Neck Dissection - Level 2-4

Considerations

Preparation

Procedure

Sample operative report

An incision was planned from the submental area down into a low transverse skin crease and then back to the post auricular area near the mastoid process to include the old scar. A total of 7 ml of epinephrine 1:100,000 solution was then infiltrated into the proposed incision line. The neck was then prepped and draped in standard fashion.

The skin was then incised through skin and subcutaneous tissue and platysma muscle. A subplatysmal flap was then raised a superiorly to expose level 2. The inferior edge of the submandibular gland was identified and the fascia overlying the gland was then elevated off of the gland. The flap was then elevated to the inferior aspect of the mandible. The marginal branch of the facial nerve was preserved. The soft tissue posterior and inferior to the gland was dissected away from the gland and the posterior belly of the digastric muscle. The posterior belly of the digastric was then traced posteriorly and the spinal accessory nerve was identified running over the internal jugular vein at the level of C2 transverse process.

An inferior skin/subplatysmal flap was then raised down to the level of the clavicle. The fascia overlying the sternocleidomastoid muscle was then divided with a 15 blade, and the fascia was then dissected off the anterior and medial aspects of the muscle. The spinal accessory nerve was identified superiorly in the anterior muscle and traced superiorly toward the IJV. The hypoglossal nerve was also dissected out and away, dissected toward the skull base as well. The dissection of the SCM away from the soft tissue continued until approximately 3-4 cm of soft tissue were exposed posterior to the posterior aspect of the internal jugular vein. The spinal accessory nerve was freed up from its surrounding soft tissue attachments so that it was freely mobile, and the level 2B area was then dissected away from the sternocleidomastoid muscle and the deep floor of the neck fascia, and the fat and lymph nodes were then located under the nerve and onto the internal jugular vein. The fat and soft tissue were then divided from superiorly to inferiorly 3-4 cm posterior to the posterior edge of the internal jugular vein. The cervical plexus rootlets were identified and preserved. The omohyoid muscle was retracted inferiorly and the soft tissue in level IV was mobilized and brought superiorly. The transverse cervical artery and vein were identified and preserved, and the specimen was then rotated onto the carotid sheath contents. The specimen was then dissected away from the internal jugular vein, the common carotid artery, vagus nerve, and internal jugular vein, and the specimen was rotated medially so that the final attachments to the strap muscle fascia was then divided and specimen was removed. The phrenic nerve was identified and preserved. The specimen was then divided in levels 2, 3, and 4.

The wound was then inspected for hemostasis. No bleeding was encountered. No evidence of leak from an accessory duct/thoracic duct was identified with Valsalva maneuver. The wound was then Irrigated with copious amounts of Bacitracin irrigation. A round Blake drain was then placed into the wound deep in the posterior triangle and then brought out through the anterior triangle superiorly. The drain was secured to the skin using 3-0 Nylon. The skin flaps were then reapproximated. The incision was closed in two layers; The subcutaneous layer was closed using buried 3-0 Polysorb. The skin was closed using subcuticular running 5-0 Biosyn. The wound was then dressed with steri-strips, Mastisol, gauze, and Tegaderm.

The patient was returned to the anesthesiologist for further management and was subsequently transferred to PAR in stable condition. Final needle and sponge counts were correct. No complications were encountered.

Post-op

Pearls & Pitfalls

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