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Fig. 10.5 Modied and shortened tip of an Endo GIA 30 stapler (top),
compared with the original version (bottom)
S. J. Stoeckli et al.
Fig. 10.7 Endoscopic view of the closed stapler in position
Fig. 10.6 Endoscopic view of the open stapler in position
means of a thinner, non-spreadable diverticuloscope (Karl
Storz, Tuttlingen, Germany). As the stapler does not pass
through this diverticuloscope, the transection of the common
wall must be performed with the CO2 laser (Fig.10.9).
Fig. 10.8 Endoscopic view of the transected diverticular bar after
removal of the stapler. A minimal residual bar has been transected with
the CO2 laser
Fig. 10.9 Endoscopic view through a thinner diverticuloscope, show-
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ing myotomy of the cricopharyngeus muscle with the CO2 laser
10.5 Postoperative Care
It is the authors’ policy to leave the patients on nil per os on
the day of surgery, to restrict oral intake to uids for 24h
thereafter, and then to introduce soft diet for the next 7days,
before returning to normal diet. A feeding tube is not routinely placed. Although this procedure can be done as a day
case, the age and comorbidities of most patients, and the risk
of complications, result in most patients staying one night in
hospital. In particular, after laser myotomy, patients may
experience heavy retrosternal chest pain, which may be
mistaken for a myocardial infarction. Analgesia is usually
necessary for the rst few postoperative days. Success of the
procedure is assessed clinically, with no need for routine
postoperative barium swallow. Patients should be made
aware that recurrence of symptomatic ZD is rare but possible
and is amenable to successful endoscopic revision surgery.
References
1. Ludlow A.A case of obstructed deglutition from a preternatural bag
formed in the pharynx. Med Obs Inquiries. 1769;3:85–101.
2. Zenker FA, Von Ziemssen H.Dilatations of the esophageus. In:
Cyclopaedia of the practice of medicine, vol. 3. London: Low,
Marston, Searle & Rivington; 1878. p.46–68.
3. Killian G. Ueber den Mund der Speiseröhre. Z Ohrenheilkd
Krankheiten Luftwege. 1908;55:1–41.
4. van Overbeek JJ.Meditation on the pathogenesis of the hypopharyngeal (Zenker’s) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol. 1994;103:178–85.
115
5. Cook IJ, Blumbergs P, Cash K, Jamieson GG, Shearman
DJ. Structural abnormalities of the cricopharyngeus muscle in
patients with pharyngeal (Zenker’s) diverticulum. J Gastroenterol
Hepatol. 1992;7:556–62.
6. Resouly A, Braat J, Jackson A, Evans H. Pharyngeal pouch:
link with reux and oesophageal dysmotility. Clin Otolaryngol.
1994;19:241–2.
7. Migliore M, Payne H, Jeyasingham K. Pathophysiologic basis
for operation on Zenker’s diverticulum. Ann Thorac Surg.
1994;57:1616–21.
8. Vakil NB, Kahrilas PJ, Dodd WJ, Vanagunas A.Absence of an upper
esophageal sphincter response to acid reux. Am J Gastroenterol.
1989;84:606–10.
9. Huang BS, Unni KK, Payne WS. Long-term survival following
diverticulectomy for cancer in pharyngoesophageal (Zenker’s)
diverticulum. Ann Thorac Surg. 1984;38:207–10.
10. Mosher HP.Webs and pouches of the esophageus, their diagnosis
and treatment. Surg Gynecol Obstet. 1917;25:175–87.
11. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula. A roentgencinematographic study. Arch
Otolaryngol. 1960;71:744–52.
12. van Overbeek JJ, Hoeksema PE.Endoscopic treatment of the hypopharyngeal diverticulum: 211 cases. Laryngoscope. 1982;92:88–91.
13. Knegt PP, de Jong PC, van der Schans EJ.Endoscopic treatment of
the hypopharyngeal diverticulum with the CO2 laser. Endoscopy.
1985;17:205–6.
14. Collard JM, Otte JB, Kestens PJ.Endoscopic stapling technique of
esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac
Surg. 1993;56:573–6.
15. Martin-Hirsch DP, Newbegin CJ.Autosuture GIA gun: a new application in the treatment of hypopharyngeal diverticula. J Laryngol
Otol. 1993;107:723–5.
16. Baldwin DL, Thoma AG. Endoscopic stapled diverticulotomy: a
real advance in the treatment of hypopharyngeal diverticulum. Clin
Otolaryngol. 1998;23:244–7.
17. Koay CB, Bates GJ.Endoscopic stapling diverticulotomy for pharyngeal pouch. Clin Otolaryngol. 1996;21:371–6.
18. Peracchia A, Bonavina L, Surendra N, Segalin A, Antoniazzi
L, Marotta G. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg.
1998;133:695–700.
19. Cook RD, Huang PC, Richstmeier WJ, Scher RL. Endoscopic
staple- assisted esophagodiverticulostomy: an excellent treatment of
choice for Zenker’s diverticulum. Laryngoscope. 2000;110:2020–5.
20. Van Eeden S, Lloyd RV, Tranter RM.Comparison of the endoscopic
stapling technique with more established procedures for pharyngeal
pouches: results and patient satisfaction survey. J Laryngol Otol.
1999;113:237–40.
21. Murer K, Soyka MB, Broglie MA, Huber GF, Stoeckli SJ.Zenker’s
diverticulum: outcome of endoscopic surgery is dependent
on the intraoperative exposure. Eur Arch Otorhinolaryngol.
2015;272:167–73.
22. Stoeckli SJ, Schmid S. Endoscopic stapler-assisted diverticuloesophagostomy for Zenker’s diverticulum: patient satisfaction and
subjective relief of symptoms. Surgery. 2002;131:158–62.
23. Ishaq S, Sultan H, Siau K, Kuwai T, Mulder CJ, Neumann
H. New and emerging techniques for endoscopic treatment of
Zenker’s diverticulum: state-of-the-art review. Dig Endosc.
2018;30:449–60.
24. Lau K, Watson MG. Pharyngeal pouch: comparison of surgical
treatment with botulinum toxin injection to the cricopharyngeus.
J Laryngol Otol. 2019;133(2):125–8. https://doi.org/10.1017/
S0022215119000124. [Epub ahead of print].
25. Shah RN, Slaughter KA, Fedore LW, Huang BY, Deal AM, Buckmire
RA.Does residual wall size or technique matter in the treatment of
Zenker’s diverticulum? Laryngoscope. 2016;126:2475–9.
Open Approach toPharyngeal Pouch
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andCricopharyngeal Myotomy
JemyJose andR.JamesA.England
11
11.1 Introduction
Pharyngeal pouch (also termed Zenkers diverticulum) refers
to a false pulsion diverticulum of the hypopharynx passing
most commonly through Killian’s dehiscence [1]. It is most
common in the eighth decade. The etiopathogenesis of pharyngeal pouch formation remains unclear, although most
theories centre on cricopharyngeal dysfunction which could
be initially associated with dysphagia and later with aspiration and regurgitation as a pouch forms.
Pharyngeal pouches may be treated conservatively.
However, when sufciently symptomatic, surgical intervention may be required. When required, a number of different
techniques are employed. Nationally, the commonest intervention involves endoscopic stapling of the pouch. Open
pouch surgery provides an alternative feasible option. NICE
guidelines in 2003 state that endoscopic stapling allows a
more rapid recovery, and requires a shorter stay in hospital
(1–2days) than open surgery [2]. A Cochrane review in 2005
failed to nd any suitable trials comparing the efcacy of the
two interventions [3]. NICE guidelines in 2015 recommend
exible endoscopic management of pharyngeal pouch. This
was despite perforation rates of 27% in one of the series
quoted [4]. A recent series comparing open pouch surgery
with pouch stapling suggests the endoscopic approach is
quicker than the open approach. However, it also suggests
endoscopic treatment is not possible in 9% of cases and is
associated with a 23% recurrent surgery rate. Additionally, if
pouch resection is avoided when performing the open
approach, inpatient stay is equal when comparing the two
methods [5].
J. Jose (*)
Department of ENT, Hull University Teaching Hospitals NHS
Trust, Castle Hill Hospital, Cottingham, UK
e-mail: jemy.jose2@nhs.net
R. J. A. England
Department of Otorhinolaryngology, Head and Neck Surgery, Hull
and East Yorkshire Hospitals NHS Trust, Hull, UK
11.2 Preop Checklist/Considerations/
Anaesthesia
The procedure is performed under general anaesthesia with
oral intubation. The endotracheal tube is normally sited on
the right-hand side. There is no documented evidence
explaining the left-sided approach, but this is probably to
minimize risk to the recurrent laryngeal nerve, because the
nerve is more medially placed on the left side than the right.
External pouch surgery may be performed on the right side
in the same manner, and this is worth bearing in mind in the
case of revision surgery.
11.2.1 Indications
1. Cricopharyngeal muscle hypertrophy/stricture/spasm
causing dysphagia
2. Pharyngeal pouch of any size
11.2.2 Surgical Technique withTips
1. Pharyngoscopy is performed in order to identify the
pouch. If access is difcult, a short oesophagoscope may
be used. An oesophageal bougie of appropriate size is
used to dilate the cricopharyngeal segment that is always
found anterior to the neck of the pouch. The authors prefer to leave the bougie in situ for the duration of the procedure, because this facilitates cricopharyngeal myotomy
(it helps when dividing the muscle bres from the outside
as it provides a rm surface on which to cut). Insertion of
a roll of BIPP pack into the pouch is another technique
that may help identication of the pouch during dissection in the neck; this is often not feasible, however,
because the BIPP may fall out of the pouch and into the
oesophagus.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_11
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118
Oesophagus
Thyropharyngeus
dissected
(divided)
Cavotid sheath
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J. Jose and R. J. A. England
2. The patient is then positioned for the open procedure
using a cushion/sandbag under the shoulder and a head
ring in order to achieve exion of cervical vertebrae and
extension at the atlanto-occipital joint. The patient’s head
is rotated to the right in the majority of cases.
3. A J-shaped incision is made along the anterior border of
the sternocleidomastoid muscle from the level of hyoid
bone curving medially down to 1cm below the cricoid
cartilage. The incision is deepened through platysma
and deep cervical fascia. The sternocleidomastoid muscle is lateralized with a retractor to identify the carotid
sheath. The omohyoid muscle is divided. The middle
thyroid vein when seen is ligated and divided. The
carotid sheath is then retracted laterally to demonstrate
the prevertebral fascia. In this manner, the midline struc-
Fig. 11.1 Exposing the pouch after dividing
the omohyoid muscle
Cricopharyngeus
tures have been separated from the carotid sheath. The
laryngeal skeleton is then rotated away from the surgeon, whereby the posterolateral aspect of the inferior
constrictor bres and the pouch come into view
(Fig.11.1). Rotation is crucial, as it protects the recurrent laryngeal nerve from damage by ensuring the
approach is posterolateral and behind the nerve. The
pouch is separated from the remaining hypopharyngeal
and esophageal mucosa to identify its neck. If the neck
of the pouch can thus be identied easily, then a myotomy may be performed at this stage. If the neck is not
obvious, as is often the case, then a vertical myotomy is
performed starting in the oesophageal musculature and
extending up through the cricopharyngeus (Fig.11.2).
This is best performed using a 15 blade gently running
Thyroid
cartilage
Cricoid
cartilage
Fig. 11.2 Isolating the pouch
away from carotid sheath
structures
Pouch
out
Pouch
Omohyoid
Sternocleidomastoid
left intact
Neck of
11 Open Approach toPharyngeal Pouch andCricopharyngeal Myotomy
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(b) It does not physiologically add any benet to the pro-
4. At this juncture, pharyngoscopy is performed again
the sac
Cricoid
cartilage
Mucosa
Trachea
5. A nasogastric tube is then inserted if there is any doubt
6. Finally, closure of platysma with soluble sutures and skin
11.2.3 Postoperative Care
1. Monitor temperature, pulse, and blood pressure hourly
Fig. 11.3 A cricopharyngeal myotomy
the knife over the muscle bres, which are kept under
tension by retraction and the oesophageal bougie. Once
oesophageal mucosa is visible, it is often possible to
extend the myotomy by opening them perpendicular to
the mucosal surface to separate muscle from mucosa
and extending the incision cranially. If this is not possible, then the myotomy is extended using the scalpel to
expose the oesophageal mucosa. This myotomy is then
continued upward until it blends with the cricopharyngeus and, further up, with the thyropharyngeus. In this
manner, a generous myotomy 3–4cm long is performed
(Fig.11.3).
Some authors suggest excising the pouch mucosa
using a stapling device or excision with primary suture.
We do not believe this to be necessary in most cases,
because of the following reasons:
(a) It creates a stula that needs to heal in patients who
are often elderly and frail.
2. If observations are normal, clear uids are allowed over-
References
1. Siddiq MA, Sood S, Strachan D.Pharyngeal pouch (Zenker’s diver-
2. National Institute for Health and Care Excellence (NICE).
3. Sen P, Lowe DA, Farnan T. Surgical interventions for pharyngeal
4. National Institute for Health and Care Excellence (NICE). Flexible
5. Agalato E, Jose J, England RJ.Is pharyngeal pouch stapling supe-
119
cedure, because, once the tight cricopharyngeal
sphincter muscle bres are divided completely, the
pouch stops being a sump.
(BIPP pack removed if inserted) and the scope is inserted
into the oesophagus to conrm that the cricopharyngeal
bar is no longer present. If the bar is persistent, then return
to the neck to divide more muscle bres that have been
missed towards the neck of the pouch.
about the integrity of the pharyngoesophageal mucosa.
by clips or sutures is performed.
for 4 h and observe for evidence of backpain, surgical
emphysema, tachycardia, and pyrexia, which are features
of a perforated oesophagus.
night and normal feeding allowed the following morning
followed by discharge.
ticulum). Postgrad Med J. 2001;77(910):506–11.
Endoscopic stapling of pharyngeal pouch: interventional procedures guidance [IPG22]. overview 2003.
pouch. Cochrane Database Syst Rev. 2005;(3):CD004459.
endoscopic treatment of a pharyngeal pouch: interventional procedures guidance [IPG513]; 2015.
rior to open pharyngeal pouch repair? An analysis of a single institution’s series. J Laryngol Otol. 2016;130(9):873–7.
Part V
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Neck Dissection
Radical andModified Radical Neck
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Dissection
AnthonyBrianPowellMorlandt andAnilD’Cruz
12
12.1 Introduction
The lymphatic basins draining the head and neck contain
approximately 300 lymph nodes, 40% of the body’s total,
invested within a network of brofatty tissue. Considered the
most important prognostic indicator in head and neck epithelioid carcinomas, regional lymph node metastasis decreases
survival by greater than 50% when compared with localized
disease. Radical neck dissection, rst described in 1905, was
once performed in conjunction with excision of nearly all
primary head and neck cancers. In the current era, however,
selective neck dissection with preservation of the internal
jugular vein, sternocleidomastoid muscle, and spinal accessory nerve is recommended prophylactically for all but the
most thin, supercial mucosal head and neck cancers.
12.2 Indications forSurgery
12.2.1 Selective Neck Dissection
A modied radical or selective neck dissection is performed
in an elective or therapeutic fashion to remove all lymph
nodes from at-risk cervical echelons. In patients with oral
tongue tumours deeper than 2–3mm, a survival benet has
been seen following selective neck dissection. The selective
neck dissection, when performed by an experienced surgeon,
involves minimal morbidity and scarring, and can be performed on an outpatient basis in some units. In the salvage
setting, isolated nodal recurrences have been shown to
A. B. P. Morlandt (*)
Section of Oral Oncology, Department of Oral and Maxillofacial
Surgery, University of Alabama at Birmingham,
Birmingham, AL, USA
e-mail: morlandt@uab.edu
A. D’Cruz
Department of Head and Neck Surgery, Tata Memorial Hospital,
Mumbai, Maharashtra, India
decrease disease-specic survival by 54%. Sentinel lymph
node biopsy, though accepted for treatment of the N0 neck in
patients with head and neck melanoma, has not supplanted
the selective neck dissection as the standard of care for earlystage oral cavity or oropharyngeal tumours.
12.2.2 Radical Neck Dissection
The radical neck dissection is carried out for therapeutic purposes when bulky nodal disease precludes preservation of
the internal jugular vein, sternocleidomastoid muscle, or spinal accessory nerve.
12.2.3 Microvascular Free Flap Access
In some cases, such as sarcoma, low-grade salivary gland
malignancy, or early-stage squamous cell carcinoma of the
oral cavity, a low risk of occult metastasis may preclude elective neck dissection. In these instances, to provide access to
the blood-supplying artery and recipient vein used for microvascular anastomosis, the surgeon may be inclined to perform a limited neck dissection, with removal of the
submandibular gland and lymph node–bearing brofatty tissue, on approach to the vessels.
12.3 Surgical Technique withTips
Positioning: The operation is performed in the supine position, with a shoulder roll oriented vertically between the
scapulae or horizontally at the level of C7. In one of the
authors’ units, we position the patient’s head 180° from the
anaesthesia machine to provide adequate space for the surgeon’s team and any additional equipment needed (endoscope, navigation, etc.).
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_12
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A. B. P. Morlandt and A. D’Cruz
Incision: For selective neck dissection, the incision is
designed in a curvilinear fashion and extends from the sternocleidomastoid muscle towards the midline. In patients
with a thin neck and lax skin, a short-scar incision (4–5cm)
improves cosmesis. A radical neck dissection requires unrestricted access to level V, so a posterior releasing incision is
often used. A popular design is the “inverted wine glass”–
shaped Schobinger modication.
Flap elevation: The wound is deepened through the subcutaneous tissues and platysma muscle, and subplatysmal
aps are elevated to the inferior border of the mandible superiorly and to the clavicle inferiorly (Fig.12.1). In the radical
neck dissection, care must be exercised when raising the
posterior skin aps to avoid injuring the spinal accessory
nerve, which runs immediately deep to the dermis in this
region. Skin hooks or Lahey clamps are used to provide skin
retraction during ap elevation. Maintaining a plane above
the external and anterior jugular veins and greater auricular
nerve is key to avoid injuring these structures inadvertently.
The operation then proceeds generally in the anterior to
posterior direction, starting in level Ia with elevation of the
brofatty node-bearing tissues off of the anterior bellies of
the digastric muscles bilaterally, the mandibular symphysis
superiorly, and, on the deep aspect, the mylohyoid muscle.
The submental vessels are clipped and divided, and the specimen is retracted inferiorly towards the hyoid bone. The
anterior jugular veins are a potentially troublesome source of
bleeding if entered during sharp elevation of the specimen
off of the infrahyoid muscles.
Next, inferior to the antegonial notch, the supercial layer
of deep cervical fascia is incised to expose the submandibular gland and provide access to the anterior facial vein and
facial artery; the marginal mandibular branch of the facial
nerve may be visualized coursing through the fascia. The
“Hayes Martin” manoeuvre involves ligating and dividing
the facial vessels, then superiorly retracting the ligature to
protect the facial nerve, positioned superiorly and
supercially.
Level Ib is then cleared by skeletonizing the lateral surface of the mylohyoid muscle. Lying on the muscle are
numerous ranine veins, which should be controlled prior to
dividing, lest they retract into the muscle and continue to
bleed during the procedure or even after the patient is sitting
upright in the recovery suite. An appendiceal or Army-Navy
retractor retracts the mylohyoid muscle superomedially to
expose the submandibular ganglion and submandibular duct,
both of which are clipped and divided. The lingual nerve
may be seen coursing under the mylohyoid muscle
(Fig. 12.2), and when the ganglion is divided, it typically
retracts towards the oor of the mouth. Deep to the digastric
posterior belly, the hypoglossal nerve may be encountered
and should be protected from injury. After dividing the submandibular duct and ganglion, the gland and remaining
specimen are retracted inferiorly, where the facial artery is
once again encountered and divided.
Tip: If microvascular reconstruction is planned, an additional 1–3cm of length may be gained by freeing the facial
artery from the medial aspect of the gland until the rst major
branch point is encountered. This manoeuvre, which is often
necessary when upper or midface reconstruction is planned,
may obviate the need for vein grafting to augment the pedicle length.
Fig. 12.1 Subplatysmal aps
Fig. 12.2 Lingual nerve is seen in level Ib, with the submandibular
ganglion connecting the nerve with the submandibular gland (retracted
inferiorly in Allis clamps)
12 Radical andModied Radical Neck Dissection
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Dissection is then carried posteriorly across the tail of the
parotid gland, where the retromandibular vein is ligated and
divided. When clinically free of disease, judicious removal
of the parotid gland is advised, as signicant facial oedema
may follow.
Attention is then directed to the midline, where dissection
proceeds along a broad front, from level Ia superiorly to the
inferior edge of the omohyoid muscle inferiorly. The superior thyroid and superior laryngeal arteries are preserved, as
is the common facial vein (also an important option for
microvascular reconstruction).
Next, the carotid artery is exposed by incising the carotid
sheath vertically along its length. The vagus nerve and internal jugular vein (IJV) are now seen, and care must be
exercised to include the nodes posterior to the vein in the
specimen.
One of several techniques may be then used to skeletonize
the IJV.The surgeon may dissect sharply with a #10 or #15
blade or Metzenbaum scissors, or may choose to bluntly
separate the vein from its fascial sheath with Kittner dissecting sponges or a plain gauze pad, using digital pressure.
Regardless of the method used, the four to six tributary veins
draining into the IJV must be carefully identied and ligated
before proceeding to the next step in the operation. Failure to
recognize disruption of one of these small veins may result in
signicant postoperative haemorrhage, and the weight of the
large IJV may occlude and obscure bleeding during the
operation.
At this point, the specimen is laid upon the great vessels
and attention is directed to the lateral edge of the sternocleidomastoid (SCM) muscle. The fascia overlying the muscle is
grasped with Allis clamps and lifted off the muscle, including any external jugular lymph nodes associated with the
vein. The external jugular vein and greater auricular nerve
should be carefully protected, again preserving the length of
this vein for the microsurgeon. As the SCM is unwrapped
medially, many vessels must be clipped as they enter the
muscle. With a Green or similar retractor, the SCM is then
held laterally and dissection continues towards the deep cervical fascia (Fig.12.3).
Radical Neck Dissection Modication: The IJV is doublesuture ligated and divided superiorly at the skull base and
inferiorly just above the clavicle. A transxion suture provides additional safety.
At the junction of the upper third and lower two-thirds of
the SCM muscle, the spinal accessory nerve is found piercing the muscle on its course from the skull base to the trapezius muscle. Judicious mobilization of the nerve is
recommended, as even minor trauma may result in postoperative shoulder weakness and pain. A nerve hook is then
used to gently lift the nerve, so that the contents of level IIb
may be elevated off of the splenius capitus muscle and
brought under the nerve, in continuity with the remainder of
125
Fig. 12.3 Specimen out
the specimen. Occasionally, the occipital artery is seen
coursing laterally through the submuscular recess of level
IIb.
With two Army-Navy retractors oriented at right angles to
one another—one under the SCM and one under the posterior belly of the digastric muscle—the specimen is then
brought off of the deep cervical fascia using monopolar cautery. The phrenic nerve runs immediately deep to this fascia,
so dissection should proceed in a more supercial plane. To
aid with orientation, the surgeon maintains the plane of dissection above the cervical nerve rootlets. A vein retractor is
used to protect the great vessels medial to the specimen.
With the omohyoid muscle retracted inferiorly towards the
clavicle, the inferior boundary of the dissection is dened at
the lower edge of level IV. Here, the transverse cervical
artery and vein are seen and should be protected. At times, a
high-riding subclavian vein is seen in this location. On the
left side of the neck, the thoracic duct also resides in this
location and should be checked for injury by asking the
anaesthetist to perform a Valsalva manoeuvre (Fig.12.4).
Radical Neck Dissection Modication: The SCM is
divided, and the spinal accessory nerve may be sacriced as
well during this step if bulky disease is present. The cervical
nerve rootlets are also divided and included with the
specimen.
The specimen is then delivered intact, oriented with
sutures or tags for the pathologist, and submitted for permanent section histology. The neck wound should then be irrigated with warm saline and closed over suction drains.
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A. B. P. Morlandt and A. D’Cruz
Fig. 12.4 (a) Thoracic duct injury is seen deep in level IV, with clear, instead of white, chyle egress in the fasting surgical patient. (b) Repaired
thoracic duct injury and no chyle seen on Valsalva manoeuvre
12.4 Nomenclature andClassication
12.5 Complications andPostoperative
Management
The rst widely adopted classication system was presented
in 1991 by the American Society of Head and Neck Surgery
and was later revised in 2002 and 2008 (Robbins etal.). In
2011, Ferlito etal. proposed an updated, concise classication schema based on three designations:
1. Symbol ND with laterality indicated
2. Specic lymphatic levels removed (Ia/b, IIa/b, III, IV,
Va/b, VI, and VII)
3. Specic nonlymphatic structures removed (e.g. SCM,
IJV, CN XII, skin, ECA)
For example a selective neck dissection including removal
of levels I through IV with preservation of the SCM, IJV, and
CN XI would be designated as “ND (R) (Ia, Ib, IIa, IIb, III,
IV).” Outdated terms such as “supraomohyoid” or “anterolateral neck dissection, ” among others, have been largely
replaced by the more descriptive terms above.
12.5.1 Neurologic Injury
Risk of injury to CN VII (marginal mandibular branch), X,
XI, and XII and the phrenic nerve accompanies the modied
and radical neck dissection operations, though permanent
dysfunction is rare. The brachial plexus theoretically may be
injured low in level IV if the deep fascia is violated. Dividing
the cervical nerve rootlets is associated with temporary incisional numbness, which may extend to the earlobe or supraclavicular skin, though this often presents nothing more than
a nuisance to the patient.
12.5.2 Vascular Injury
If the great vessels of the neck are entered during surgery, the
vessel wall should be repaired rapidly using nonabsorbable
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