Radical Neck Dissection

Rolled sheet beneath shoulder
Neck rolled toward opposite side
Reverse Trendelenburg
Hockey stick incision (encompass prev biopsy) Start @ mastoid process and curve along posterior border of SCM and curve at base of neck into horizontal limb
Divide platysma down to enveloping layer of deep cervical fascia and elevate skin flaps in subplatysmal plane
Laterally platysma is absent, stay in correct plane be staying superficial to greater auricular nerve
STEP 1: LATERAL (LEVEL V OR POSTERIOR TRIANGLE) DISSECTION
Accessory nerve is an important landmark
Divide greater auricular nerve and mastoid head of SCM, which facilitates medial rotation of specimen, dissect from lat to med in floor of posterior triangle
Identify inferior belly of omohyoid @ corner of clavicle and trapezius. Nothing of significance lies superficial to this plane
Divide muscle and dissect of brachial plexus
Dissect inferior border medially, divide EJV and identify phrenic nerve on scalenus anterior
After phrenic nerve, don't dissect further as this risks damaging sympathetic chain which lies deep to carotid artery
STEP II: LEVEL 1 DISSECTION
Skeletonise contralateral digastric
Clear submental triangle
Identify MM br of CN VII by identifying anterior facial vein (nerve lies immediately superficial to this) Dissect submandibular triangle
Exposing mylohyoid muscle to delineate its lateral border is crucial to identify vital structures (lingual nerve above, hypoglossal nerve below and the submandibular gland duct bewtween the two.
Posterir belly of digastric is important landmark in this region: superficial to it are no vital structures, IJV, carotid, vagus, accessory and hypoglossal below it.
STEP III: JUGULAR DISSECTION
Divide IJV after identifying carotid and vagus. Preserve thoracic duct at base of neck on the left side
STEP IV: MEDIAL DISSECTION
Plane of dissection is sternothyroid and sternohyoid muscles

Meticulous haemostasis
Interrupted sutures to platysma