coass v-neck dissection
TRANSCRIPT
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NECK DISSECTIONNECK DISSECTION
AM-H&N-Study Literatur20-Juli -2001
ASNOMINANDA
Study Literatur
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PENDAHULUAN
AM-H&N-Study Literatur20-Juli -2001
Cervical lymphadenectomy“to the systematic removal of lymph nodes with their
surrounding fibrofatty tissue from the various compartments of the neck”
Primer : - rongga mulut- faring - laring
Faktor-faktor yang mempengaruhi penyebaran Ca ke KGB reg. :
- histologi- klasifikasi Tumor / stadium- lokasi primer
Sejarah : - Koeher (1880)- George Crile- Blair dan Martin- Suarez dan Bocca (1960s)
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PENDAHULUAN
AM-H&N-Study Literatur20-Juli -2001
Terminology : - AAO-HNS (1988)Group KGB : - Level I : the submental dan the submandibular
group- Level II : the upper jugular lymph nodes- Level III : the middle jugular lymph node group - Level IV : the lower jugular lymph node group- Level V : the posterior triangle group- Level VI : the anterior neck compartment
Vascular supply : - Menghindari komplikasi
- Cab. descenden dari a. facial, submental dan occip. dan cab. ascenden dari a. cervical transversa dan a. suprascapula
- Suplay darah yg adekuat ke “skin flap”Fascia leher : - superficial
- middle (visceral fascia )
- deep (prevertebral fascia)
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CLASSIFICATION (AAO-HNS)
AM-H&N-Study Literatur
1. Radical neck dissection
2. Modified radical neck dissection (type I, II and III)
3. Selective neck dissection
- Supraomohyoid type
- Lateral type
- Posterolateral type
- Anterior compartment type
4. Extended radical neck dissection
20-Juli -2001
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RADICAL NECK DISSECTION
AM-H&N-Study Literatur
Definisi
Mengangkat semua group kgb leher mulai dari mandibula (superior) s/d klavikula (inferior) termasuk levels I s/d V, N. accessory spinal, V. jugular interna, dan M. Sternokleidomastoideus
Tidak termasuk : nodus postauricular dan suboccipital, periparotid kecuali nodus di ekor glandula parotid, nodus perifacial dan buccinator, nodus retropharyngeal dan nodus paratracheal.
Indikasi
Metastase kgb yg luas atau perluasan yang melebihi kapsul dari nodus atau nodus meliputi N. accessory spinal dan V. jugular interna. Juga pada masa tumor metastatik yang besar atau nodus multipel tidak beraturan di bagian atas dari leher.
Tehnik
Posisi : Supine , leher
ekstensi optimal
Incisi : A, hockey stick; B, inverted hockey stick
C, Mc Fee; D, modified Schobinger
(Babcock dan Conley); E, Apron atau bilateral hockey stick; F, Latyschevsky dan Freud;G, Crile; H, Martin 20-Juli -2001
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RADICAL NECK DISSECTION
AM-H&N-Study Literatur
Flap elevation
superiorly dan inferiorly
Diseksi segitiga posterior : exposed batas anterior dari musk. trapezius s/d batas posterior dari musk. sternokleidomastoideus dan di inferior mla dari klavikula
Lantai otot dari segitiga posteriorDiseksi segitiga anterior : dielevasi ke medial, sarung karotis exposed, ligasi v. jugular internal, thoracic duct, common carotid artery, carotid bifurcation, and v. thyroid media & superior dan v. retromandibular
Diseksi ruang leher atas :
- Excision of level I lymph nodes - allows visualization of the lingual nerve, submandibular duct, and hypoglossal nerve.
- The submandibular duct is isolated, divided, and ligated
- The submandibular ganglion next should be clamped and divided - complete excision of all contents
of the submandibular triangle within its muscular
boundaries, and not just the submandibular gland, is required - Neck drains are inserted and
brought through separate .....
20-Juli -2001
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MODIFIED RADICAL NECK DISSECTION
AM-H&N-Study Literatur
Definisi
“as the en bloc removal of lymph node bearing tissue from one side of the neck (levels I to V)”
- The dissection extends from the inferior border of the mandible above to the clavicle below and from the lateral border of the strap muscles medially to the anterior border of the trapezius muscle laterally
Klasifiikasi
Type I, in which only one structure, the spinal accessory nerve, is preserved.
Type II, the spinal accessory nerve and the internal jugular vein, are preserved.
Type III, the spinal accessory nerve, the internal jugular vein, and the stenocleidomastoideus muscle are preserved.
Indikasi
Major : “to remove probable
or grossly pathologic visible
lymph node disease that is
not directly infiltrating or
fixed to the nonlymphatic
structures” Tehnik : Unlike the radical neck dissection, the next step is to identify the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle
20-Juli -2001
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SELECTIVE NECK DISSECTION
AM-H&N-Study Literatur
Definisi
“..... performed for patients who are at risk for early lymph node metastases. The procedure consists of en bloc removal of one or more lymph node groups at risk for harboring metastatic cancer, an assessment which is based on the location of the primary tumor”
Alasan
It was based on removing lymph node groups that were at highest risk for patients with N0 nodal disease.
....... if nodal disease is encountered during the execution of the selective neck dissection, the field of dissection may be extended to remove all levels of potential lymph node involvement
Pembagian
-
Supraomohyoid
type
(levels I-III) -
Lateral type
(levels II - IV)
- Posterolateral type
- Anterior compartment
typePenting : They concluded that tumors of the oral cavity metastasize most frequently to neck nodes in levels I, II, and III, whereas carcinomas of the pharynx, hypopharynx, and larynx involve mainly the nodes in levels II,
III, and IV 20-Juli -2001
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SELECTIVE NECK DISSECTIONSupraomohyoid type (levels I to III)
AM-H&N-Study Literatur
Definisi & Alasan
- for patients with oral cavity cancer who are at risk for harboring occult nodal disease
- removal of levels I through III (level IV for those with tongue cancer)
- Elective contralateral : * for patients with primary lesions
involving the floor of mouth, ventral surface or midline involvement of the tongue, no definite indications for postoperative radiotherapy
- Contralateral therapeutic : * for patients with clinically N2c disease
Tehnik incisi
- modified apron
- bilateral apron incision - bilateral hockey stick - carefully injuring :
mandibular branch of the facial nerve, the external jugular vein and branches of the greater auricular
nerve - not to cut across the sensory branches of the cervical plexus- A drain is placed
20-Juli -2001
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SELECTIVE NECK DISSECTIONLateral type (levels II to IV)
AM-H&N-Study Literatur
Definisi & Alasan
- to remove nodal disease
associated with
carcinomas originating
in the pharynx,
hypopharynx, and larynx
- selective removal of levels
II to IV
- neck dissection usually is
performed on both sides
Tehnik incisi
• identify the spinal
accessory nerve
• adequate exposure of levels II to IV
• hockey stick incision
• bilateral hockey stick incision
• the fibrofatty contents of the anterior triangle are removed en bloc
20-Juli -2001
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SELECTIVE NECK DISSECTIONPosterolateral type
AM-H&N-Study Literatur
Definisi & Alasan
- to eradicate nodal
metastases
associated with
cutaneous
malignancies and soft-
tissue sarcomas
- located in the
posterior scalp, nuchal
ridge, occiput, or
posterior upper neck
Tehnik incisi
• exposure along the nuchal ridge to the
occiput and the posterior triangle and
exposure of the upper, middle, and
lower jugular lymph nodes
• a lazy S pattern or the combination of the
hockey stick pattern with a horizontal
extension from its upper aspect along
the nuchal ridge
• placed in the lateral decubitus position
• The posterior auricular and suboccipital
nodes are removed
• the posterior triangle is cleared in a fashion 20-Juli -2001
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SELECTIVE NECK DISSECTIONAnterior compartment type
AM-H&N-Study Literatur
Definisi & Alasan
- to eradicate nodal metastases from the anterior compartment of the neck
- cancers originating in the thyroid gland, hypopharynx, cervical
trachea, cervical esophagus, and laryngeal tumors extending
below the level of the glottis
- removal of the perithyroidal nodes, pretracheal and paratracheal nodes along its cervical portion, precricoid (Delphian) nodes, and nodes located along each recurrent laryngeal nerve
Tehnik incisi
• possibly one or more sternal heads
• this procedure is done first, if ….
• The carotid artery, the superior thyroid artery, the thyroid gland, the parathyroid glands, the
recurrent laryngeal nerve,
• dissection is carried superiorly as far as the hyoid bone and inferiorly as far as the suprasternal notch
• total thyroidectomy is performed
• splitting the sternum or removing the manubrium and one or more clavicular heads
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SELECTIVE NECK DISSECTION
Extended neck dissection
AM-H&N-Study Literatur
Definisi & Alasan
- extended to remove either lymph node groups or vascular, neural, or muscular structures
- Tumors of the base of the tongue, tonsil, soft palate, and retromolar trigone also may spread to these lymph nodes when they involve the lateral or posterior walls of the oropharynx.
- Adequate removal of a metastatic tumor in the neck may dictate the need to extend a neck dissection to resect structures such as the hypoglossal nerve, the levator scapulae muscle, or the carotid artery
- Controversy still exists about the advisability of resecting the common or the internal carotid artery
- Moore and Baker, for example, observed a mortality rate of 30% and a cerebral complication rate of 45% among patients who underwent carotid ligation. 20-Juli -2001
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RESULTS OF NECK DISSECTION
AM-H&N-Study Literatur
Radical neck dissection
- 3% to 7% of patients will have disease recur in
the ipsilateral neck
- 44% recurrence rate for macroscopic extracapsular spread versus 25% for microscopic
- 5% in patients with positive nodes in one level versus 71% in patients with positive nodes in multiple levels
Modified radical neck dissection
• patients with clinically N0 disease, the
rate of recurrence varies between 4%
to 7%
• used therapeutically for patients with clinically positive disease, the recurrence rate between 0% to 20%.
20-Juli -2001
Selective neck dissection
• For supraomohyoid : recurrence rate
5.8%, positive nodes : 10 – 15 %
• For lateral neck dissection 3.9% (7,3%)
• Postoperative radiotherapy is recommended
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SEQUELAE OF NECK DISSECTION
AM-H&N-Study Literatur
Radical neck dissection
- removal of the spinal
accessory nerve
- 44% recurrence rate for macroscopic extracapsular spread versus 25% for microscopic
- 5% in patients with positive nodes in one level versus 71% in patients with positive nodes in multiple levels
Modified radical neck dissection
• patients with clinically N0 disease, the
rate of recurrence varies between 4%
to 7%
• used therapeutically for patients with clinically positive disease, the recurrence rate between 0% to 20%.
20-Juli -2001
Selective neck dissection
• For supraomohyoid : recurrence rate
5.8%, positive nodes : 10 – 15 %
• For lateral neck dissection 3.9% (7,3%)
• Postoperative radiotherapy is recommended
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COMPLICATIONS OF NECK DISSECTION
AM-H&N-Study Literatur
• Circulation of air through a wound drain
• prevented by using an adhesive
• used to immobilize the skin graft nyl drape
20-Juli -2001
Air leaks
Bleeding
Chylous fistula
Facial/cerebral edema
• immediately after surgery
• controlled by ligation or infiltration
• hematoma is detected early, ‘‘milking’’ the drains
• if this is not accomplished immediately, return to the OR
• wound infection !!
• Spiro and Strong found that 14 patients (1.9%)
• early surgical exploration before the tissues exposed
• are managed conservatively with closed wound drainage, pressure dressings, and low-fat nutritional support
• mechanical problem of venous drainage
• who had previous radiation to the head and neck
• prevented by preserving at least one external jugular vein
• Ligation of the IJV leads to increased intracranial pressure
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COMPLICATIONS OF NECK DISSECTION
AM-H&N-Study Literatur
• Visual loss after bilateral neck dissection is a rare but catastrophic complication
• In one report, histologic examination revealed intraorbital optic nerve infarction, suggesting intraoperative hypotension and severe venous distension as possible etiologic factors.
20-Juli -2001
Blindness
Carotid artery rupture
• lethal complication after surgery
• occur in the presence of malnutrition, diabetes, infection, and previous radiotherapy, which impair healing capacity and compromise vascular supply
• use of perioperative antibiotics
• to stop the bleeding and repair the area of rupture
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S U M M A R Y
AM-H&N-Study Literatur
Neck dissection is an operative procedure designed to remove metastases involving the regional cervical lymph nodes
The gold standard procedure is the radical neck dissection
Modifications of the radical neck dissection procedure subsequently have evolved, designed to reduce morbidity by sparing nonlymphatic structures
Selective neck dissection is an operative procedure to treat early nodal disease by removing only the lymph node groups at greatest risk for harboring metastases
The AAO-HNS have endorsed a classification system for neck dissection procedures and a standard nomenclature for the terminology of the lymph node groups based on the level system
20-Juli -2001
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A L G O R I T H M
AM-H&N-Study Literatur20-Juli -2001
ORAL CAVITY PRIMARY
OROPHARYNX PRIMARY
LARYNGOPHARYNX PRIMARY
No palpable nodes High risk for occult nodes*
Palpable nodes No palpable nodes Palpable nodes
SND (levels I –III) Bilateral SND for midline/floor
of mouth primary
Ipsilateral/bilateral† MRND‡ (levels I-V)
Bilateral © SND (levels II-IV)
Ipsilateral MRND contralateral SND® (levels II-IV)
* T1-T4 oral tongue; T2-4 other site; perineural/lymphatic invasion † Bilateral neck dissection for N2c disease ‡ RND if gross tumor invasion of nonlymphatetic structures © Ipsilateral neck dissection for oropharyngeal primaries if postoperative radiotherapy is planned ® SND for N0 disease only Sumber : Cummings