Neck
Pre-work:
Each resident should choose at least one structure (write your name after it)
For this structure, find the ‘best’ article describing its surgical anatomy
this must come from the primary literature (i.e. a study, not review article or book chapter)
You will be responsible for teaching this to your colleagues
emphasize anatomic relationships and landmarks
Dissection:
Identify the following structures and follow along the entire length:
Neck Base (below cricoid)
on full cadaver
(may be helpful to have bone cutters or saw to extend dissection into chest)
4 residents, 2 on each side
Vessels
subclavian artery subclavian vein - BLandau
thoracic duct
lymphatic duct
thyrocervical trunk - BLandau
vertebral artery - BLandau
Nerves
Vagus - RLN (follow into chest)
sympathetic chain - BSong
brachial plexus
Ansa Cervicalis
Phrenic - TSong
Muscles
omohyoid
trapezius
scalene muscles
Upper Neck (cricoid to angle mandible)
on cadaveric head/neck
4 residents, 2 on each side
Vessels
Entire External Carotid System
lingual artery - SChen
Nerves
Spinal Accessory - JLin
Marginal Mandibular - JGilde
Most commonly injured in dissection of level Ib
The Hayes-Martin maneuver involves ligation of the posterior facial vein and superior reflection of the investing fascia (superficial layer of the deep cervical fascia) below the mandible to preserve the marginal mandibular nerve. The peri-facial nodes thus remain undissected. (article link, atlas link)
Original articles (bold underlined signifies best articles, red signifies full text was not available)
NOTE: The literature varies in quality and methodology (cadaveric vs live) and the results and conclusions vary accordingly. The classic paper came in 1962 from Dingman and Grabb. Much of the literature since comes from outside the US. To my knowledge, there are no review articles on this topic.
2005 http://www.ncbi.nlm.nih.gov/pubmed/15768421
Point A at the angle of the mandible, Point B just anterior to the facial artery, and Point C, 2 cm anterior to Point B. A metric and geometric morphometric analysis, including thin-plate spline and relative warp analysis was done to determine the variation of nerve position in relation to these three bony landmarks. The metric study indicated a median distance from Point A to the nerve 2.3 mm inferior to Point A, 2.4 mm superior to Point B, and 10.7 mm superior to Point C. The shape analysis indicated that variation in the position of the nerve occurs most commonly at Points A and B.
2006 http://www.ncbi.nlm.nih.gov/pubmed/16721470
The evaluation of the anatomic pieces showed 1 to 3 branches of the marginal mandibular branch, anastomoses with the buccal and cervical branches of the facial nerve and distances between –1.3 cm to +1.2 cm from the inferior margin of the mandible. In 57.7% of the cases, the nerve passed superiorly and along the length of the inferior margin of the mandible.
2007 http://www.ncbi.nlm.nih.gov/pubmed/18058753
one branch (32%), two branches (40%) and three branches (28%). The relationship of the nerve to the lower border of the mandible was variable: it was either totally above the lower border of the mandible (28%), below the mandible (44%) or in 28% of cases lying above and below it. The branch which lay below the lower border of the mandible crossed it opposite the masseter muscle or opposite the facial artery or else anterior to the facial artery. The branches which lay above the lower border of the mandible were always deep into the superficial layer of the parotid fascia, while below the mandible all the branches ran intrafascially. The termination of the nerve was always deep to the muscles of the lower lip.
2013 http://www.ncbi.nlm.nih.gov/pubmed/23552588
one branch (36.4%), and 2 branches (63.6%). The distance of the nerve from the inferior border of the mandible varied from 13.06-40.08 mm, with an average distance of 21.91 mm. There were communications with buccal branch only in 2 specimens (4.6%). All the branches of the marginal mandibular branch ran laterally to the facial artery in 43 (97.7%) of the 44 specimens. In one specimen, the 2 marginal mandibular branches ran between the facial artery and vein.
2014 http://www.sciencedirect.com/science/article/pii/S2090506814000025
Hypoglossal - LHarless
Lingual - ARivero
Glossopharyngeal
Muscles
digastric
Bones
Styloid
C1, Transverse Process - SChen