A thorough understanding of the anatomy of the neck is essential to avoid injury to vital structures when performing radical neck dissection. The complicated anatomical relations of the various nerves, vessels, and muscles within the confined area of the neck can often be daunting. We outline strategic anatomical landmarks and their relationships to important nerves, arteries, veins, and lymphatics to simplify the complicated and formidable anatomy of the neck. We also delineate key maneuvers that, when combined with the anatomical landmarks, offer a stepwise and logical approach to performing radical neck dissection that confers improved safety.
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Location of clinically positive lymph nodes using the level system based on landmarks encountered during neck dissection. Level I is the submandibular/submental triangle; level II, the upper jugular; level III, the mid jugular; level IV, the lower jugular; and level V, the posterior triangle. The inset shows the hockey stick incision.
Lateral (level V or posterior triangle) dissection showing the lymphoareolar tissue being grasped with several hemostats and elevated from the muscle floor of the posterior triangle formed by the splenius capitis, levator scapulae, and middle scalene muscles.
The inferior belly of the omohyoid muscle is divided, and blunt finger dissection is performed in the plane under the muscle to separate the specimen from the brachial plexus.
After the sensory and motor roots of C2 and C3 have been encountered, the plane of dissection should change from the floor of level V to the plane between the cervical sensory and motor roots. The C2, C3, and C4 sensory roots are divided (dashes), and the motor roots are pushed away from the specimen to preserve the phrenic nerve.
The mylohyoid muscle is retracted medially to expose the critical structures within the submandibular triangle, ie, the lingual nerve above, the hypoglossal nerve below, and the submandibular gland duct between the 2 nerves. In the inset, superior retraction of the posterior belly of the digastric muscle reveals the carotid artery, the internal jugular vein, and the adjacent cranial nerves X and XI.
After division of the internal jugular vein, dissection proceeds from the inferior to the superior direction, separating the specimen from the common carotid artery and the vagus nerve. The phrenic nerve can be seen lying on the surface of the scalenus anterior muscle.
View of the neck after completion of the radical neck dissection.
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