Fig. 12.1
A 6-cm incision site is marked within a horizontal neck crease
At this point the fascia overlying the submandibular gland is incised at the most inferior aspect of the gland. The fascia is then bluntly elevated from the underlying submandibular gland to allow for preservation of the marginal mandibular nerve. If level I of the neck warrants dissection based on pathology, then the submandibular gland and remainder of the level I contents of the neck are excised. If level I does not warrant dissection, then the submandibular gland is elevated and lifted with the superior flap to allow for identification of the digastric muscle and hypoglossal nerve.
This “minimal access” form of neck dissection commences in the traditional fashion of selective neck dissection. However, as the incision is small and typically at the inferior aspect of the dissection, focus is placed on sequential retraction to allow for adequate visualization of all aspects of the neck. Initially, static retraction is placed at four points with the use of tapered hooks or silk sutures. Dynamic retraction is then applied as needed throughout the case to visualize the borders of the neck dissection. This may be accomplished with use of Army-Navy retractors, as well as appendiceal retractors in the deeper portions of the neck.
Once the digastric muscle has been identified, it is traced laterally to the medial border of the SCM. The fascia overlying the SCM is then excised, and the SCM is rotated laterally. The omohyoid is identified and retracted inferiorly to allow for visualization of the level 4 contents of the neck. The accessory nerve is identified to allow for careful preservation (Fig. 12.2). The level IIb through V contents of the neck may then be unrolled from the muscular floor of the neck and carotid sheath in the standard surgical fashion.
Fig. 12.2
With use of retraction, a left-sided accessory nerve is easily identified and preserved. The forceps indicate the nerve. Dynamic retraction allows for visualization of the neck from the level of the digastric muscle to the clavicle
Other Techniques
Endoscopic Neck Dissection
As the endoscopic neck dissection is still a matter of study, there has yet to be an established standard. Methods include both gas insufflation techniques and endoscopic-assisted techniques that rely on retraction to maintain the operative space. A few of the described methods will be highlighted in this section.
Gas Insufflation Technique
The gas insufflation technique has been described for performing selective neck dissections and submandibular gland resections. This approach is in the development phase, but the central components of this technique have been defined. The incisions for the camera and operative ports are marked and injected with local anesthetic. A 14 mm incision for the operative port is then made. With use of a blunt trocar, a subplatysmal tunnel is created. A surgical balloon is then inserted through this tunnel and inflated to 300–500 ml while monitoring the patient’s heart rate and blood pressure. The surgical balloon bluntly creates space for the gas insufflation. The balloon is then removed and a 10–12 mm trocar is inserted. This serves as the port for a 10 mm, 0° endoscope. CO2 insufflation at 4 mmHg is then provided. The operative ports are then established by making 7 mm incisions and placing spring-loaded, bladed trocars under endoscopic visualization.
Once visualization is achieved with the endoscope, the steps of the procedure follow those of conventional, open surgery (Fig. 12.3). Grasping instruments are used in the nondominant hand and cutting instruments are controlled by the dominant hand. An assistant holds the camera. Advanced energy devices or clips may be used for ligation of blood vessels. Once the tissue has been dissected, it is retrieved through the larger camera port incision. This retrieval is completed under direct visualization provided by a 5 mm endoscope placed through an operative port.
Fig. 12.3
Endoscopic view of the porcine neck immediately after insufflation. (EJV) external jugular vein, (THY) thymus, (SMG) submandibular gland
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