THE LONDON
HEAD AND NECK DISSECTION
COURSE
DISSECTION MANUAL
Compiled by Tunde Odutoye
2
CONTENTS
1. TRACHEOSTOMY Page 3
2. SUBMANDIBULAR GLAND DISSECTION Page7
3. PAROTIDECTOMY Page 11
4. THYROIDECTOMY Page 16
5. LARYNGECTOMY Page 21
6. NECK DISSECTION Page 29
7. REFERENCES Page 37
3
TRACHEOSTOMY
Extend the head on the
neck.
Horizontal skin incision.
Halfway between cricoid
cartilage and suprasternal
notch.
Exposure of strap
muscles.
Dissect through the
subcutaneous tissue down
to the deep cervical fascia
and strap muscles. The
anterior jugular veins can
usually be retracted to
one side with the straps,
but if they are in the way
simply clamp, divide and
ligate them.
Relationship of anterior
jugular veins to midline.
4
Opening strap muscles
down the midline. The
fascia of the strap muscles
is carefully incised in the
midline avoiding entry
into the thyroid capsule.
Crossing veins between
anterior jugulars are
divided.
ALWAYS PALPATE
THE TRACHEA AT
EACH STEP FROM
HERE, AND ENSURE
THAT YOU ARE IN
THE MIDLINE.
Exposure of thyroid
isthmus and trachea.
PALPATE THE
TRACHEA AND
ENSURE THAT YOU
ARE IN THE MIDLINE.
Thyroid isthmus divided.
Either use diathermy, or
clamp and ligate using
suture ligature.
Gently use a peanut swab
to reflect the thyroid
gland off the trachea.
5
Identify the larynx –
Thyroid and cricoid
cartilages ( 1 ). Make your
opening into trachea
between tracheal rings
two to four ( 4 ). It is
possible sometimes to
push the isthmus of the
thyroid gland ( 2 )
upwards, thus avoiding
dividing the isthmus. Do
not go below ring six ( 3 )
because of danger to the
brachiocephalic artery.
Relation of
brachiocephalic artery to
trachea.
Second tracheal ring
incised.
6
Get your anaesthetist to
withdraw the
endotracheal tube until
you can just see the tip.
Then insert your
tracheostomy tube.
Proper placement of
tracheostomy.
7
SUBMANDIBULAR GLAND EXCISION
Start with a skin crease incision two fingerbreadths below
the ramus of the mandible, or just above the level of the
hyoid bone.
Go through the subcutaneous fat to expose the platysma.
Go through the platysma to expose the deep cervical
fascia.
Also identify the digastric tendon, and muscle as this
serves as a very good landmark, especially in the fat neck
where one could easily get lost !!
8
Sumandibular gland and
digastric below it.
One can protect the marginal mandibular nerve
in one of two ways
1. Go right through the deep cervical fascia,
and lift it off the gland thus pulling the laterally
placed nerve out of the way.
2. Identifying the facial vein, and ligating it
and dividing it and then pulling it up, thus
pulling the laterally placed nerve out of the way.
9
(1)
(2)
Pull gland down
inferiorly and
posteriorly, dissecting it
off the mylohyoid
muscle. Expose the facial
artery, and clamp, divide
and ligate this. You may
have to do this twice, as
the artery runs up under
the ramus of the
mandible, and then back
out again.
10
Now retract the
mylohyoid muscle,
exposing the
submandibular
( Whartons ) duct.
Pull the gland inferiorly
whilst retracting the
mylohyoid muscle and
the lingual nerve will be
exposed.
Clamp, divide and ligate
Whartons duct keeping
the lingual nerve in
direct view.
Deliver the
submandibular gland.
11
PAROTIDECTOMY
Modified Blair incision.
Make sure that the lower
limb of the incision is two
fingerbreadths below the
ramus of the mandible to
avoid damaging the
marginal mandibular
branch of the facial nerve.
Raise your flap just over
the parotid fascia.
In essence one is raising a
sub superficial musculo
aponeurotic ( SMAS ) layer
and sub platysmal flap ( so
called face lift layer ).
SMAS incorporates the
platysma which will be
found more inferiorly and
anteriorly in your
dissection.
12
Dissect out the tragal
pointer and cartilage.
Also known as Conley’s
pointer, the facial nerve can
be found approximately
1cm inferior and deep
( medial ) to this landmark.
Conley’ pointer at tip of
clamp.
13
Find the greater auricular
nerve, and divide it.
Now find the posterior
belly of the digastric
muscle. It lies deep and
anterior to the upper
sternomastoid.
In the fat person it is often
useful to palpate the area
for the transverse process
of the C2 vertebrae. The
muscle lies just superior
and anterior to this. The
accessory nerve is usually
just behind this.
14
Follow the digastric muscle up to its attachment
to the mastoid. Bisecting the angle between this,
and the estimated position of the bony tympanic
ring gives the rough path of emergence of the
main trunk of the facial nerve.
Alternatively one can dissect down onto the
tympano-mastoid suture ( junction where the
bony tympanic ring meets the mastoid bone.
Dissecting carefully medially along this suture
will lead one to the facial nerve which emerges
lateral to the palpable styloid process.
Try to find the facial nerve using all three
methods.
Gently dissect the parotid
tissue of the facial nerve,
using a mosquito forceps to
expose and protect the
facial nerve, whilst cutting
away the parotid tissue
above it with either scissors
or knife.
15
16
THYROIDECTOMY
Collar incision. Do in a
skin crease
approximately 2
centimetres ( one
fingerbreadth ) above
the suprasternal notch
Flap dissection. Raise
subplatysmal flaps
taking care to avoid
damaging the anterior
jugular veins.
Begin your dissection
laterally as there is no
platysma medially, and
it is easy to get lost in a
bloody fibro-fatty plain.
Deep cervical fascia.
17
Opening strap muscles
down the midline. The
fascia of the strap
muscles is carefully
incised in the midline
avoiding entry into the
thyroid capsule.
Crossing veins between
anterior jugulars are
divided.
Elevating strap muscles.
Two fingers are used to
elevate both strap
muscles on each side to
the level of the thyroid
lobes. It is important to
not push too deeply
posteriorly before direct
visualization is achieved
to avoid tearing the
middle thyroid
veins. For a massive
goiter, division of the
straps is prudent.
Adequate thyroid
exposure
18
Gently retract back the
strap muscles on one
side using digital
dissection. Then use a
figure of eight suture, or
Allis clamp to gently
pull the thyroid lobe on
one side medially ( to
the opposite direction of
the lobe) thus exposing
the middle thyroid vein.
Clamp, divide and
ligate this.
Expose the upper pole
of the thyroid gland.
You may have to divide
some of the upper fibres
of the strap muscles
particularly the
sternothyroid muscle in
order to get adequate
access.
Dissect out the superior
thyroid vessels staying
as close to the thyroid
gland as possible. In this
way one helps to
preserve the blood
supply to the superior
parathyroid gland. Also
remember that the
external branch of the
superior laryngeal
nerve lies postero -
medial to these vessels.
See if you can identify
it.
19
While delicately
retracting the superior
pole laterally, a small
hemostat is insinuated
just medial to the fascia
containing the vessels,
hugging the contour of
the top of the lobe.
Opening the clamps
separates the vessels
from the superior
laryngeal nerve.
Once the upper pole is
free, further retract the
lobe medially. See if you
can identify the
superior parathyroid
gland and dissect it off
the thyroid capsule.
Also at this point try to
identify the recurrent
laryngeal nerve which
lies in the tracheo -
oesophageal groove.
20
Left recurrent laryngeal
nerve exposure.
The inferior thyroid
artery is now dissected
and elevated. The
recurrent laryngeal
nerve can also be
identified at this stage,
usually posterior to the
vessel and within
or anterior to the
tracheo-eosphageal
groove. Also try to
identify, dissect off the
thyroid capsule, and
spare the inferior
parathyroid along with
its blood supply from
the inferior thyroid
artery.
The lobe is then
retracted further,
exposing the suspensory
ligament (of Berry) that
attaches it to the
trachea. The ligament is
sharply divided close to
the gland keeping the
recurrent laryngeal
nerve under direct
vision. The isthmus is
then easily mobilized
from the trachea and
divided at its junction
with the opposite lobe.
21
TOTAL LARYNGECTOMY
Gluck Sorenson or
Apron flap incision.
From 1 to 2 cm
lateral to the greater
cornu of the hyoid
bone, down the
sternomastoid muscle
to midway between
the cricoid cartilage
and suprasternal
notch, and back up
again.
Raise subplatysmal
flap. Then dissect
through the deep
cervical fascia on
either side along the
anterior border of the
sternomastoid, and
expose the strap
muscles.
Retract the
sternomastoid,
carotid sheath and
great neck vessels
laterally.
22
Divide the strap
muscles.
Now decide what you
are doing with throid
gland. If saving it
divide the isthmus,
and dissect it off
trachea sparing its
feeding and draining
vessels.
If it is to be sacrificed,
go round behind it,
and tie of all feeding
and draining vessels.
Clamp and divide
thyroid isthmus.
23
Demonstrating right
thyroid lobe dissected
off trachea, with right
recurrent laryngeal
nerve at tip of
mosquito forceps.
Hooks pulling
amputated straps on
thyroid cartilage.
Left side
Now moving up along
the side of the
trachea, and larynx
tie off all the vessels
feeding or draining it.
In particular find and
divide and ligate the
superior laryngeal
artery and vein.
24
Now cut through the
pharyngeal
constrictor muscles
totally freeing the
larynx at both sides.
Cut sharply with a
knife at the posterior
border of the thyroid
cartilage. Be careful
not to enter the
pharynx.
The larynx will now be free on either side.
Now dissect the tongue base muscles off the
superior border of the hyoid bone. Stick to
the hyoid bone as wandering superiorly brings
grave danger to the lingual arteries, and
hypoglossal nerves.
25
Lingual artery, and
hypoglossal nerve just
above the hyoid bone.
See danger if one
strays above the
hyoid bone.
Now that larynx is
free on all sides make
your opening in
trachea, stitching the
lower trachea to the
lower skin flap to
prevent retraction of
the trachea into the
thorax.
Insert laryngectomy
endotracheal tube.
Now make your entry into the pharynx above the
hyoid bone.
Note that side of entry is usually determined by
the tumour.
Once in, aim for the superior cornu of the thyroid
cartilage on either side cutting through the soft
tissues to free the larynx from the remaining
tongue base muscle and mucosa.
26
This picture
demonstrates the
mucosal cuts once you
are inside the
pharynx.
Once you have made
these cuts one can
dissect the larynx and
trachea off the
remaining lower
pharynx, oesophagus,
and trachea as
demonstrated below.
Post larynx excision –
Pharyngeal defect
with tongue base
musculature above.
Do a cricopharyngeal
myotomy now. Get a
member of the faculty
to demonstrate.
27
Pass nasogastric tube,
and then close defect
with a running
Connell stitch.
Pharyngeal defect
closed.
Put in two large
drains, and close
incision, and stitch
upper flap to trachea
thus creating a
laryngeal stoma.
28
29
NECK DISSECTION
Modified radical type 1
Modified Crile
incision.
Upper limb from mid
chin to level of hyoid
bone and back to
mastoid.
Lower limb from
midpoint of upper
limb to midpoint of
clavicle. Curve in a
lazy S.
Alternatively use a J
shaped utility incision
from the mastoid
process to the mid-
chin, running down
the posterior border of
the sternomastoid (
SCM ), as far down as
the clavicle if
necessary.
Raise subplatysmal
flaps, keeping internal
jugular vein ( IJV )
and greater auricular
nerve intact.
Raise the upper flap
up the ramus of the
mandible, the anterior
flap to the midline and
clavicle, and the
posterior flap to the
anterior border of the
trapezius and clavicle.
30
Ditto for utility
incision
Identify marginal
mandibular nerve in
the deep cervical
fascia, and lift this
fascia off with nerve.
31
Alternatively identify
facial vein which lies
medial to fascia and
nerve, clamp, divide
and ligate it, and then
lift it up retracting
fascia and nerve safely
away from
submandibular gland.
Next find the accessory
nerve. It lies embedded
in the posterior
triangle or
supraclavicular fat
1cm above Erbs point.
Erbs point is the
junction of the greater
auricular nerve with
the posterior border of
the SCM.
Dissect out the
accessory nerve till it
disappears under the
trapezius muscle.
32
Follow the nerve
through the superficial
fibres of the SCM up
to the posterior belly
of the digastric, being
careful to avoid
damaging the IJV.
Now divide lower end
of SCM carefully,
taking care not to
puncture the IJV.
Now identify the
omohyoid muscle
which runs medial to
the SCM. Divide the
omohyoid as lowdown
as possible, thus
exposing the lower
IJV.
33
Expose, ligate and
divide the lower IJV.
Make sure you identify
the vagus nerve first.
34
Correct way of ligating
off IJV.
See if you can identify
thoracic duct, just
lateral to IJV.
Now dissect out
supraclavicular fat
pad, exposing the
prevertebral fascia.
Start at the IJV stump
medially, and then
proceed laterally along
the clavicle staying
above the transverse
cervical artery. Then
go up along the
anterior border of the
trapezius, being
careful to avoid
damaging the
accessory nerve. Do
not go through the
prevertebral fascia
35
which covers and
protects the brachial
plexus and phrenic
nerves.
As you proceed
anteriorly you will
come across the
cervical plexus roots.
Divide these as high as
possible.
Then divide upper end of SCM, and swing the
entire fat pad and SCM forward, amputating the
tail of the parotid gland as you move forward
and medially.
Use the posterior belly of digastric as a safety
landmark. Called the registrars friend it lies
lateral to the IJV, internal carotid, vagus,
hypoglossal and accessory nerves. So if you stay
lateral to it you will do no harm.
The upper end of the IJV lies anterior to the
36
accessory nerve as it disappears under the
digastric. Ligate and divide it as you did at the
lower end.
Dissect out the submandibular gland as
previously described, and take the submental fat
as well, taking care to keep it all attached to the
main specimen.
Deliver the specimen.
37
REFERENCES
1. www.vesalius.com
2. www.emedicine.com
3. www.thyroidcancer.com
4. Stell and Maran’s Head and Neck Surgery – 4th Edition
5. Gray’s Anatomy – www.bartleby.com
6. Dissection photographs from the Head and Neck Unit,
The Erasmus University Teaching Hospital,
Rotterdam,
The Netherlands.
