What are the steps in a neck dissection procedure?

Neck Dissection Surgical Steps

Preoperative Planning and Classification

The type of neck dissection performed is determined by the clinical N-stage: selective neck dissection for N0 disease, selective or comprehensive for N1-N2 disease, and comprehensive neck dissection for N3 disease. 1, 2

Determine Laterality

• Perform bilateral neck dissections for tumors at or approaching the midline (base of tongue, palate, supraglottic larynx, deep pre-epiglottic space involvement) due to bilateral lymphatic drainage risk 1, 2
• For advanced anterior tongue or floor of mouth lesions crossing midline, perform contralateral submandibular dissection as needed for adequate tumor resection 1
• Unilateral dissection is appropriate only for clearly lateralized tumors 2

Select Nodal Levels Based on Primary Site and N-Stage

For N0 Disease (Selective Neck Dissection): 1, 2

• Oral cavity: Levels I-III minimum
• Oropharynx: Levels II-IV minimum
• Hypopharynx: Levels II-IV, plus Level VI when appropriate
• Larynx: Levels II-IV, plus Level VI when appropriate (mandatory for infraglottic cancers)

For N1-N2 Disease: 1, 2

• Either selective or comprehensive neck dissection acceptable
• Comprehensive dissection generally preferred for therapeutic intent with higher tumor burden
• Selective dissection may prevent morbidity in carefully selected low-burden cases

For N3 Disease: 1, 2

• Comprehensive neck dissection removing all lymph node groups (Levels I-V) is mandatory

Surgical Technique Steps

Incision and Flap Elevation

• Create skin incision appropriate for planned dissection extent (modified Schobinger, apron, or utility incision) 3, 4
• Elevate subplatysmal flaps superiorly to the mandible and inferiorly to the clavicle 3, 4
• Identify and preserve the marginal mandibular nerve during superior flap elevation 3

Systematic Nodal Level Dissection

Level I (Submental and Submandibular Triangles): 4

• Dissect submental triangle contents between anterior bellies of digastric muscles
• Remove submandibular gland with surrounding lymphatic tissue
• Identify and preserve the marginal mandibular nerve, lingual nerve, and hypoglossal nerve
• Ligate facial vessels as needed

Levels II-III (Upper and Mid-Jugular Nodes): 3, 4

• Identify the spinal accessory nerve in the posterior triangle
• Preserve the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle in modified/selective dissections 3, 4
• Dissect lymph node-bearing tissue from the skull base (Level II) down to the omohyoid muscle crossing point (Level III)
• Remove jugulodigastric and jugulo-omohyoid lymph node groups
• Preserve cutaneous branches of cervical plexus anteriorly

Level IV (Lower Jugular Nodes): 3

• Continue dissection from omohyoid muscle to clavicle
• Preserve the phrenic nerve on the anterior scalene muscle
• Identify and preserve the thoracic duct on the left side

Level V (Posterior Triangle): 3

• Dissect lymphatic tissue posterior to sternocleidomastoid
• Preserve the spinal accessory nerve unless involved by tumor
• Identify brachial plexus and avoid injury

Level VI (Central Compartment): 1, 2

• Perform for laryngeal and hypopharyngeal primaries, especially infraglottic cancers
• Remove pretracheal, paratracheal, and prelaryngeal (Delphian) nodes
• Preserve recurrent laryngeal nerves bilaterally

Structure Management Based on Dissection Type

Comprehensive Neck Dissection: 2, 3

• Remove all lymph node levels I-V
• May sacrifice sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve if involved

Modified Radical Neck Dissection: 3, 5

• Remove all lymph node levels I-V
• Preserve one or more non-lymphatic structures (nerve, vein, muscle)

Selective Neck Dissection: 2, 3, 4

• Remove only at-risk nodal levels based on primary site
• Preserve all non-lymphatic structures

Specimen Handling

• Orient or section the specimen to identify specific lymph node levels for accurate pathologic staging 2
• This allows determination of need for adjuvant therapy based on extracapsular extension, number of positive nodes, and margin status 6, 2

Critical Technical Pitfalls to Avoid

• Never omit Level VI dissection for infraglottic laryngeal cancers where this level is frequently involved 2
• Never perform unilateral dissection for midline tumors without bilateral assessment 7, 2
• Never perform selective neck dissection for clinically evident nodal disease beyond N1-N2a; these patients require comprehensive dissection 2
• Direct nerve invasion or preoperative paralysis may warrant segmental resection and nerve grafting if tumor-free margins are assured 1
• For parotid malignancies requiring neck treatment, perform ipsilateral selective dissection of Levels II-IV for T3-T4 or high-grade tumors 2

Wound Closure

• Place closed suction drains in the dissection bed 3
• Re-approximate platysma and close skin in layers 3
• Consider reconstructive options (pectoralis myocutaneous flap) if extensive skin excision performed 8