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A level VI neck dissection can be done through a formal thyroid incision and simply involves an extended total thyroidectomy with removal of the soft tissue bearing areas of level VI that con-

Bilateral Neck Dissection Incision
Figure 13.5 Standard thyroidectomy incision with bilateral thyroid utility extensions.A"W"plasty can be incorporated at the upper end of the utility incision in order to achieve a better scar.

tains the lymph nodes. The parathyroid glands are preserved together with the recurrent laryngeal nerves and external branches of the superior laryngeal nerves. The dissection may be facilitated by the use of operating loupes and can be extended using the cervical approach to remove the lymph node bearing areas of level VII down to the brachiocephalic vein [30]. This is usually facilitated by cervical thymectomy. For extensive disease with possible vascular involvement, a formal approach to the mediastinum is required using either a limited or full sternotomy.

The incision for a standard selective lateral compartment neck dissection is usually best done with an extended thyroid incision (thyroid utility: Figure 13.5). This facilitates formal access to levels II to V (Figures 13.6 and 13.7). Further access to levels II to IV can be achieved either by lifting sternomastoid up to dissect beneath the muscle or (in the author's preference) by dividing the sternomastoid at its lower end and

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Figure 13.6 Schematic outline of central compartment dissection and a lateral neck dissection, dissecting levels II, III, IV, and V below the accessory nerve. RLN = recurrent laryngeal nerve.

Figure 13.6 Schematic outline of central compartment dissection and a lateral neck dissection, dissecting levels II, III, IV, and V below the accessory nerve. RLN = recurrent laryngeal nerve.

Figure 13.7 As part of a selective neck dissection, the lymph node bearing tissue of level V is removed followed by access to levels II, III, and IV obtained by either retracting or dividing the sternomastoid muscle. The internal jugular vein and accessory nerve are also preserved.The cervical plexus is usually divided. (Reproduced with permission from Johnson JT and Gluckman JL (eds), Carcinoma of the Thyroid, Oxford: Isis Medical Media, 1999, page 79.)

Figure 13.7 As part of a selective neck dissection, the lymph node bearing tissue of level V is removed followed by access to levels II, III, and IV obtained by either retracting or dividing the sternomastoid muscle. The internal jugular vein and accessory nerve are also preserved.The cervical plexus is usually divided. (Reproduced with permission from Johnson JT and Gluckman JL (eds), Carcinoma of the Thyroid, Oxford: Isis Medical Media, 1999, page 79.)

elevating it up to improve the exposure. Access to level VII can easily be achieved with a cervical approach (Figure 13.8). The accessory nerve is formally identified in the posterior triangle at Erb's point (which is 1cm above where the greater auricular nerve winds around the posterior border of sternomastoid) and in the untreated neck there is no need to dissect above the nerve. Lymph node bearing tissue of the posterior triangle below the accessory nerve (essentially level VB) is removed together with tissue in levels IIA, III, and IV to include the omohyoid muscle. Special care is taken to access Chais-saignac's triangle, which lies behind the posterior part of the lower end of the internal jugular vein (Figure 13.4) and which often contains occult metastases from differentiated thyroid cancer.

The dissection proceeds in an upward and medial direction clearing levels IIA to VB with every attempt made to preserve the sensory branches of the cervical plexus, although it is difficult to carry out an adequate selective neck dissection without sometimes dividing some or all of these branches. This is the author's practice and the technique of routinely taking the cervical plexus with a selective neck dissection is well described [38]. For more extensive disease, level I may have to be dissected and one or all of the internal jugular vein, sternoma-

Figure 13.8 During a formal total thyroidectomy with level VI neck dissection, access to level VII can usually be achieved by a cervical approach. (Reproduced with permission from Johnson JT and Gluckman JL (eds), Carcinoma of the Thyroid, Oxford: Isis Medical Media, 1999, page 78.)

stoid muscle, and accessory nerve sacrificed (modified radical or radical neck dissection). Very occasionally, other structures have to be removed (i.e. the digastric muscle, external skin) and this is an extended radical neck dissection. The areas dissected and key steps of a selective neck dissection (levels IIA-VB) are shown in Figures 13.9-13.15. In a personal

Figure 13.9 Lateral utility incision marked out on the skin.

Figure 13.10 Posterior triangle identified with the accessory nerve having been isolated with a sloop.

Figure 13.11 The sternomastoid muscle has been divided and retracted superiorly. The accessory nerve is identified with a sloop and the lymphoid bearing tissue in level V below the nerve is removed; the dissection is carried forward to remove the lymph node bearing area in level IV together with the scalene nodes behind the lower end of the internal jugular vein (Chaissaignac's triangle - this area is being pointed to with a pair of forceps).

Figure 13.13 The dissection is completed showing from lateral to medial, the divided lower end of the sternomastoid muscle, accessory nerve with a sloop around it, the brachial plexus, Chaissaignac's triangle, the internal jugular vein, the vagus nerve and the common carotid artery. The author's index finger is retracting the trachea medially and the recurrent laryngeal nerve can be seen between it and the common carotid.

Figure 13.11 The sternomastoid muscle has been divided and retracted superiorly. The accessory nerve is identified with a sloop and the lymphoid bearing tissue in level V below the nerve is removed; the dissection is carried forward to remove the lymph node bearing area in level IV together with the scalene nodes behind the lower end of the internal jugular vein (Chaissaignac's triangle - this area is being pointed to with a pair of forceps).

Total Neck Dissection
Figure 13.14 Final result following total thyroidectomy and bilateral selective neck dissection (levels IIA-VB).
Thyroid Lymph Node Removal

Figure 13.12 The dissection is continued superiorly removing the lymph node bearing tissue in levels III and IIA. The mass is dissected from the internal jugular vein.

Figure 13.15 Final result following total thyroidectomy and bilateral selective neck dissection in the same patient.

Figure 13.12 The dissection is continued superiorly removing the lymph node bearing tissue in levels III and IIA. The mass is dissected from the internal jugular vein.

Figure 13.15 Final result following total thyroidectomy and bilateral selective neck dissection in the same patient.

Table 13.8 Author's personal series of patients undergoing lateral neck dissection for differentiated thyroid cancer (1994-2004)

series of 77 neck dissections (Table 13.8), the hematoma and infection rates were 0.8%. One patient had an accessory nerve palsy (the nerve was deliberately divided), and another had a chyle leak which required re-exploration.

The key steps for performing a selective neck dissection in differentiated thyroid carcinoma are shown in Table 13.9.

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