column : that descends from the base of the skull to the
thorax. This represents a pathway for the spread of
infection, and it clinically very important.

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Triangles of Neck

The two muscles (trapezius and sternocleidomastoid) that form

part of the outer cervical collar divide the neck into anterior and
posterior triangles on each side.

The boundaries of each anterior triangle are:

1. the median vertical line of the neck,

2. the inferior margin of the mandible, and

3. the anterior margin of the sternocleidomastoid muscle.

The posterior triangle is bounded by:

1. the middle one-third of the clavicle,

2. the anterior margin of the trapezius, and

3. the posterior margin sternocleidomastoid.

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Neck Triangles

1. Anterior
2. Posterior

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What's in the Anterior triangle?

Strap muscles: 3 further Triangles

Common carotid artery bifurcates within the triangle into the

external and internal carotid arteries.

The internal jugular vein also can be found within this area. It
drains blood from the head and neck.

• Facial [VII], Glossopharyngeal [IX], vagus [X],

• Accessory [XI], and Hypoglossal [XII] nerves.
• Lymph nodes
• Facial artery and vein (Submandibular triangle)
• Thyroid and Parathyroids

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Facial Nerve

What's in the posterior triangle?

• Omohyoid muscle- The inferior belly crosses the posterior

triangle
• Scalene muscles
• Subclavian artery-between anterior and middle, Crosses
1st rib
• CVP lines: External jugular vein which empties into
Subclavian vein.

Nerves in Posterior triangle

• The accessory nerve (XI), descends down the neck. After

innervating the sternocleidomastoid muscle, it enters the

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 posterior triangle. Lies relatively superficially in the
posterior triangle, and is at danger of injury.
• The cervical plexus forms within the muscles of the floor
of the posterior triangle. A major branch of this plexus is
the phrenic nerve, which arises from the anterior divisions
of spinal nerves C3-C5. It descends down the neck, within
the prevertebral fascia, to innervate the diaphragm.
• The trunks of the brachial plexus also cross the floor of the
posterior triangle.

NECK LAYERS

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 1. Investing Layer
2. Pretracheal Layer
3. Prevertebral Layer

1. Investing Layer

• Most superficial of the deep cervical fascial layers.

• Surrounds all the structures in the neck.
• When it meets the trapezius and sternocleidomastoid
muscles, it splits into two to completely invest the muscle.

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2. Pretracheal Layer

• It envelops the trachea, oesophagus, thyroid gland, and the

infrahyoid muscles, running from the hyoid bone down to
the superior thorax, where it fuses with the pericardium.
• This layer of fascia can be functionally split into two parts:
Visceral part - encloses the thyroid gland, trachea and
oesophagus.
Muscular part - encloses the infrahyoid muscles.

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3. Prevertebral Layer

• Surrounds the vertebral column and its associated muscles

(scalence, pre-vertebral, and deep muscles of the back).
• In the inferior region of the neck, the fascia surrounds the
brachial plexus and subclavian artery, and here it is known
as the axillary sheath.

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Sinuses

• Air filled extensions of the respiratory part of the nasal

cavity.
• There are four paired sinuses, named according to the
bone they are located in; maxillary, frontal, sphenoid and
ethmoid.
• Contribute to the humidifying of the inspired air. They
also reduce the weight of the skull.
• As they are outgrowths of the nasal cavity, they all drain
back into it.

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Frontal Sinuses: Drain into the nasal cavity via the
frontonasal duct.

Sphenoid Sinuses: Drain out onto the roof of the nasal cavity.
This relations of this sinus are of clinical importance the
pituitary gland can be surgically accessed via passing through
the nasal roof, into the sphenoid sinus and through the sphenoid
bone.

Ethmoidal Sinuses: Empty into nasal cavity at different places

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Maxillary Sinuses: The largest. Located laterally and slightly
inferiorly to the nasal cavities. It drains into the nasal cavity
underneath the frontal sinus opening. This is a potential
pathway for spread of infection - fluid draining from the frontal
sinus can enter the maxillary sinus.

Clinical Relevance: Sinusitis

Sinusitis

As the paranasal sinuses are continuous with the nasal cavity,

an upper respiratory tract infection can spread to the sinuses.
Infection of the sinuses causes inflammation (particularly pain
and swelling) of the mucosa.

Toothache.

The maxillary nerve supplies both the maxillary sinus and

maxillary teeth, and so inflammation of that sinus can present
with.

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Lymph Nodes

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Facail muscles

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 RISK FACTORS AND CAUSES
Factors that can increase your risk of throat cancer include:

▪ Tobacco use, including smoking and chewing tobacco

▪ Excessive alcohol use
▪ Viral infections, including human papillomavirus (HPV)
and Epstein-Barr virus
▪ A diet lacking in fruits and vegetables
▪ Gastroesophageal reflux disease (GERD)
▪ Exposure to toxic substances at work
▪ Lack of physical activity
▪ Certain hormones
▪ Some viruses and bacteria
▪ Overweight
▪ Radiation exposure

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 SIGNS & SYMPTOMS
➢ Hemoptysis
➢ Dyspea
➢ Respiratory obstruction
➢ Dyspagagis
➢ Voice change
➢ Weight loss
➢ Pain

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INVESTIGATION AND EXAMINATION
➢ Physical examination/blood and urine tests
➢ Endoscopy
➢ Biopsy
➢ Biomarker testing of the tumor
➢ X-ray/ barium swallow
➢ Panoramic radiograph
➢ Ultrasound
➢ Computed tomography (CT or CAT) scan

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 MANAGEMENT
MODIFIED NECK DISSECTION (MND) SURGERY

TYPE OF OPERATION : Grade 5

TYPE OF ANESTHESIA : General Anesthesia

ANAESTHETIST : Dr. Vandana & Dr. Thushara

OT IN TIME : 9:15 am

OT OUT TIME : 11:30 am

SETS REQUIRED:

• Head and neck set

• Liga clip applicator
• Instrument for Dr. Pradhan Sultan set
• Basic pack
• Gown pack
• Ethicon liga clip applicator set

ACCESSORIES:

• Blades no 15,20
• R/o gauze
• Rubber catheter no 5
• Black silk no 1/0
• Linen 40,60,80
• PVC tubing
• Liquid paraffin
• Light handles
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 • Bipolar
• Cautry
• Small sponge and big sponge

DRAPPING:

• 2 small towel
• Three bed sheet
• One bed sheet for screen
• Op towel and drawsheets for head drape
• Two drawsheets for side tuck

TRAULLY:

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 PROCEDURE
NECK DISSECTION OPERATIVE STEPS

F IGURE 1: COMPLETED RIGHT MND TYPE II WITH SEQUENCE OF OPERATIVE STEPS

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Figure 1 shows a completed right-sided MND type II. The
superimposed numbers indicate the sequence of the main
operative steps that will be referred to in the description of the
surgery that follows.

STEP 1:

The neck is opened via a horizontal incision placed in a skin

crease at about the level of the hyoid bone. The incision is made
through skin, subcutaneous fat, and platysma muscle. Identify
the external jugular vein and greater auricular nerve overlying
the sternocleidomastoid muscle (SCM) (Fig:2).

F IGURE 2: NOTE PLATYSMA MUSCLE ( TRANSECTED ), AND THE EXTERNAL JUGULAR VEIN AND
GREATER AURICULAR NERVE OVERLYING THE SCM

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Next the superior flap is elevated with cautery until the
submandibular salivary gland is identified. The submandibular
gland fascia is then incised inferiorly over the gland to avoid
injury to the marginal mandibular nerve (Fig:3).

F IGURE 3: INCISION OF SUBMANDIBULAR SALIVARY GLAND CAPSULE

The surgeon then resects the fat and lymph nodes from the
submental triangle (Level Ia). A subplatysmal dissection of the
overlying skin is extended to the opposite anterior belly of
digastric muscle, taking care not to injure the anterior jugular
veins. The submental triangle is resected inferiorly to the hyoid

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bone with electrocautery. The deep plane of dissection is the
mylohyoid muscles (Figures 4 & 5).

F IGURE 4: RESECTION OF SUBMENTAL TRIANGLE

F IGURE 5: RESECTION OF SUBMENTAL TRIANGLE ONTO MYLOHYOID MUSCLES

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STEP 2:

The surgeon next addresses Level Ib of the neck. Because the

marginal mandibular nerve runs in an extracapsular plane, the
submandibular gland capsule is dissected from the gland in a
superior direction in a subcapsular plane (Fig:3). The marginal
mandibular nerve does not need to be routinely identified. The
assistant however watches for twitching of the lower lip, as this
indicates proximity of the nerve. The facial artery and vein are
identified by blunt dissection with a fine haemostat (Fig:6). The
marginal mandibular nerve crosses the facial artery and vein
(Fig:6). Next attention is directed at the fat and lymph nodes
tucked anteriorly and deeply between the anterior belly of
digastric and mylohyoid muscle. These nodes are especially
important to resect with malignancies of the anterior floor of
mouth. To resect these nodes one retracts the anterior belly of
digastric anteriorly and delivers the tissue using electrocautery
dissection with the deep dissection plane being the mylohyoid
muscle (Figures 6, 7).

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F IGURE 6: : THE SUBMANDIBULAR GLAND HAS BEEN DISSECTED IN A SUBCAPSULAR PLANE ;
THE MARGINAL MANDIBULAR NERVE IS SEEN CROSSING THE FACIAL ARTERY AND VEIN ( AT
TIP OF HAEMOSTAT ); FAT AND NODES ARE DELIVERED FROM THE ANTERIOR POCKET DEEP
TO THE DIGASTRIC

F IGURE 7: : D IVIDING THE FACIAL VESSELS BELOW THE MARGINAL MANDIBULAR NERVE

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Other than the nerve to mylohyoid and vessels that pierce the
muscle that are cauterized or ligated, there are no significant
structures until the dissection reaches the posterior free margin
of the mylohyoid muscle. Next attention is directed at the
region of the facial artery and vein. The surgeon palpates
around the facial vessels for facial lymph nodes; if present, they
are dissected free using fine haemostats, taking care not to
traumatise the marginal mandibular nerve. The facial artery and
vein are then divided and tied close to the submandibular gland
so as not to injure the marginal mandibular nerve (Fig:7). This
frees up the gland superiorly, which can then be reflected away
from the mandible (Fig:8). Next the surgeon addresses the
lingual nerve, submandibular duct, and XIIn. The mylohyoid
muscle is retracted anteriorly, and the clearly defined dissection
plane between the deep aspect of the submandibular gland and
the fascia covering the XIIn is opened. This is done with finger
dissection taking care not to tear the thin-walled veins
accompanying XIIn. The XIIn is now visible in the floor of the
submandibular triangle (Fig:9).

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F IGURE 8: MARGINAL MANDIBULAR NERVE VISIBLE OVER DIVIDED FACIAL VESSELS ; GLAND
REFLECTED INFERIORLY ; MYLOHYOID MUSCLE WIDELY EXPOSED

F IGURE 9: FINGER DISSECTION DELIVERS THE SUBMANDIBULAR GLAND AND DUCT AND
BRINGS THE LINGUAL NERVE INTO VIEW . T HE PROXIMAL STUMP OF THE FACIAL ARTERY
IS VISIBLE AT THE TIP OF THE THUMB , AND THE XII N BEHIND THE NAIL OF THE INDEX
FINGER

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Inferior traction on the gland brings the lingual nerve and the
submandibular duct into view (Fig:9). The submandibular duct
is separated from the lingual nerve, divided and ligated (Figures
10, 11). The submandibular ganglion, suspended from the
lingual nerve, is clamped, divided and ligated, taking care not
to cross-clamp the lingual nerve (Fig:11).

F IGURE 10: SUBMANDIBULAR DUCT

F IGURE 11: SEPARATING THE SUBMANDIBULAR GANGLION FROM THE LINGUAL

NERVE

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The facial artery is divided and ligated just above the posterior
belly of digastric (Figure 12). (Note: A surgical variation of the
above technique is to preserve the facial artery by dividing and
ligating the 1-5 small branches that enter the submandibular
gland. This is usually simple to do, it reduces the risk of injury
to the marginal mandibular nerve and permits the use of a
buccinator flap based on the facial artery (Figure 13)).

F IGURE 12: CLAMPING AND DIVIDING THE FACIAL ARTERY JUST ABOVE THE
POSTERIOR BELLY OF DIGASTRIC

F IGURE 13: F ACIAL ARTERY HAS BEEN KEPT INTACT ; A BRANCH IS BEING
DIVIDED

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 STEP 3:
This step entails identifying the XIIn in Level IIa and freeing
and tracing the XIIn posteriorly where it leads the surgeon
directly to the internal jugular vein (IJV). First divide the fascia
along the lateral aspect of the digastric (Fig:14). Then divide
the external jugular vein (Fig:15). Continue to expose the
posterior belly of digastric along its entire length, taking care
not to wander above the muscle as this would jeopardise the
facial nerve (Fig:16). This step is the key to facilitating
subsequent exposure of the IJV and XIn.

F IGURE 14: D IVIDE THE FASCIA OVERLYING THE F IGURE 15: D IVIDE THE EXTERNAL JUGULAR VEIN
POSTERIOR BELLY OF THE DIGASTRIC MUSCLE

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 F IGURE 16: D ISSECT THE ENTIRE LENGTH OF THE DIGASTRIC

Next identify the XIIn below the greater cornu of the hyoid
bone before it crosses the external carotid artery. It is generally
more superficial than expected and is located just deep to the
veins that cross the nerve. Carefully dissect in a posterior
direction and divide the veins to expose the XIIn (Fig:17).

F IGURE 17: D IVIDING THE VEINS THAT CROSS THE XII N

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After the nerve has crossed the external carotid artery, identify
the sternomastoid branch of the occipital artery that tethers the
XIIn (Fig:18). Dividing this artery releases the XIIn (Fig:19).
The nerve then courses vertically and leads the surgeon directly
to the anterior border of the IJV (Fig:19).

F IGURE 18: STERNOMASTOID BRANCH OF OCCIPITAL

ARTERY TETHERING THE XII N

F IGURE 19: D IVIDING THE STERNOMASTOID BRANCH OF THE

OCCIPITAL ARTERY FREES THE XII N THAT THEN LEADS DIRECTLY
TO IJV. NOTE THE XI N AND THE TUNNEL CREATED BEHIND IJV

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STEP 4:
Using dissecting scissors or a haemostat to part the fatty tissue
in Level II, the surgeon next identifies the XIn which may
course lateral, medial or very rarely through the IJV (Fig:20).
Create a tunnel immediately posterior to the IJV (Fig:19). This
maneuver speeds up the subsequent dissection of Level 2 (Steps
4 & 7). The transverse process of the C1vertebra can be
palpated immediately posterior to the XIn and IJV and serves
as an additional landmark for these structures in difficult
surgical cases. Note that the occipital artery crosses the IJV at
the top of Level II, branches of which may need to be cauterized
should they be severed while dissecting in Level II.

F IGURE 20: XIN PASSING THROUGH THE IJV

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STEP 5:
Surgery now is directed at the anterior neck. The surgeon raises
an anteriorly based subplatysmal flap and exposes the
omohyoid muscle and the SCM muscle inferiorly down the
clavicle, leaving the anterior jugular vein in the elevated flap
(Fig:21). The anterior margin of the omohyoid corresponds
with the anterior margin of the neck dissection. The omohyoid
is divided with cautery and freed up posteriorly with the
surrounding fatty tissue of Levels II and III (Fig:22). Finger
dissection deep to the omohyoid after it disappears behind the
SCM exposes the carotid sheath.

F IGURE 21: ANTERIORLY BASED FLAP ELEVATED F IGURE 22: D IVIDING THE OMOHYOID AND
TO EXPOSE THE OMOHYOID AND SCM CLEARING LEVELS II AND III

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 STEP 6:
The surgeon elevates a posteriorly based flap using
electrocautery or a knife, with good counter traction provided
by an assistant. The platysma is often absent posteriorly and the
flap may be very thin. Placing the index finger behind the flap
permits the surgeon to gauge the thickness of the flap and avoid
“buttonholing” the skin (Fig:23). Take care not to elevate the
external jugular vein or the greater auricular nerve with the flap,
but to leave them lying on the SCM muscle. Movement of the
shoulder is noted as one approaches the XIn or the trapezius
muscle. The dissection continues until the anterior border of
trapezius is reached (Fig:24). In a thin patient the XIn may be
extremely close to skin. Note that the XIn, unlike branches of
the cervical plexus, passes deep to the tr

F IGURE 23: TECHNIQUE OF ELEVATING THE F IGURE 24: POSTERIOR FLAP FULLY ELEVATED TO
POSTERIOR SKIN FLAP THE TRAPEZIUS MUSCLE

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STEP 7:
This step involves dissecting out the XIn and mobilizing Level
IIb. The XIn is identified by dissecting with a haemostat at the
posterior border of the SCM muscle, approximately 1-2cm
posterior to the point where the greater auricular nerve curves
around the muscle (Fig:25). The nerve is often located by
seeing movement of the shoulder due to mechanical stimulation
of the nerve. The XIn passes through the SCM, unlike the
cervical plexus that pass-es deep to the muscle. It is dissected
up-ward through the SCM muscle by tunnel-ing though the
muscle over the nerve with a haemostat, and the cutting the
muscle with diathermy (Fig:26). The lesser occipital nerve (C2)
crosses the XIn at the inferior margin of the SCM (Fig:27).
Take care not to mistake it for the XIn when dissecting
superiorly through the SCM muscle.

THE XIN IS LOCATED 1-2CM BEHIND THE GREATER

AURICULAR NERVE

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F IGURE 26: XIN IS DISSECTED UPWARD THROUGH THE
SCM MUSCLE

F IGURE 27: THE LESSER OCCIPITAL NERVE (C2) CAN BE

CONFUSED WITH THE XI N

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Once the XIn has been exposed up to and freed from the IJV,
expose the nerve distally to where it disappears behind the
trapezius muscle, and then free the nerve completely and
section the branches to SCM (Figs 28, 29).

F IGURE 28: : F REE THE XIN AND DIVIDE ITS F IGURE 29: OPERATIVE FIELD AT END OF STEP 7;
BRANCHES TO SCM NOTE DIVIDED SCM ALONG COURSE OF XI N

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STEP 8:
This step involves dissection of Level IIb and transposition of
the XIn. The SCM is divided below the mastoid. This exposes
fat at the top of Level IIb. The dissection is carried deeper until
the deep muscles of the neck that run in a posteroinferior
direction appear. The only structure that can be injured here is
the occipital artery, and this is simply ligated or cauterized. The
dissection is then directed posteroinferiorly, where the greater
occipital nerve (C1) is divided (Fig:30). The contents of Level
IIb and IIa are then dissected off the deep muscles of the neck
deep to the epimysium until the upper branches of the cervical
plexus come into view (Fig:31). The XIn is now trans-located
posteriorly (Fig:32). Fig:33 illustrates the status of the neck
dissection at this point.

F IGURE 30: D IVISION OF SCM AND IDENTIFICATION AND

DIVISION OF GREATER OCCIPITAL NERVE AND DEEP MUSCLES
OF THE NECK

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F IGURE 31: D ISSECTING LEVEL II F IGURE 32: THE XIN HAS BEEN TRANSLOCATED
POSTERIORLY

F IGURE 33: STATUS OF NECK DISSECTION BEFORE PROCEEDING

TO S TEP 9. NOTE THE TRANSECTED SCM SUPERIORLY

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STEP 9:

The clavicular and sternal heads of the SCM are next divided
with cautery just above the clavicle (Fig:34). The surgeon
applies continuous traction to the muscle during the dissection
to part the muscle fibres as they are transected and to visualise
the IJV immediately deep to the muscle (Fig:35). A scalpel is
used to cut through the carotid sheath onto the IJV (Fig:36).

F IGURE 34: TRANSECTING THE STERNAL HEAD OF THE SCM

F IGURE 35: EXPOSING THE IJV BY INCISING THE CAROTID

SHEATH

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Take care not to dissect immediately lateral to the IJV, as the
right lymphatic duct (right neck) or thoracic duct (left neck)
may be injured leading to a troublesome chyle leak (Fig:36).
Next identify the external jugular vein and the omohyoid
muscle (Fig:37). The external jugular vein is divided and
ligated, followed by division of the omohyoid with cautery
(Figures 38, 39).

F IGURE 36: A DISTENDED THORACIC DUCT IMMEDIATELY LATERAL

TO THE CAROTID ARTERY AND IJV IN THE (L) NECK

F IGURE 37: T HE HAEMOSTAT IS UNDER THE OMOHYOID ; THE

EXTERNAL JUGULAR VEIN IS MORE POSTERIORLY

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 F IGURE 38: EXTERNAL JUGULAR VEIN IS DIVIDED

F IGURE 39: D IVISION OF THE OMOHYOID WITH CAUTERY

F IGURE 40: EXPOSING THE SUPRACLAVICULAR FAT

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The surgeon then incises the fascia overlying the
supraclavicular fat just above the clavicle, once again steering
clear of the right lymphatic duct or thoracic duct (Fig:40). Once
the fat has been exposed, a finger can be used to expose the
fascia covering the brachial plexus (Fig:41). The finger is then
swept medially to expose the phrenic nerve, laterally towards
the axilla and superiorly along the carotid sheath. Take care not
to tear the transverse cervical vessels with the medial sweep.

F IGURE 41: EXPOSING THE BRACHIAL PLEXUS

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STEP 10: Supraclavicular vascular pedicle

This step involves freeing the inferolateral part of Level V. First

identify and divide the supraclavicular nerves, which are
branches of the cervical plexus (Fig:42). Next incise the fatty
vascular pedicle containing the transverse cervical artery and
vein (Fig:43). Figures 44 and 45 demonstrate the isolation and
division of the transverse cervical artery and its proximity to
the XIn.

F IGURE 42: THE SUPRACLAVICULAR NERVES F IGURE 43: NOTE THE PROXIMITY OF THE XIN
( BELOW THE DIATHERMY ) WHEN DIVIDING THE
VASCULAR PEDICLE .

F IGURE 45: D IVISION OF TRANSVERSE

F IGURE 44: TRANSVERSE CERVICAL VESSELS
CERVICAL VESSELS

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STEP 11:

This part of the neck dissection involves anterograde dissection

of Levels II – V and is done with a scalpel. The assistant
maintains firm anterior traction on the neck dissection
specimen, and the surgeon establishes a subepicardial
dissection plane on the deep muscles of the neck, except over
the brachial plexus where the overlying fascia is retained to
protect the nerves (Fig:46). The dissection proceeds over a
broad front until the entire cervical plexus has been exposed.
The phrenic nerve is identified as it descends obliquely across
the scalenius anterior muscle, deep to the prevertebral layer of
deep cervical fascia (Fig:47). The cervical plexus nerves are
each divided, taking care not to injure the phrenic nerve
(Fig:48). This brings the carotid sheath containing common and
internal carotid arteries, the vagus nerve and the IJV into view
(Fig:49). The carotid sheath is incised along the full course of
the vagus nerve, and the neck dissection specimen is stripped
off the IJV while remaining inside the carotid sheath. The ansa
cervicalis, which courses either deep or superficial to the IJV
may be preserved (Fig:50). Inferiorly the pedicle adjacent to the
IJV containing fat, thoracic or right lymphatic duct, and

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 transverse cervical artery and vein is divided, taking care not to
include the vagus or phrenic nerves in the pedicle (Fig:51).

F IGURE 47: D ISSECTION UP TO THE CERVICAL PLEXUS ;

F IGURE 46: ANTEROGRADE DISSECTION OF
NOTE THE PHRENIC NERVE RUNNING PARALLEL TO THE
L EVELS II – V
IJV.

F IGURE 48: D IVISION OF NERVES OF CERVICAL F IGURE 49: THE COMMON CAROTID ARTERY , THE
PLEXUS , STAYING WELL CLEAR OF THE VAGUS NERVE AND IJV
PHRENIC NERVE

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F IGURE 50: THE NECK DISSECTION SPECIMEN HAS F IGURE 51: INFERIORLY THE PEDICLE ADJACENT TO
BEEN STRIPPED OFF THE CAROTID , VAGUS AND IJV THE IJV IS DIVIDED ; NOTE THE PROXIMITY OF THE
IN A PLANE DEEP TO THE CAROTID SHEATH ; THE PHRENIC NERVE
ANSA CERVICALIS HAS BEEN PRESERVED

STEP 12:
The final step is to strip the neck dissection specimen off the
infrahyoid strap muscles, to identify and preserve the superior
thyroid vascular pedicle, and to deliver the neck dissection
specimen (Fig:52).

F IGURE 52: COMPLETED MND TYPE 2; NOTE THE SUPERIOR THYROID

PEDICLE AND ANSA CERVICALIS

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CLOSURE

The neck is irrigated with water, the anaesthetist is asked to do

a valsalva maneuver to elicit unsecured bleeding vessels and
chyle leakage, and a 5mm suction drain is inserted. The neck is
closed in layers with continuous vicryl to platysma and
sutures/staples to skin.

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 NURSING MANAGEMENT
PREOPERATIVE:-
➢ The desk nurse receives the patient
➢ She greets and introduces herself to the patient.
➢ Makes the patient comfortable
➢ Check preoperative checklist
• OTC {operation theater clearance slip}
• Patient identification record
• Nil by mouth status
• Patient identification band
• Medical records (ECG, X-ray, MRI, CT SCAN,
USG, OUTSIDE FILE.)
• CONSENT (Operation consent, Anesthesia consent,
High risk consent, Blood consent)
• Jewellery removed
• Pin/thread/nail polish
• Undergarments removed
• Loose teeth
• Prosthesis, dentures, lens
• Hearing aid present
• Physical preparation (skin shaving)

INTRAOPERATIVE:-
CIRCULATING NURSE
➢ Circulating nurse receives the patient
➢ She introduces herself to the patient
➢ She makes the patient comfortable

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➢ And then she confirms patients name, surgery, surgeons
name both verbally and checking the wrist band
➢ All the health care team workers inside the OT introduce
themselves to the patient
➢ She fills the timeout sheet (if delay in taking patient she
notifies the problem).
➢ She fills the OT utilization form.
➢ She takes the counts of the gauze, sponges from the scrub
nurse.
➢ She enters the counts in the count sheet.
➢ She provides all the items required during the surgery to
the surgeon as well as scrub nurse.
➢ She checks the belongings of the patient.
➢ After the surgery the circulating nurse then shifts the
patient to the recovery room where, she handovers the
patient to the recovery sister along with the patient’s
surgical information and specifies about the drains present
for the patient
➢ Once the patient is shifted to the recovery room circulative
nurse calls the respected floor and inform the sister, she
enters the entire detail of the patient and surgery in the
main register.
➢ She asks the doctor to fill the histopathology form
➢ The specimen is labelled with patients details along the
patients bradma, and formaline is added.

67
 ➢ Further, she enters the specimen details in the specimen
register and asks the attendant to send the sample to the
lab.
➢ Further, she mentions that the has been sent for histopath
in the nursing kardex and the OT charge sheet.
➢ Once the patient is shifted she returns the store tray, calls
the cleaning boy
➢ She ensures that the OT is ready for next case
SCRUB NURSE:
➢ Scrub nurse is the one who helps the surgeon throughout
the procedure
➢ She scrubs for the surgery
➢ She sets the traully for the case
➢ She counts the instruments after opening the set {if any
instrument is less she informs to the circulating nurse to
call the CSSD department and inform and inform about
the same.}
➢ She ensures that the sterility is maintained
➢ She gives the counts of the gauze, small mops and big
mops (before skin incision, before closure of cavity,
before closure of skin)
➢ She helps the surgeon for draping the patient
➢ During the surgery, when the scrub nurse receives the
sample from the surgeon, she labels the specimen with the
marker-pen.
➢ After the surgery she ensures that all the instrument given
to the surgeons are returned back to her
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 ➢ She counts the instruments after the completion of the
surgery
➢ Handover the used instruments to the CSSD department
➢ She handovers all the specimen to the circulating nurse.

POSTOPERATIVE:-
POSTOPERATIVE ORDERS
➢ NBM till further orders
➢ INJ SUPACEF 1.5GM IV BD
➢ INJ PAN 40MG IV TDS
➢ INJ PERFALGAN 1GM IV TDS
➢ INJ TREMAZAC EMSET IV BD
➢ Steam inhalation
➢ Saline nebulization
➢ TPR, BP and input output charting
➢ IV FLUIDS NS/RL
➢ IV NS 60 Ml/Hr
RECOVERY ROOM:-
➢ The patient is received by the recovery nurse.
➢ She introduces the patient about herself and the
postoperative room.
➢ She connects the oxygen mask and attaches all the leads,
pulse oximeter, bp cuff, and fluids.
➢ She provides warmer and makes the patient comfortable
and takes the over from the circulating nurse

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➢ She fills up the anesthesia sheet and the aldrete score
which showed 12 when receiving the patient. She then
observes the patient for 1 hour
➢ She checks the patients belongings.
➢ After all the parameters are normal, the nurse then seek
the permission from the anesthetist about shifting the
patient to the respective ward.
➢ All the belongings along with the specimens sent is
handed over to the floor sister.

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 BIBLIOGRAPHY
❖ https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-
586fbaeba29d/Modified%20and%20radical%20neck%20dissection%20te
chnique.pdf

❖ https://www.slideshare.net/search/slideshow?searchfrom=header&q=hea
d+and+neck+anatomy

❖ https://www.slideshare.net/Buttsa/head-and-neck-anatomy

❖ https://www.slideshare.net/jameelkhan948/neck-dissection-procedure

❖ https://www.slideshare.net/DrsaharAlshamary/types-of-neck-dissection

❖ https://www.slideshare.net/MedicineAndHealth14/radical-neck-dissection

❖ https://www.ncbi.nlm.nih.gov/books/NBK563186/

❖ https://www.ent.cuhk.edu.hk/images/publication/head-and-neck-
dissection-and-reconstruction-manual/05_MODIFIED-RADICAL-
NECK-DISSECTION-TYPE-II.pdf

❖ https://jomi.com/article/238/Bilateral-Modified-Radical-Neck-Dissection

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