Left Lateral Neck Dissection for Metastatic Papillary Thyroid Carcinoma

CHAPTER 1

I'm Antonia Stephen. I'm an endocrine surgeon at the Massachusetts General Hospital, and today, we are performing a left lateral neck dissection on a young woman with a diagnosis of metastatic papillary thyroid carcinoma. This patient previously, approximately a year ago, underwent a total thyroidectomy and central neck lymph node dissection with removal of the lymph nodes around her thyroid. She was found to have a papillary thyroid cancer in the left lobe of her thyroid, as well as positive lymph nodes in the central portion of the neck. She was then referred to an endocrinologist, who noted a suspicious lymph node lateral to her prior surgery in the level 4 neck lymph node area, which was just above the clavicle. This lymph node was biopsied and was positive for papillary thyroid carcinoma. The plan therefore was to return to the operating room in order to remove the lateral neck lymph nodes in this area. What we plan to do in this case is to open up her lateral neck. We use a portion of her prior incision and extend it towards the left side. This is made within a skin crease for cosmetic reasons. We then divide the platysma muscle and make superior and inferior subplatysmal flaps. In the preoperative planning, we did perform an ultrasound, and that helps us decide which lymph nodes to remove during the surgical procedure. The only suspicious lymph node noted on our ultrasound was the level IV lymph node. We do do a compartment-based lymph node dissection, meaning we don't simply remove the lymph node that we see on the ultrasound that was biopsied, but we also remove a portion of the lymph nodes around there. So in this case, we decided to remove what is called the IIb, III, and IV lateral neck lymph nodes. After entering the neck and dividing the platysma muscle and raising the flaps, we then enter the carotid sheath area by dividing the medial edge of the sternocleidomastoid muscle from the lateral edge of the sternohyoid muscle, which is one of the midline strap muscles. This allows us access to the area of the carotid artery, the vagus nerve, and the internal jugular vein, as well as the area where the lymph nodes are located. We then plan to divide the omohyoid muscle, which typically crosses over this region in order to access those lymph nodes. We then proceed to the more superior aspect of the lymph node dissection, which is the level IIb lymph nodes. This is typically located above the cricoid cartilage and in the region of the submandibular area. If we were planning to perform a complete level IIa lymph node dissection, we would dissect the submandibular lymph nodes. However, in this case, because her highest level lymph node was the level IV, which is quite low, we decided not to perform that portion of the procedure today. After dissecting the superior edge of the lymph nodes and the more lateral aspect along the junction of the level IV and level V neck lymph nodes, we then carefully dissect these lymph nodes off the deep cervical fascia, with care not to enter the phrenic nerve, which lives just underneath the deep cervical fascia in this region. As we proceed towards the clavicle, we're planning to identify and preserve the thoracic duct. If the thoracic duct is very adherent to the group of metastatic lymph nodes, we can divide the thoracic duct; however, we prefer to avoid it when possible. We do identify it. We then complete the lymph node dissection along the clavicle, and complete the dissection laterally along the level IV and level V lymph node junction. We would then irrigate the neck, check for any bleeding or lymphatic leakage, apply Tisseel, which is a sealant for both lymphatics and blood vessels, and close the neck in layers.

CHAPTER 2

So you wanna be able to see if you can the lower lip. And the reason you wanna see the lower lip is because you often end up close to what's called the marginal mandibular branch of the facial nerve. Oh, okay. Do you have another thousand? One of the most important things to consider, we're doing a right lateral neck, sorry, a left lateral neck dissection for papillary thyroid cancer. The patient has already had a total thyroidectomy and what's called a central neck dissection, meaning the lymph nodes were removed from the center part of her neck. Those are also called level VI lymph nodes. So the center compartment is level 6, and that's where the thyroid is. We're not gonna be there today. Out here in the lateral neck, and what's out here in the lateral neck is something called the internal jugular vein. Carotid artery. And behind that, the vagus nerve, so IJ, carotid, and vagus. And there's a lot of lymph nodes that live out here. These are also numbered in compartments. Up near the mandible is level IIa, just below that is IIb. Then there's level III, and down here near the clavicle is level IV. The lymph node that we can see on her ultrasound that was biopsied is right here in level IV, just underneath the internal jugular vein. So we don't need to be up near IIa, which is where the marginal mandibular branch of the facial nerve is, but I always drape that out clearly. Okay. In case we end up near her mandible. So that's why we're putting the clear drape there. Now we're still doing a compartment-based lymph node dissection, which, typically for this type of cancer, would include IIb, III, and IV, depending, once again, on what the scans show to be the involved lymph nodes. So once again, in this case, we will not be performing a level IIa lymph node dissection in this particular patient, because her highest lymph node is level IV, which is down near her clavicle. So we're gonna put this, Rachel, a little higher than usual. Once again, so we can kind of see her lip there. Just make sure you have that all set there. So the lower lip is right there. Okay, so once again, let's like redraw our diagram here. Here is the trachea. This is where the thyroid lived. And once again, the level VI lymph nodes. Out here in the left lateral neck is the carotid artery. We'll label that C. The internal jugular vein, we'll label that IJ, and usually just deep and in between them is the vagus nerves. Nestled around the carotid sheath are lymph nodes. And the lymph node that we know has been biopsied as positive is sitting just right underneath the internal jugular vein, right near what's called the clavicle. Once again, there are nodal stations that we number. Up here near the mandible is IIa. Just below that is IIb. III is here, and IV is the region near the clavicle that we'll be doing most of our dissection. We will also remove the level III nodes and possibly some IIb lymph nodes as well. Watch this here. And then this here. So we're gonna use part of her prior thyroidectomy incision extending over towards the left. Marking pen, please. Here's the patient's clavicle right here, labeled with a C. And up and down here is her carotid sheath.

CHAPTER 3

Can I take a knife please? Is it okay to start, Rachel? Yes. All right. So we make an incision within a skin crease in the lower neck, and as I mentioned previously, we're just using part of her prior thyroidectomy incision, so we're not making a separate one. Okay, knife is back, and I'll take a fine Kelly, please. I see it right there. So we carry this down through the dermis. And I like to use only the coag function of the Bovie because the neck is so vascular, it prevents a lot of skin bleeding, both now and later on. Good. We're now getting down to what's called the platysma muscle. Going through the platysma. Just as we would in a thyroidectomy procedure. Give me a buzz. Okay, right there to the corner please. She's right in the dermis there. And underneath that, you can see the platysma muscle right here. Okay, dermis And more platysmal muscle fibers here. And as we go towards the midline, we will get a little bit of scar tissue from her prior thyroidectomy procedure.

CHAPTER 4

So after we've divided the platysma muscle, we now raise inferior and superior subplatysmal flaps just as we would for a thyroidectomy. And right now, we're raising a superior subplatysmal flap. Thank you, Tiffany. You're good with the ultrasound right? Yep, all set. Thanks Kelly. So we just get right underneath the platysma, and this is where it's really important to stay very close to the platysma just underneath it. So we're just staying very superficial. This vessel out here superficially is the external jugular vein. Show that to them there, Tiffany. See. Right here? Yep. So this is probably one of the anterior jugular veins. Okay. So now we're gonna raise our inferior flap, which goes down towards the clavicle. Nope, you're gonna pick up the platysma there, please. Actually right at the edge of there. Great. Can I have the suction, please? So your landmark for the inferior flap is the clavicle. Your landmark for the superior flap really depends on how, what packets of lymph nodes you're planning to remove. But it's somewhere around the level of the mandible. As you raise your flap superiorly, and right now we're going inferiorly, that's when you have to be very careful not to injure the marginal mandibular branch of the facial nerve. So we're all the way down to the level of the clavicle here, and I can just palpate the edge of the mandible going up. Great. I will take, let me try the spring retractor, please. And Bovie, please. One second. A little lower.

CHAPTER 5

Okay. So the way we access the lateral neck and the lymph nodes in that region is by coming just between the most medial edge of the sternocleidomastoid muscle, and the most lateral edge of the sternohyoid muscle. That's what we're gonna do next. So we're going on the most medial edge of the sternocleidomastoid muscle. Right over here. We do not go between the two heads of the sternocleidomastoid muscle. You can do that, but we typically approach it on the more medial edge. You're gonna come a little more towards me, Tiffany, because I think this is all SCM here. Okay. And we wanna see the whole SCM go towards you. Give me a buzz. Okay. So we're trying to find right now, the most medial edge of the sternocleidomastoid muscle. And that would be the sternal head of that muscle, not the clavicular head. Yep. Good, so see where we are right there? Yeah. Give me a buzz. Mm-hmm. Okay. So this muscle here is the sternocleidomastoid muscle, and we're on the medial edge of it. Good, hold here. And once again, proceeding down towards the clavicle. Right. Okay now, there's a little vascularity there, right? So we're gonna leave that alone for now. Got it. Come up this way. And we're gonna go upwards towards the mandible. Now hang on for one second. Sometimes there's some little vein branches, and oftentimes for that reason, we'll use the Harmonic to come alongside that medial edge of the muscle. Can I have a baby abdominal? And at this point, if you feel you might need a little bit more room going upwards, then you can raise more flap. I think for now, we're good, and we're just gonna keep progressing along that medial edge of the SCM. All right, may I have a Weitlaner retractor? The larger of the two. Thank you. So we're gonna put this Weitlaner retractor on one edge of the sternocleidomastoid, on the other edge, the sternohyoid or one of the strap muscles. Okay. Suction. To open up this space. Okay. We're gonna continue to come alongside the medial edge of the sternocleidomastoid muscle. And one of the things that we will see very soon is a muscle that crosses right over the carotid sheath. It's called the omohyoid muscle. Right angle to me. And Harmonic please up to Tiffany. So you wanna seal it down towards me. Good. Now move up towards you. Stop. Good. Don't pull up on it. Good. Bovie, please.

CHAPTER 6

So right here, coming right across the carotid sheath, underneath the SCM is called the omohyoid muscle. And that's a muscle, in order to access the lymph nodes that we want, we will likely divide that muscle. Great. Thank you, Tiffany. There's right here. What's that, Tiffany, right there? Obviously the jugular. Yep. The internal jugular vein is right there. So a lot of this procedure is just identifying and making sure you preserve well the important structures like the internal jugular vein, which is located right here. And the vagus nerve, which is just deep to it. And the carotid artery, which is just medial to it. Okay, you're gonna pick up right here. Suction right there. So right now we're dissecting free the omohyoid muscle, and we're actually gonna divide the omohyoid muscle. Right angle, please. And Harmonic please, to Tiffany. You can let go there, Tiffany. Great. So this is the omohyoid muscle that we're dividing in order to access the internal jugular vein, and hence just lateral, and underneath that, the lymph nodes that we're planning to remove. It's often helpful to get the omohyoid muscle underneath the retractor. Bovie please, to Tiffany. There we go. So we're just dissecting the omohyoid, which has already been divided off the internal jugular vein. Right. So that's gonna go that way. Okay. Can I have the fine Kelly, please? Could you tilt the table slightly towards me?

CHAPTER 7

Yep. All right. We are now gonna dissect free... That's great, Dan. Thank you. You're welcome. The internal jugular vein. And you can use some Bovie electrocautery here. You can also use some sharp dissection with the Metzenbaum scissors depending on how close you are to the vein. So just make sure you don't pass point there. Good. Baby abdominal. Baby abdominal retractor, please. So we're going up towards the level III lymph nodes. You can use the Bovie there. Good, very nice, Tiffany, showing that to yourself. Great, perfect. All right, now you're gonna put that down, and get a forcep please. I'm gonna pick up the jugular vein. You're gonna pick up the tissue next to it. Mm-hmm. There's a lymph node right here. It does not look terribly pathologic, but this is where we're gonna start to find our lymph node packet, just lateral and underneath the jugular vein. Good. So I think I'm gonna put the Harmonic in there. It looks a little like there's some small vessel branches there. Can I have the baby abdominal again? Thank you Tiffany. Yep. Great. And forcep back to Tiffany. Yep. And just as you're doing this, you just wanna look out for any little branches of the jugular vein that could cause some bleeding. Okay, right here. Right now, we're just dissecting right alongside the lateral edge of the jugular vein. And as mentioned, we're starting to see some lymph nodes in this area. Look right here, please. And it's usually a good idea at some point for several reasons to get all the way around and under the jugular vein, that way you can see where your vagus nerve is, where your carotid artery is. And you can also pass a small vessel loop around the jugular vein in case you do get into some bleeding. You can have control of that. Do you have like, a blue vessel loop please, yet? Yes. See if that's the... Can you turn the nerve monitor on, please? Do you think that's the vagus there? I don't know. It might be. It's sort of an anterior vagus, though. 10 to 20% of the time. Yeah. So this is interesting in here. So fine Kelly, please. Here's the internal jugular vein right here that we're dissecting free. Scissors, please. Here's the, not that, but this out here is the carotid artery, which we're not seeing quite as well yet, but we will. And in between the two is a big nerve. That's the vagus nerve. Usually the vagus nerve is deeper than this. We call this an anterior vagus. And as Tiffany was saying, that happens in a small percentage of people. Fine Kelly. So you have to be careful of that, because if the vagus is anterior, you could injure it if you're anticipating it being deeper. And there's a branch of the internal jugular vein right there that we also don't want to injure. So we're just continuing to dissect free the jugular vein and the important structures here. And there is that branch right there. Which we may or may not divide. All right. You can hold there. Do you have the vessel loop? Yeah. Can you guys turn the heat down in here? You can pass that right up to... I'm like, sweating. Do you have a snap? Yeah. So this is a blue vessel loop for the jugular vein, so we can have a clear understanding of its anatomy, and also have control of it if we need to. You can also do this with the vagus and the carotid if you feel like you need to do that, but we're gonna be staying a little more lateral. There's the carotid artery right under there. Scissors, please. Great. Scissors, please. And once again, it's helpful to do - use the Bovie sometimes, but also liberally do sharp dissection, 'cause there are so many important nerves in this area that you're less likely to cause thermal damage with the scissors than you are with the Bovie. Great, Bovie, please. So we'll take that out. See that little lymph node there? Yeah.

CHAPTER 8

So at some point, you need to decide in these cases, if you're not doing a full level IIa lymph node dissection, which is up here, you have to decide how superior you wanna go. Now we know that her only known radiologically positive and biopsy-proven node is down here near the clavicle. So I'm gonna proceed probably about six centimeters or so above that. And we can see up here several benign-appearing lymph nodes. So we're gonna pull this tissue down, and probably complete our dissection at around the junction of level IIa and level III. So can I get the deep? There we go. Okay. But, and then the other nerve, so one of the nerves that can be up here, and we'll go through a bunch of nerves, is called the spinal accessory nerve, which innervates the muscles over here in the shoulder. And occasionally, you do get quite close to that depending on how lateral you are high up. Bovie, please. I always use the nerve monitor to test for these nerves. So the only thing really out here that you can hurt at this point is the spinal accessory nerve. Just the spinal? Yeah. As long as you're lateral to the jugular and the vagus. Okay. If you go up higher, that's when you get into the marginal mandibular branch, which is more superficial, and also the hypoglossal nerve. Something to think about in terms of carotids. So we're staying just lateral to the jugular. Vagus is also medial to us at this point. And what we're doing up here is creating the most superior aspect of our flap. I'm sorry, not our flap, our lymph node dissection. All right. Nerve monitor, please. Once again checking for the spinal accessory nerve or cranial nerve XI. Is the nerve monitor on five? Right. Right angle. Sometimes there's some... You know what? I'm gonna do the Harmonic here. Yeah. Yeah, it's at five. I think it's, okay, thank you. Just release it. Now pull those over towards you. And then the one thing to look over when you're pulling tissue from underneath the jugular, you have to make sure you don't rotate and pull over the vagus. So it's still very, very medial, which is good. Harmonic. But you can see how you could roll that underneath. So I usually check the vagus nerve several times throughout this dissection, make sure it hasn't gotten pulled over. Bovie, please.

CHAPTER 9

So we talked about the superior border of the dissection, which depends on what level you're planning to proceed to. And in this patient, it was really level IIb and level III. The lateral edge of the dissection is just underneath the SCM muscle. If you go any more lateral, you start getting into what's called the level V lymph nodes. And we don't need to take those lymph nodes out in this case. And rarely do they need to be removed in papillary thyroid cancer, but occasionally they do.

CHAPTER 10

The deep border of the dissection is the deep cervical fascia. Underneath the deep cervical fascia, you have to make sure not to get too deep. Right angle. Because underneath there is a very important nerve, the phrenic nerve. And we'll be stimulating for that one as well. Okay. And we're gonna test our vagus again over here. Good. See if you can relax. Yeah, we do need a retractor. And there's two, but is Diaz around again? can I have another Weitlaner? Can we try the baby abdominal, please? All right. And Bovie to Tiffany, please. A little bit of bleeding in here. Buzz me. That was a little twitch from what nerve? Did you see that? From the shoulder, so that's... Spinal accessory. Spinal accessory that we're talking about. Yep. Suction. Buzz, please. Good. Okay. Take that. And some Tisseel and Vistaseal, please. Either one is fine. Pull that over towards you. So right now, we're carefully dissecting the lymph node packet away from the deep cervical fascia. So right now you're seeing a twitch down here near her diaphragm. That's because I'm stimulating the left phrenic nerve, which innervates the diaphragm. Once again, that lives underneath the deep cervical fascia. And when you're resecting these lymph nodes... Bovie. You have to make sure you don't get too deep, or you can pull that nerve up and injure it. So in addition to monitoring the vagus, which runs just medial to our dissection plane, we're also monitoring the phrenic nerve, which innervates the diaphragm. So here's the start of our lymph node packet here coming from up here, which is about level IIb or level III, extending downwards towards the clavicle. There's another node right here. See that? Take that with us? Yeah. We will. So, yep, exactly. There you go, Tiffany, you wanna include that with our packet. Yeah, good. That was perfect. It's okay. So you're gonna, this is a small lymph node that looks benign, that came out on its own from adjacent to the jugular vein. So we're gonna include that with our specimen. It does not look suspicious. Hold that over. But one of the important points about this surgery is that you don't wanna just remove the lymph nodes that look suspicious. Right angle. You want to do what's called the compartment-based lymph node dissection. So you remove all of the lymph nodes in the area of that compartment regardless of their appearance. Harmonic. Now as we proceed inferiorly, the other thing we have to be very careful of which is gonna be very close to the positive lymph node here is something that's called the thoracic duct. Oh. Right, that's what I was asking you about. Right angle, please. Exactly. The thoracic duct is a large lymphatic duct that drains directly into the internal jugular vein, right just above the clavicle. And if that becomes injured or torn, small clip please. The patient can get a thoracic duct leak and a large seroma that occasionally does need operative intervention. It's an important potential complication of the surgery. Bovie, please. So I'm feeling the carotid artery under here, and that's dissected out right there. Yep. So there's the carotid artery. And then the vagus nerve is just above the two of them. So you're gonna pull that over there. Thank you very much, Tiffany. You're doing a great job. It's actually quite easy to get deep into the deep cervical fascia where the phrenic nerve is, so it's really important to pay attention to that. There we go. And I typically use the Bovie quite a bit for the level II and III lymph nodes, but I stop using it for level IV, because that's where the thoracic duct lives and you do not wanna come across the thoracic duct with the Bovie. So now we're getting into what looks like it could be the area of both the thoracic duct and the positive lymph nodes.

CHAPTER 11

Okay, so we're gonna shift this down here. Great. Bovie, please. You wanna pick up right there. Okay. Can I have a fine Kelly, please? And then I'm gonna have you pick up here instead. So now we're dissecting that more lateral edge of the jugular vein, and I can tell there's a firmer, almost little matted group of lymph nodes under here that probably represent the lymph nodes that were biopsied as metastatic papillary thyroid cancer. So we're progressing very carefully along this edge of the vein in order to free up this region. Bovie. Okay, and you're gonna hold right here. Can I have a fine Kelly, please? So we're gonna circumferentially dissect the vein. Nerve monitor. Harmonic. And we are now well into what's called the level IV lymph nodes. And as you can see, one of them is quite dark. That is very suspicious for metastatic involvement. There you go, perfect. Bovie, please. Actually, you know what? Can I have the fine Kelly? And Viet, would you mind holding that for us? Sure. And she's gonna take the Harmonic. Hold this right here, please. Thank you Yeah, right there. Good. Good, relax. Once again, see how easy it is, Tiffany, to pull the floor up? Like, under there is the phrenic. Can I have the nerve monitor, please? But do you see what I'm saying? So like you could imagine trying to get under that. You don't wanna do that. Those are not lymph nodes, That's just fat. Okay. Yep. Okay. Checking the vagus. We're good. Okay, Viet. Hold right there. I'm gonna put you very gently on the jugular vein with the retractor there, Viet. Actually, do you have a vein retractor or no? No. Okay. Hold that right there. Hold that right there. Can I have a fine Kelly? Hold that gently right there. She's a little, something right there. I think that's probably a lymphatic. Can I have a small clip please to Tiffany? So put a small clip down this way. You wanna make sure to secure the lymphatics very well. You don't wanna Bovie right through them. Scissors to her, please. And then cut up near the lymph node packet because otherwise you can get seromas after surgery that can be quite bothersome. There we go. Harmonic. Great. And as we reach around to the most medial edge of these level IV lymph nodes, this is when you have to be particularly careful. 2-0 tie, please. I'll take a right angle. She'll take the 2-0 tie. Of the lymphatic duct and the vagus nerve. There we go. Once again, I tend not to use the Bovie very much in this region for that reason. So you want to tie that out towards the vein. So this way towards me. Good. Great. Do you have an Allis? Yeah. Great, I'll get that. Hold that gently right there. Okay, I'm gonna take that towards me. You're gonna take this lymph node packet, yep, towards you. Suction please. I will take the nerve monitor, please. The other thing about lymph nodes, especially metastatic ones, is they tend to bleed a lot. That's the vagus nerve. Right angle, please. Knife, please. Make sure you leave something on your tie. So Tiffany is excising the lymph node that way. We're leaving our larger lymphatic vessels. Can I have a small clip, please? And I'm doing a double ligation on this one. Tie and a clip. Okay. Can I have a DeBakey? So here's our metastatic level IV lymph node. It's very dark, it's about two centimeters. And once again, very important to understand the anatomy of the thoracic duct. at this point. Can I have a fine Kelly, please? Okay, so let's move this. Okay, hold that gently towards you. Suction.

CHAPTER 12

This is the most delicate and important part of the dissection is that down near the clavicle where you're gonna encounter the thoracic duct. Okay. So we're gently putting the retractor right on the internal jugular vein here. The carotid artery is right here, and it's right in here that we suspect the thoracic duct could be. Could I have a right angle, please? And Harmonic please, to Tiffany. This is probably too superficial for the thoracic duct, so we're gonna divide this first. And actually, right down in here, it's always very difficult to see. It's a very clear structure, is the thoracic duct, which is probably entering into the internal jugular vein somewhere in this region. Let's see how close we're to the... So I'm just feeling where we are in relation to the clavicle. Hold that right there. Good. Right angle, please. 2-0 tie to Tiffany. Once again I tend to tie. I'll take this Tiffany. Tie everything here, in case it's either a large lymphatic, or the actual thoracic duct itself. So this is just at the very lateral edge of the internal jugular vein. Just above the clavicle is where you wanna be most careful of the thoracic duct. I'm gonna take that. You're gonna take this. Harmonic. It's a little, way up towards the specimen. Good. Good. Yep. Small clip, please. And once again, double ligation. We have a tie and a clip. Forcep, please. Okay, hold that right there. Hold that right, yep. Suction. We're gonna move you around there to there, Viet. Fine Kelly, please. So this was a very low lymph node, the one that's seen as positive. I just wanna make sure there aren't any other lymph nodes beneath it or deep to it. So we're just dissecting free... Bovie, please. These are the sort of lowest level IV lymph nodes here that we're just making sure are not involved. 2-0 tie, please. This is going to be level III and level IV left lateral neck lymph nodes. Try to get, I don't know if that's a node there, is it? Yeah, there you go. Yep. Suction. And right angle please, to me. And you can get the Harmonic. Okay. Scissors, please. And another 2-0 tie, please. Peanut, please. And Harmonic, please. Right angle. So she's putting a tie on the side that's staying in and she's Harmonicking the side that's coming out. Scissors. Bovie. Some superficial muscle attachments that can be Bovied DeBakey. Good.

CHAPTER 13

So now we're kind of at the junction of the level IV and level V neck lymph nodes here, moving out laterally. Harmonic, please. Actually 2-0 tie. And Viet, if you're able to reach over and just take that from her. Yeah, while she ties that. Harmonic. Great. I think you can Harmonic this, if you wanna just keep that on for now. Mm-hmm. Okay, scissors, please.

CHAPTER 14

So we still have our index lymph node, a little bit adherent to the deep cervical fascia. You can get the Harmonic there. So we're gonna finish up this deep margin now Suction, please. Right angle. And now, we're once again back to the junction of the level IV and level V. You can use that. You can use that. Neck lymph nodes. Right angle. So if you can hold that over a tad. There we go. Tie please. 2-0. And just slide that. Yep. Down towards you? Yep. Okay, you're gonna hold the lymph node packet over there. I'll take a right angle. And knife, I think Scissors, please. Knife down. And you can let go of that with your forcep. So this is our last little short junction towards the level V neck lymph nodes. Mm-hmm. Bovie, please. These are just some clear attachments to the deep cervical fascia, and then the Harmonic one more time. Right across there. Mm-hmm. Yep. Great. So you can let go of that, Viet. Watch the suction.

CHAPTER 15

So I'm just gonna orient these lymph nodes. So these were the level sort of III and IIb lymph nodes up here. Can I have a marking pen, please? Here was the clavicle. Here's a level IV lymph node that was biopsied as positive right here. Here the level IIb and III, and then extending into IV neck lymph nodes. Out here, which we did not remove, are the level V neck lymph nodes. And that's where we divided the lymph node packet here. Deep to this is the deep cervical fascia, and here is the jugular vein. Any questions? And this is the angle of the mandible up here? Yep, mandible is here. There's our lymph node packet. Let's take a little marking suture. And I would mark level IIb lymph nodes up here. Long stitch? Just one stitch. So this is the left lateral neck dissection, stitch marks level IIb lymph nodes. Can I have a baby abdominal, please? Yep, that can go in there as well. So we're marking the lymph nodes and sending them to pathology.

CHAPTER 16

Now we have a beautiful view in here of several things. You have a needle there, Viet. So if you look in the wound here. Hold that up there please. Forcep please. Viet, if you can hold that right there. Yep, right there, perfect. So here's the jugular vein and anterior vagus. The carotid artery is right next to them, or actually sort of almost underneath them right there. Point to the carotid artery, please. Right here. We dissected the lymph nodes from underneath the jugular vein up towards here. And as you progress down towards the clavicle, as I mentioned, you're always concerned about a very important structure called the thoracic duct. You can actually see the thoracic duct beautifully. Another forcep to me. Right here. Do you see that? Yes. It's almost like a tissue paper like clear structure that enters right into the jugular vein. And that's what you need to make sure you don't injure when you remove lymph nodes from the left level IV area.

CHAPTER 17

Irrigation, please. You can hold that there, Tiffany. Yep. So we're gonna irrigate the wound. Make sure there's no bleeders up towards the mandible. Great. Do you have the Tisseel or Vistaseal? Yep. We can also stimulate the nerves that we were concerned about. Make sure they're all working. We'll start with the vagus. So that's working. And then we're gonna go down to the phrenic. So feel, put your hand right there. Yep. Okay. Got that right there? Yep. Yep. Okay, so the phrenic nerve is working. We were probably too medial and below the spinal accessory nerve, the hypoglossal, and the marginal mandibular branch of the facial nerve. And we also identified and preserved the thoracic duct. All right, could we have the Tisseel, please? So Tisseel is a great sealant, both for small bleeding vessels, and for lymphatics. So I apply Tisseel in every neck dissection. And then can I please have the Surgicel and a second forcep? And I also place the Surgicel as well, especially once again around the lymphatics, down near the clavicle. Okay.

CHAPTER 18

All righty. Can we please… And I don't typically leave a drain, which some people do, with neck dissections, especially with a rather limited neck dissection such as this one where we were able to clearly visualize the thoracic duct. So Tiffany's gonna just tack two sutures of the sternohyoid muscle to the edge of the SCM. Yep. Just to close the tissue over the carotid sheath. Just be careful, there's an anterior jug there. Yep, there. Can I have a stitch as well, please? Can I have a scissors? I do not do an airtight closure of the SCM and the sternohyoid muscle, 'cause I don't want the patient to get a lot of pulling in their neck. So as long as you've covered up the carotid artery and the interior jugular vein, you can leave a small space above and below. Could you let the thyroid bag down, please? Yes. And we're now gonna close the platysma muscle. Clean, dry gauze, please. Can we get two Adsons, actually? Actually, you know what, let's just do a little stitch right here. Can you tie this for me? And then if you could actually straighten out her head from what we tilted. Just watch out for the needle there. Yeah. Great. Good. See, if you don't straighten out her head, Tiffany, you close it like that, you know? Oh. So you wanna make sure you don't do that. Off center. Yeah. Okay, we'll just take Adsons. So you wanna make sure that she lines up like this. See what I mean? I see. So you have to pull it a little this way. Can I have some Adsons, please? I see what you mean. So we're gonna close the platysma, so we have to make sure. So is that straight? Now it's straight, yeah. Okay, second forcep to me. I'm gonna have you put this in while I hold it. Okay. Hold on. Wait. Let go for one second, Tiffany. Right here. You pick that up. Pick up the skin. Yeah, there. Now when you tie, make sure that lines up in the corner. Does that make sense? Yes. You don't want the corner to go like that. Yes. It's like that. Okay. So I'm tying. Scissors, please. It's looking pretty minor. It has a tendency to go that way, so another stitch, please. So I'm gonna pull it this way while you put in another one right here. Yep. That's looking better. Yeah. Stitch to me, please. So you have to make sure when you close the incision that you don't dog ear the lateral corner. That's what we've been talking about. So it's helpful to have one person hold it straight while the other person puts in a few stitches. So we close the platysma and skin in layers. We start with the platysma, and then we often put in a few, what we call deep dermals. So this has a tendency to ride over it. So you've gotta go deeper on this side. Does that make sense? Deeper on the inferior side. Yep. To kind of bring the inferior side up. Okay. Do you think you need more Vicryl? We may need one more. Can I please have one more Vicryl? Please? One? Yeah. Scissors, please. And then you can cut this needle off here. I think you overdid it a little here. Too deep? You see, well... Yeah, I think you can line that up. That actually is fine. See how it's a little... Maybe a little too deep on the inferior side? I think it's good. All right, so just make sure the same thing that you don't have a dog ear when you put in the Monocryl. So now we're gonna finish this up with a knotless subcuticular Monocryl and Steri-Strips.

CHAPTER 19

So in this case, this was quite straightforward. The patient had very clear anatomy. We were able to enter the area of her lateral neck lymph nodes by dividing the medial edge of the sternocleidomastoid muscle, and that allowed us access to this region. We did divide the omohyoid muscle as expected. We carefully dissected free the jugular vein, which allowed us access to the lymph nodes just underneath and lateral to the vein. As we proceeded from the level II and III lymph nodes, we did note the clearly positive lymph node, which was directly underneath and lateral to the jugular vein and sitting right on top of the thoracic duct, which was clearly identified and preserved. In this region, we carefully used 2-0 silk ties to ligate the larger lymphatics, which exited the area of the thoracic duct. The thoracic duct itself was, as described, left intact, and we were able to remove the full packet of lymph nodes, including the clearly positive one, and the region of lymph nodes around it as well.