1. College of Medicine of Mosul
Surgery of the neck(4)
بِسْمِ اللهِ الرَّحْمنِ الرَّحِيم
Dr. Karam Kamal Sharif
Assist. prof. of surgery
College of Medicine of Mosul

2. Neoplastic cervical LAD
80% of neoplastic LN are malignant
80% of malignant LN are secondary
80% of primary tumors above the clavicle
A- primary in head and neck (80%) =SCC from
1-Known primary: in oral cavity, nasopharynx
Oropharynx, hypopharynx or thyroid
2- Occult hidden primary in base of tongue, hypophx.,
Pyriform sinuses, tonsils ,nasophx. & postcricoid area
B- primary below the clavicle (20%)
1- bronchus
2- stomach, colon, pancreas.
3- testes, prostate.
Character of LN involved by secondary malignant
deposit are rapidly enlarged, big > 2 cm stony hard, irregular shape, fixed, painless with subsequent ulceration to skin
secondary malignant LN
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

3. Electro surgery in Gynaecology - Prof.S.N.Panda
Primary cervical LN malignancy
Represent 20% of malignant tumors mostly lymphomas /leukemias
Hodgkins disease-lymphoma
Usually involves children& young adults.
More common in male.
Clinically:
Painless progressive enlargement of discrete mobile & rubbery LN
May be very large LNs “bull neck +/-hepato/splenomegaly +/- B symptoms – fever, night sweats, pruritus& weight loss
Management of neoplastic cervical LAD
The primary should always searched and managed accordingly.
Biopsy or FNAC for confirmation of diagnosis
Surgery =excise LN with primary by neck dissection .
Radiotherapy
Can be used initially like in nasopharyngeal ca.
Recurrent nodal disease.
Residual tumour
Hodgkins disease
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

4. Electro surgery in Gynaecology - Prof.S.N.Panda
Cervical LN metastasis decreases the 5-year survival rate in
upper aero-digestive malignancies by 50%.
. .
NECK DISSECTION
The gold standard for control of cervical metastasis is radical neck dissection (RND) with en-block removal of primary tumour if feasible
Many incisions (Crile, Ward, Martin, Schechter, Macfee and Hockey stick)
The aim is to fulfill 1-adequate exposure. 2-capable for extension. 3- cosmetically acceptable 4- not damage vital structure under the skin 5- avoid middle portion of the neck
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

5. Electro surgery in Gynaecology - Prof.S.N.Panda
Types of neck dissection
& SM salivary gland.
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

6. Electro surgery in Gynaecology - Prof.S.N.Panda
Complications of RND
A- Early: 1- Bleeding 2-Pneumothorax 3- Increase intracranial pressure due to ligation of IJV. 4-Chylus fistula due to injury to thoracic duct. 5- Carotid artery rapture. B-Late: 1- Scar formation and disfiguring 2-Frozen shoulder 3- Recurrence of tumour
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

7. Electro surgery in Gynaecology - Prof.S.N.Panda
NECK INJURIES
Aetiology
Blunt: mostly in car accidents fracture cervical spine
Penetrating: (penetrate platysma) in stabs or missiles causing visceral or vascular injuries
The neck is divided into 3 anatomical zones: to aid in decision making- diagnostic tests,-timing of surgery
Zone I- thoracic outlet (clavicles to cricoid cartilage),
Zone II- mid neck (cricoid to angle of the mandible).
Zone III- upper neck (angle of mandible to base of skull).
Why serious?
Vital viscera/vessels
Cx spine
injuries have the highest mortality
The most frequently involved region
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

8. Electro surgery in Gynaecology - Prof.S.N.Panda
Management steps
1-AcBCDE
2-Examination for: ” Hard signs” of significant neck damage:
-Vascular injury -Shock/Expanding or pulsatile hematoma Neurologic deficit
-Venous air embolism due to IJV injury
-Bruit or thrill in neck(AV fistula)
-Thoracic duct injury Chylous fistula up to 2 L/D
-Neurologic deficit Vagus / recurrent laryngeal/sympathetic chain
-Laryngotracheal injury -Subcutaneous emphysema
-Acute Airway obstruction
-Sucking wound
-Hemoptysis
-Dyspnea
-Stridor
-Hoarseness or aphonia
-Pharynx/esophagus injury Subcutaneous emphysema
-Hematemesis
- leakage ,cellulitis ? mediastinitis
-Dysphagia or odynophagia
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

9. ZONE I INJURY-MANAGEMENT
3-Definitive treatment: according to NECK zones
Penetrating injuries are potentially fatal. Arrange for
Angiography or CT angio for suspected vascular injury to plan selective exploration
Esophageal barium swallow to detect- missed esophageal injury- mediastinitis
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

10. ZONE II INJURY- MANAGEMENT
Asymptomatic-stable pt with no penetrating wound So arrange for Selective exploration :. mandatory neck exploration or directed evaluation and serial examinations by Angio / duplex Doppler or CT A-gram, contrast study of esophagus, rigid endoscopy, and rigid bronchoscopy. Operation reserved for identified injuries
Symptomatic- as Pt with refractory shock, uncontrollable bleed, expanding hematoma & wounds penetrating platysma all need (immediate) neck exploration & treat accordingly
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

11. Electro surgery in Gynaecology - Prof.S.N.Panda
Specific injuries zone II:
Wounds above hyoid bone Rx as in tongue injuries
Wounds of thyroid and cricoid cartilage
Distal tracheostomy, larynx cartilages repositioned. + stent inserted for 5 days removed endoscopically later
Division of the trachea (rare)
Distal Tracheostomy (below wound) & repair of trachea.
Neurovascular injury =exploration under GA with repair .
Thoracic duct injury rare
If recognised intraoperatively, the duct ligated.
If undetected, chyle discharge from neck wound within 24 hours of surgery. Treatment= either by firm pressure, or wound reexplored and duct ligated.
Esophageal injuries sutured & drained +antibiotics .
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

12. Electro surgery in Gynaecology - Prof.S.N.Panda
CUT-THROAT
Is due to attempted suicide
Head extended- great vessels escape injury,while in homicidal cut throat there is a risk of great vessel injury
Treatment
proper neck exploration,
debridement of ischemic tissue,
the air passages are – repaired + tracheostomy
Bleeding from thyroid artery- secured
IJV- ligated above and below the injury site
Pharyngeal injury- suture, with drainage
NG tube for feeding
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

13. ZONE III INJURY- MANAGEMENT
Potential for injury to major blood vessels and cranial nerves near the skull base
Surgical exposure – difficult
Arrange for Angiogram- interventional radiology to embolize bleeders
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

14. الْحَمْدُ للّهِ رَبِّ الْعَالَمِينَ
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda 14