General Overview of Neck Dissection
History
1888
Franciszek Jawdynski (1851–1896), a surgeon from Warsaw, was the first to perform a neck dissection in metastasizing head and neck carcinomas. He described an en bloc resection of the lymph nodes together with the carotid artery, the internal jugular vein, and the sternocleidomastoid muscle; unfortunately, because his description was in Polish, it did not gain much popularity.
1906
George Washington Crile (1864–1943), from Cleveland, Ohio, described his experience with 132 cases of radical neck dissection in head and neck carcinomas.
1962
Argentinian Osvaldo Suarez (1912–1972), from Cordoba, introduced in the Spanish literature his concept of the modified neck dissection with preservation of one or more nonlymphatic structures. It was reported that he did a modified neck dissection in an astonishing 20 minutes. After some visits to Argentina, Ettore Bocca (1914–2003), from Ferrara, Italy, popularized the modified neck dissection in English language publications.
Classification and Clinical Management
As a basic principle, ipsilateral neck dissection of levels I to III is performed in all carcinomas of the oral cavity that have not been operated on previously. Bilateral neck dissection of levels I to III is categorically done when the intraoral malignancy extends over the midline. Neck dissection is started with dissection of the ipsilateral level II and III lymph nodes, which are immediately sent to a pathologist who performs instantaneous sections from the tissue. If lymph node metastasis is found, neck dissection is extended to levels IV and V on the ipsilateral side and levels I to III on the contralateral side.
Management of the clinical and radiological negative neck includes a functional neck dissection. Strict focus has to be paid to preserving the spinal accessory nerve (SAN), the sternocleidomastoid (SCM) muscle, and the internal jugular vein (IJV). Even in positive necks, these structures should be preserved when the lymph nodes can be dissected clearly off these structures.
Management of lymph node–positive necks with clear adherence of lymph node metastases to one of the mentioned structures includes a modified radical neck dissection. The adhered structure (SAN, SCM muscle, or IJV) has to be included in the dissection.
Management of the lymph node–positive neck with adherence of the lymph node metastasis to all three structures (SAN, SCM muscle, and IJV) includes a radical neck dissection.
There is no evidence-based clinical benefit in resecting the neck dissection specimen en bloc. Therefore, splitting the neck dissection levels in stages is preferred as shown in the following techniques of neck dissection. This approach facilitates the postoperative tumor board review discussion. The exact pinpointing of cervical metastasis for adjuvant radiotherapy is alleviated.
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