Neck Dissection (Level I-IV)

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Preoperative Considerations

Consent:

  • Bleeding: possible transfusion
  • Infection
  • Sensory & motor nerve damage
  • Difficulty Swallowing
  • Hoarseness & difficulty speaking
  • Shoulder Dysfunction: frozen shoulder, limited range
  • Lymphedema:
  • Cosmetic Changes

Anesthesia/Positioning:

  • Supine
  • Shoulder roll with adequate neck extension
  • Paralysis per surgeon preference

Other:

  • Type & screen
  • Communicate with ICU PRN

Armamentarium:

  • Scalpel Handle
  • Metzenbaum Scissors
  • Dissecting Forceps (e.g., Adson Forceps)
  • Hemostatic Forceps (e.g., Kelly Forceps)
  • Bipolar Cautery or LigaSure Vessel Sealing Device
  • Suction Apparatus
  • Weitlaner Retractor
  • Richardson Retractor
  • Senn Retractor
  • Electrocautery or Harmonic Scalpel
  • Suture Material (e.g., Vicryl, Nylon)
  • Specimen Containers
  • Anesthesia Equipment
  • Sterile Draping Materials
  • Sterile Gauze and Sponges
  • Topical Hemostatic Agents (e.g., Surgicel, Floseal)
  • Optional Imaging Equipment (e.g., intraoperative ultrasound, nerve monitoring devices)

Technique

  • ​Intubation and standard headwrap ensuring exposure below clavicles (if large reconstruction is planned, prudent to prep till xiphoid in case pectoralis salvage flap is needed
  • Mark skin incision ​in skin crease. Various designs per surgeon preference
  • Skin incision with blade or monopolar
  • Dissect through skin and subcutaneous tissue until platysma is encountered

Postoperative Considerations

Immediate:

  • Elevate HOB
  • Monitor drain output
  • Maintain normotension
  • CXR if concomitant trach

Follow Up:

  • Remove skin sutures POD7
  • Remove skin staples POD10

Operative Note

Surgeon(s): ***

Assistant Surgeon(s):  ***

Preoperative Diagnosis: ***

Postoperative Diagnosis: Same

Procedure(s): ***

Anesthesia: General

Implants: None

Specimen:***

Drains: None

Fluids: See anesthesia record

EBL: Minimal

Complications: None

Counts:  Correct x2

Indications: ​***

Findings: As expected

Procedure in Detail:

The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

A curvilinear utility incision was made in a natural skin crease extending from the mastoid process crossing to the midline at the level of the cricothyroid membrane.  Superior and inferior subplatysmal skin flaps were elevated and secured with silk ties.  Level 1A was then cleared from the symphysis of the mandible to the hyoid bone inferiorly.  This was then carried to level 1B.  Care was taken to identify the marginal mandibular nerve and protected via Hayes-Martin maneuver after identifying the facial vein and facial artery which were tied and elevated superiorly.  Perifacial lymph nodes were harvested and submitted for permanent pathology.  Submandibular gland was then incised and removed out of its fossa after identifying the posterior edge of the mylohyoid and then identifying the lingual nerve.  Care was taken to preserve this as it was dissected posteriorly up towards the jugular vein.  Once the jugular vein was encountered, attention was then turned posteriorly to the SCM where the superficial layer of the deep cervical fascia was then elevated and dissected posteriorly up toward the contents of level 5.  Spinal accessory nerve was identified superiorly as well as the omohyoid inferiorly and in an inferior to superior direction, the fibrofatty contents of levels 1, 2, 3 and 4 were elevated and submitted for permanent pathology.  Hemostasis was achieved.  A 19 French Blake drain was then placed into the gutter and secured to the skin with a 3-0 nylon.  The wound was closed in layers with 3-0 Vicryl suture and a 5-0 Prolene superficially.  Confirmation of hemostasis was achieved with Valsalva maneuver by the anesthesia service.

The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

Coding

  • 21244 Reconstruction of mandible - extraoral approach, with plate application
  • 35701 Exploration of Neck / Carotid vessels
  • 41155 Composite procedure with resection of floor of mouth, mandibular resection, and neck dissection
  • 20969 Fibula free Flap, osteocutaneous
  • 20245: Deep bone open biopsy (bone deep to muscular tissue)
  • 31600 Tracheotomy
  • 21209 Osteoplasty of facial bone with reduction Incision and repair of bony defect of cheek bone including bony segment reduction
  • 69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
  • 88331, Pathology consultation during surgery
  • 14041  Local tissue rearrangement
  • 97605 Wound vac application < 50cm SQ
  • 64400 - Local anesthesia block
  • 76377 - 3D post-processing images are reconstructed on an independent workstation with concurrent physician supervision.
  • Surgical Dental extraction