Papillary thyroid carcinoma is the most common endocrine malignancy. Recently, controversy has focused on the management of lymph node metastases, which represent approximately 90% of disease recurrences and may require considerable time, effort, and resources to diagnose and treat. Current intense postoperative surveillance by endocrinologists nationwide has the sensitivity to detect even minute lymph node metastases using ultrasonography, radioactive iodine scan, and thyroglobulin monitoring.
To (1) present a succinct synopsis of the rationale and elements of our current surgical management strategy for papillary thyroid carcinoma and, within this context, (2) provide a detailed stepwise description of a compartment-oriented modified radical neck dissection. This description is combined with intraoperative photographs and a medical artist's illustrations to enhance and emphasize the most important points.
With anatomically defined precise dissection, following the steps outlined and illustrated, a thorough lymphadenectomy can be accomplished safely, with reasonable cosmetic results, minimizing disease relapse.
Modified radical neck dissection incision, subplatysmal flaps, and dissection between sternocleidomastoid muscle (SCM) and strap muscles.
Isolation and resection of omohyoid muscle.
Initial dissection along lateral border of internal jugular vein (IJV) above level of clavicle. CCA indicates common carotid artery; SCM, sternocleidomastoid muscle.
Exposure of anterior scalene muscle and phrenic nerve. CCA indicates common carotid artery; IJV, internal jugular vein.
En bloc dissection of internal jugular vein (IJV) lymph nodes and exposure of floor of neck. ASM indicates anterior scalene muscle; BP, brachial plexus; CCA, common carotid artery; MSM, middle scalene muscles; PN, phrenic nerve; SCM, sternocleidomastoid muscle; SCV, subclavian vein; and TD, thoracic duct.
Cervical plexus (CP) and spinal accessory nerve dissection (extending to level II). ASM indicates anterior scalene muscle; BP, brachial plexus; CP, cervical plexus; IJV, internal jugular vein; MSM, middle scalene muscles; and PN, phrenic nerve.
Dissection of level II exposing the digastric muscle (DM) and spinal accessory nerve (SAN).
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