Keywords neck dissection - graduate medical education - survey and questionnaires - surgical
instruments
Introduction
The current literature - including texts, articles, and conference presentations –
does not convey well the commonality and variance in neck dissection (ND) technique
across surgeons.[1 ]
[2 ] Though operative technique training is supported by a trainees' own preparation
through reading and lecture-based sources of information, the bulk of education is
through experiential learning. Surgical experiential education generally consists
of receiving verbal teaching, observing the technique, and a graduating level of supervised
participation within the operating room under the guidance of a single or group of
surgeons of varying sizes at 1 to 3 institutions during medical school, residency,
and, perhaps, a fellowship in possibly different programs. This form of idiosyncratic
learning and teaching can present the trainee with significant differences in technique
preferences within and across institutions. Moreover, individual surgeons in practice
(who have followed a particular training scheme at a certain time in history and since
then had a particular unique set of personal experiences) likely have an incomplete
understanding of the array of technique preferences by other surgeons across their
surgical field. ND technique preference variation may include preservation or resection
of anatomic structures, use of instruments, sequence and extent of resection, and
post-operative management.[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
The objective of this study is to evaluate the commonality and variance of surgical
techniques preferences used when performing a ND through a survey sent out to current
surgeon members of the American Head and Neck Society (AHNS). This study also aims
to determine whether there are relationships between respondents' demographic characteristics
and their surgical technique preferences. We were specifically interested in demographic
variables that may represent a higher level of expertise, including a higher yearly
volume of procedures, completion of fellowship training, shorter operative times,
and increased age. We analyzed the potential influence of these characteristics over
a variety of aspects of ND technique preferences reported in the survey. We hope this
data will educate current practitioners and surgical trainees on how their particular
techniques stand in the context of colleagues across the United States and internationally.
Methods
Study Design
Institutional review board approval for this study was obtained from the Committee
on Human Research at [INSTITUTION LEFT BLANK FOR REVIEW PURPOSES].
The survey was designed to elicit details of various technical decision points made
when performing a ND. We first distributed the survey to a small cohort of head and
neck surgeons at UCSF to verify respondent understanding and clarity of questions.
Then, we incorporated respondent input into the survey. The finalized survey and study
protocol was reviewed, revised, and approved by the American Head and Neck Society
(AHNS) Research Committee.
Participants
The AHNS sent the survey to its member physicians via electronic mail. Respondents
received in their correspondence a link to the SurveyMonkey (SurveyMonkey, Palo Alto,
U.S.A.) page for completion of the survey. Participants consented to participate in
the research study. Respondents were asked to self-identify as either a medical oncologist,
radiation oncologist, or a head and neck oncologic surgeon. We excluded from the survey
respondents who selected medical or radiation oncologist. We anonymously collected
and analyzed all survey responses.
Questionnaire
The survey was a 40-question web-based questionnaire that aimed to identify respondent
demographic characteristics and preferred techniques when performing a ND. Questions
were, for the most part, in reference to a non-irradiated, isolated, unilateral neck
dissection. A copy of the questionnaire is available for review in Appendix A .
Statistics
This study aimed to provide descriptive statistics of the reported practices of surgeons.
For this study, a vast majority and commonality was defined as greater than or equal
to 66% of respondents, and variance defined as anything less than 66%. The second
aim of this study was to test the hypothesis that certain technique preferences will
be based on the level of a surgeon's level of expertise. Expert demographics were
considered to be aged over 50, an annual surgical volume of more than 50 NDs a year,
fellowship trained in head and neck oncologic surgery, and have efficient self-reported
operative times (defined as completing a Levels 1–3 ND in 1.5 hours or under). We
then determined statistically significant associations between these expert demographics
and the surgeon's technique preference using chi-square and two tailed t -tests.
Results
The survey received 367 (36.3%) responses from the ANHS 1,010 surgeon members. 283
(out of 367) surgeons completed more than half the survey for a completion rate of
77%. Surgeons from 41 states and 24 countries participated. [Table 1 ] summarizes demographic characteristics, ND surgical volume, and ND operative times
of respondents.
Table 1
Demographic information, neck dissection surgical volume, and neck dissection operative
times of survey respondents
Characteristic
Total number of individuals who responded to the survey
367 (36.3%)
Number of respondents who finished more than half the survey
283 (77%)
Age
Mean: 50.3 years (Range 32–77)
Sex
Men
255 (90.1%)
Women
28 (8.9%)
Current Level of Training
Fellow
29 (10.3%)
Attending
254 (89.7%)
Type of Residency Training
Otolaryngology- Head and Neck Surgery
235 (83.1%)
Non-Otolaryngology-Head and Neck Surgery
48 (16.9%)
Completed a Fellowship in Head and Neck Oncologic Surgery
Yes
205 (72.5%)
No
78 (27.5%)
Number of Neck Dissections Per Year
Less than 10
18 (6.4%)
11–25
50 (17.6%)
26–50
110 (38.9%)
Greater than 50
105(37.1%)
How long does it take to complete a neck dissection preserving SCM, IJV and CN 11,
of the following levels?
Levels 1–3
Mean: 1.56 hours
(Range 1–2.5, SD 0.47)
Levels 1–4
Mean: 1.89 hours
(Range 1–3, SD 0.55)
Levels 1–5
Mean: 2.38 hours
(Range 1.5–4, SD 0.67)
Surgeons who completed more than 50 NDs a year had statistically significantly shorter
operative times in all three types of selective NDs compared with those who performed
fewer NDs (p < 0.001) (1.4hrs versus 1.6hrs for levels 1–3; 1.6hrs versus 1.9hrs for levels 1–4;
2.1 hour vs. 2.5 hour for levels 1–5; p < 0.01). This operative time was in reference to performing a ND without taking into
consideration any extra time needed for teaching trainees or students. The completion
of a fellowship and age over 50 were not associated with a significant increase or
decrease in ND operative time.
[Table 2 ] demonstrates the frequency and reasoning for submandibular gland (SMG) and internal
jugular vein (IJV) excision. Respondents over the age of 50 were statistically significantly
more likely to preserve the SMG than individuals under 50 years of age (50% vs. 35%;
p < 0.01). ND volume, ND operative time, and completion of a fellowship were not found
to be related to SMG preservation or excision preference. When asked specifically
about regularly excising the IJV during a neck dissection, a near unanimous amount
[n = 270 (95.4%)] of surgeons stated that they only excise the IJV when involved with
tumor. The majority [n = 205 (72.2%)] only excise the sternocleidomastoid (SCM) when involved with tumor,
excising only such a portion.
Table 2
Aggregated responses to select questions regarding preservation of the submandibular
gland (SMG), sternocleidomastoid muscle (SCM) and internal jugular vein during a neck
dissection
Submandibular Gland
Do you perform SMG transfer?
Yes
19 (6.7%)
No
264 (93.2%)
When you do not preserve the SMG during an ND, what are your reasons? (Choose all
that apply)
Usually
Preserve SMG
Do not usually Preserve SMG
Concern for incomplete lymph node removal
79 (65.8%)
138 (86.3%)
Preserving the gland would increase the difficulty of the resection of the primary
cancer
54 (45%)
28 (17.5%)
Need to access level 1B for a free flap or pedicle reconstruction
58 (48.3%)
68 (42.5%)
Worried that it will be time consuming
7 (5.8%)
13 (8.1%)
Never trained to do so
5 (4.2%)
47 (30.6%)
Worried that presence of SMG will be concerning for a palpable lymph node during surveillance
9 (7.5%)
53 (33.1%)
Doubt that the SMG will work well after resection of lymph nodes around it
10 (8.3%)
16 (10%)
Doubt that the SMG will work well after radiation
23 (19.2%)
50 (31.3%)
Total # of Surgeons
120 (42.9%)
160 (57.1%)
Internal Jugular Vein
Excise routinely; in most cases
6 (2.1%)
Excise when performing a salvage (post-radiation) neck dissection
23 (8.1%)
Excise only when involved with a tumor
271 (95.4%)
Abbreviations: 11 ND, neck dissection; CN 11, Cranial Nerve; IJV, Internal Jugular
Vein; SCM, Sternocleidomastoid; SMG, Submandibular Gland.
Variation existed between surgeons for the sequence of lymph node level excision during
an isolated unilateral level 1–4 ND. The majority [n = 149 (52.6%)] of respondents stated they followed an order of Level 1- > Level 2
- > Level 3- > Level 4 when removing lymph node regions. The next most common sequence
of excision was Level 2 -> Level 3 -> Level 4 -> Level 1 [n = 59 (20.8%)]. Eighteen (6.3%) of the surgeons stated that they had no standard sequence
for lymph node removal. Most surgeons, when asked how frequently they kept the lymph
nodes together as one en bloc resection, answered either “always” [n = 118 (41.5%)] or “often” [n = 102 (35.9%)], which together equals 76.4%. Completion of a fellowship, age, and
surgeon volume were not predictive of whether or not an individual resected lymph
nodes en bloc.
[Fig. 1 ] summarizes respondents' preferences to perform a ND before or after specific primary
tumor site resections. Preferences differed depending on the location of the primary
tumor site. Surgeons over the age of 50 compared with those under the age of 50 were
more likely to perform a ND before primary tumor resection in the oral cavity (66.9%
vs. 42.1%; p < 0.01), transcervical oropharynx (89.6% vs 79.8%; p < 0.03), transcervical hypopharynx/larynx (87.7% vs. 76.6%; p < 0.03), transoral oropharynx (55.8% vs 37.1%; p < 0.01), and transoral hypopharynx/larynx (54.3% vs 27.8%; p < 0.01). Surgeons who reported completing a ND of levels 1–3 in 1.5 hours or less
were more likely to perform a ND before primary tumor resection if the primary tumor
was located in the parotid (29.6% vs. 16.6%), transcervical oropharynx (88.9% vs.
76.8%), and transcervical hypopharynx/larynx (88% vs. 71%; p < 0.03).
Fig. 1 Sequence preferences for performing a neck dissection before or after primary carcinoma
resection.
Surgeons were asked about their indications for completing a level 5 ND for upper
aerodigestive tract mucosal squamous cell carcinoma (mSCC). Seventy-three (25%) of
respondents always excise level 5 during NDs for mSCC. Surgeons over the age of 50
[n = 47 (32.2%)] were more likely than those under the age of 50 [n = 24 (17.5%)] to always complete a level 5 ND for MSCC (p < 0.01). Surgeons who performed less than 50 NDs a year (29.2%) were also more likely
to always excise level 5 during ND when compared with individuals who completed more
than 50 NDs (18%) a year (p < 0.05). For respondents who do not usually excise level 5, indications for excising level 5 included the presence of suspicious
lymph nodes in level 5 [n = 146 (51.5%)], suspicious lymph nodes close to the anterior border of level 5 in
levels 2b, posterior 2a, 3, or 4 [n = 140 (49.5%)], and during a salvage ND for post radiation failure [n = 52 (18.4%)].
When managing blood vessels, a vast majority of surgeons stated that preserving as
many blood vessels as possible was important or very important during a ND [n = 222 (78.4%)] on a 5-point scale ranging from unimportant to very important. Surgeons
who completed a fellowship [n = 82 (39.3%)] were more likely to state that vein preservation was important or very
important than individuals who did not complete a fellowship [n = 18 (24.3%)] (p = 0.02). Surgeons who reported taking 1.5 hours or less to perform a ND of levels
1–3 were more likely to preserve venous vessels than individuals who reported spending
more than 1.5 hours on a ND of levels 1–3 (40% vs. 26%; p = 0.02).
Surgeons were asked about cervical sensory nerve rootlet management during a ND. When
asked about whether respondents routinely divided the cervical sensory rootlets, most
respondents divide these rootlets “rarely” [n = 107 (37.7%)} or “sometimes” [n = 104 (36.6%)]. Of the 71 individuals who usually excised level 5 during a therapeutic
ND for mSCC, 29 (40.8%) of them also regularly divide the cervical sensory rootlets,
which was statistically significantly more than the 30 (14%) surgeons who do not routinely perform a level 5 ND and regularly divide the cervical sensory rootlets (p < 0.01). Surgeons over the age of 50 [n = 46 (31.5%)] were more likely to divide the cervical sensory rootlets than those
under 50 years old [n = 15 (11%)] (p < 0.01). Surgeons who perform less than 50 NDs a year [n = 47 (26.4%)] were more likely to divide the cervical sensory rootlets than individuals
who performed more than 50 NDs [n = 14 (13.3%)] a year (p = 0.01).
We asked surgeons about instruments they use on specific regions of a ND (raising
subplatysmal skin flaps, dissecting fibrofatty lymph node tissue away from the IJV,
excising levels 1a, 1b, 2a, 2b, 3, 4, 5a, and 5b and the ligation of various types
of blood vessels). Multiple instruments were allowed in the survey to be preferred
for a given lymph node level. When raising subplatysmal skin flaps, surgeons generally
reported using the unipolar cautery [n = 201 (71%)], scalpel [n = 117(41.3%), and scissors [n = 28(10%)]. When dissecting lymph nodes off the IJV, surgeons mainly used a scalpel
[n = 128 (47.1%)], dissector and unipolar cautery [n = 50 (18.5%)], and scissors to dissect and cut [n = 32 (11.9%)].
Instrument preferences for use when excising lymph nodes levels are summarized in
[Fig. 2 ]. No single instrument was used by a vast majority (66.6% or more) of the surgeons
surveyed for a particular neck level. In only three instances a majority (over 50%)
of the surgeons use a particular instrument for a specific level: the use of unipolar
cautery in level 1A (64.7%), 5A (52.6%), and 5B (53.6%). Unipolar cautery was used
most often for all levels (the range for different levels was 44.0 to 64.75%) except
that the bipolar was most often used in level 1b (44.4%). Depending on the level,
the bipolar was used by 28.6 to 44.4%, the scalpel was used by 19 to 32%, scissors
were used by 20 to 31.5%, ligating energy devices were used 16.4 to 25.7%, and the
heated blade was used by 3.0 to 4.1% of surgeons (in descending order of frequency
of use for each instrument).
Fig. 2 Respondent preferences of instrument for dissection of lymph nodes by level.
Instrument preferences when ligating blood vessels are summarized in [Fig. 3 ]. Instrument use for ligating blood vessels was varied but some trends included using
free suture ties and stick ties to ligate the IJV and branches of the carotid artery.
Smaller arteries and veins were ligated using a bipolar, ligating energy device, free
suture ties, or clips.
Fig. 3 Instrument preferences for ligation/cauterization of a blood vessel during a neck
dissection.
We asked surgeons about drain placement in a non-irradiated, isolated, unilateral
ND. A vast majority of surgeons reported that they preferred to place one drain for
NDs (as opposed to two drains) involving levels 1–3 [n = 226(84.6%)], levels 1–4 [n = 196(73.4%)] or levels 2–4 [n = 217 (82.8%)]. A majority of surgeons [141 (52.8%)] placed 2 drains (as opposed
to 1) for a similar ND that encompassed levels 1–5. When two drains were used, 52.5%
(n = 82) of surgeons placed both drains deep to the SCM while 47.4% (n = 74) placed one deep to the SCM and one superficial. The number of drains a respondent
placed during a ND was independent of age, completion of a fellowship, surgical volume
or operative time.
Surgeons were also asked a free response question on their criteria for drain removal.
A majority [123 (60.2%)] stated that the criterion for removal was less than 30mL
of output from the site in 24 hours (often with the comment that the fluid looked
clear or without the appearance of bright blood or chyle). Some surgeons preferred
less than 20mL of drainage in 24 hours [n = 45(15.9%)] or less than 50mL in 24 hours [n = 28(9.9%)]. Other criteria stated by respondents included being greater than three
days post-op [n = 13(6.4%)] and having the patient tolerate a full diet with no evidence of a chyle
leak [n = 10 (4.9%)].
[Table 3 ] summarizes the main commonalities and variances of ND technique preferences among
the head and neck oncologic surgeons surveyed.
Table 3
Commonalities, controversies and variance in neck dissection operative technique as
determined by the percentage of surgeons that employ each practice
Category
Commonality in ND technique preferences performed by most (>66%) surgeons (n, %)
Variability in ND technique preferences (<66%) (n, %)
Sequence
- ND after resection of parotidectomy (193, 75%) and thyroidectomy (169, 67.3%)
- ND before transcervical oropharynx (217, 85.1%) and hypopharynx / larynx (211,
82.4%)
- Level 1
- Level 2
- No standard levels excision sequence (18, 6.3%)
- ND after oral cavity (142, 55%) and transoral hypopharynx / larynx (148, 58.7%)
Technique
- Do not perform SMG transfer (265, 93.3%)
- Do not excise level 5 unless involved by suspicious LNs (211, 74.5%)
- Generally excise LNs en bloc (220, 77.7%)
- Do not excise SCM in salvage cases unless involved with tumor (248, 87.7%)
- If SCM involved with tumor, only excise portion involved (205, 72.2%)
-Only excise IJV involved with tumor (271, 95.4%)
- Find importance in preserving venous blood vessels as much as possible ND [n = 222 (78.4%)]
- Preserves the submandibular gland (123, 43.3%)
Instruments
- Unipolar for raising subplatysmal skin flaps (192, 71.1%)
- Scalpel for removing LNs from IJV (128, 47.4%)
- Unipolar (131, 50%) and bipolar (95, 35.8%) for excising LN from neck levels
Drain
- Placing one drain, instead of two for NDs of levels 1–3 (226, 84.6%), levels 1–4
(196, 73.4%) and levels 2–4 (217, 82.8%)
- 2 Drains for levels 1–5 (141, 52.8%)
- Removing drain for output of less than 30cc a day (148, 60.2%)
Discussion
This study represents the first attempt to define the commonality and variance of
ND technique that is practiced by current surgeon members of the AHNS. We surveyed
the AHNS surgeon members because we felt they best define surgeons with a high level
of expertise and experience with performing the ND operation. This study provides
a unique perspective of the varied elements of ND operative technique. Likely, an
individual's preferences are a personal amalgamation of interpretations of various
observations during training and from the surgeon's current institution specific preferences.
The range of varied idiosyncratic preferences are not likely conveyed well in textbooks
or verbal instruction. Thus, we felt that a survey study, such as contained in this
report, could better communicate the current range of ND technique preferences to
readers. Notwithstanding, the results of this report do not necessarily reflect the
authors' opinions nor are intended to necessarily advocate that particular surgical
preferences are more evidence-based than others. Given the constraints of an appropriate
length of the survey, we allowed for only sparse information about rationale behind
technique preferences.
One significant finding of this survey study was that respondents were almost evenly
split between preservation and resection of the SMG. We were surprised by this finding,
given the fact that most operative technique text books (usually by single authors)
describe excising the SMG.[9 ] Those that stated that they never performed SMG preservation cited incomplete nodal
removal as a main concern when performing the surgery among the others listed. A prospective
anatomical study conducted by Dhiwakar et al. specifically aimed to address this concern
among Head and Neck Surgeons, demonstrated that it was technically possible to removal
all lymph nodes in Level IB and perform SMG preservation.[8 ] However, even though SMG preservation may be possible with adequate lymph node removal,
participants are valid in their concern with at least one study showing that greater
preservation of structures during a ND may lead to a decrease in the amount of lymph
tissue resected and poorer oncologic outcomes.[7 ]
[9 ]
Another significant finding in this study was that respondents who performed more
than 50 neck dissections a year also self-reported a statistically significant decreased
amount of time to complete a ND of levels 1–3, 1–4, 2–4, or 1–5. Surgeons with greater
volumes may self-report faster procedure times, increasing their ability to perform
a greater number of procedures in a given time period. This leads to the macroscopic
finding described by Kim et al that high volume hospitals performed a proportionally
greater amount of NDs than their low volume hospital counterparts.[10 ] Notwithstanding, there may be a significant amount of recall bias and even self-promotion
bias since this study asked surgeons to self-report their operative times.
This survey allowed precise documentation of instruments that surgeons use during
different parts of the ND. As we expected, there was a significant amount of variation
between respondents on their use of particular instruments for certain situations.
Surgeons' preferences for particular instruments are important to consider as technology
improves and as attention to cost containment grows. This information may be particularly
valuable to surgical trainees who may observe inter-educator variability in the choice
of instrument during a ND. Instrument choice may be made on safety, efficiency, blood
loss, ease of use, cost, ergonomics, comfort, familiarity, and experience.
Variability in drain management and the placement of a drain with respect to the SCM
are likely due to a paucity of evidence available to guide decision making. Drain
removal has become more pertinent to the discussion of cost effective medical care
as pressure increases to decrease hospital stay. It has been shown that the amount
of intraoperative blood loss is one of the biggest predictors of postoperative drainage,
however, no participants volunteered this as a criteria taken into account when removing
a drain.[11 ] No guidelines currently exist regarding the policy of drain removal. The range of
20–50cc/24 hours with a downward trend, with the patient having oral intake and showing
no chyle or new blood is possibly a good policy at this time, however, further investigation
is necessary to clarify the best policy.
Respondents classified by this survey as belonging to an “expert” demographic group
differed in opinion regarding level 5 lymph node resection and cervical sensory rootlet
preservation. Surgeons older than 50 tended more often to report that they always
resect level V lymph nodes for mSCC, while high volume surgeons were less likely to
resect level 5 compared with low volume surgeons. This variability exists despite
research that has shown that Level 5 lymph nodes may be preserved in a ND for head
and neck squamous cell carcinoma with less than N2a staging in the neck.[12 ]
[13 ]
Respondents over the age of 50 were also more likely to divide the cervical sensory
rootlets while respondents with higher volume were more likely to preserve the cervical
sensory rootlets during a ND. Previous studies have shown that division of the cervical
sensory nerve rootlets leads to a larger area of anesthesia of the neck than if the
roots were preserved.[14 ] These differences between two “expert” demographic groups may be explained by generational
differences in instruction at the time of training and also a surgeon's personal experience
influencing their preference on whether to preserve these rootlets or not.
Each of the various policies of the sequence of primary site resection and ND have
advantages and disadvantages. Performing a ND prior to a parotidectomy (25.5% of respondents
preferred this sequence) has the potential advantages of exposing the inferior and
deep aspects of the parotid and facial nerve more fully, ligating blood vessels to
the parotid to decrease bleeding, and exposing the dissected facial nerve to less
potential traction and drying injury. A potential disadvantage in performing the ND
prior to parotidectomy is that the surgical team may be more fatigued and less focused
for the facial nerve dissection or the exact pathology. Thus, the need for a ND may
be reliant on intraoperative frozen section biopsies. Performing a ND prior to a thyroidectomy
(32.7% preferred this sequence) has the potential advantages of exposing the ipsilateral
thyroid lobe, parathyroid glands, and superior and recurrent laryngeal nerves more
fully, ligating blood vessels to the thyroid, and exposing the vagus nerve for stimulation
confirmation during nerve monitoring. A potential disadvantage is, again, that the
surgical team may be more fatigued and less focused for the recurrent laryngeal nerve
dissection. Performing a ND after transoral oral cavity (45.5% preferred this sequence),
transcervical approaches to oropharynx tumor resection (14.9% preferred this sequence),
and transcervical approaches to the larynx/hypopharynx tumor resection (17.8% preferred
this sequence) has the potential advantages of time efficiency with reducing some
wasted time when waiting for frozen section margins analysis by performing the ND
during this time. Another advantage is creating less potential mucosal edema when
a ND is performed first which could cut off lymphatic circulation from the primary
site. A potential disadvantage is that the surgeon would be unable to ligate the lingual
artery ahead of time if this was considered an important step. If done during the
same operation, performing transoral oropharynx and larynx/hypopharynx resections
prior to NDs (53.1% and 58.7%, respectively) offers the same potential benefits and
drawbacks. If staged, performing NDs prior to transoral oropharynx or larynx/hypopharynx
(46.9% and 41.3%, respectively) has the potential advantages of ligating the lingual
artery ahead of time to decrease the bleeding risk during the primary resection and
determining the presence or absence of extracapsular spread which may eliminate the
need for a primary site resection.
We acknowledge that this study has several limitations. Although the response rate
of 28% was in typical range of survey studies, this low response rate limits the variability
and breadth of surgical techniques captured with this survey. However, we feel we
were able to collect data from a wide array of surgeons in different demographic and
geographical categories. Respondents were not asked to explain every response provided
in the survey, which could have provided additional rationale on a surgeon's preference
for a particular instrument or style of procedure. We wanted to maximize the breadth
of information while maintaining a reasonable time needed to complete the survey to
reduce the risk of survey fatigue. Recall bias could have limited the validity of
the results. It is possible that operative time, the use of instruments, and the preservations
of structures during a ND vary in reality from what surgeons responded in the survey.
Another limitation of this study is that it captures technique preferences in one
point of time and does not reveal trends of technique over time. It is possible that
a repeated identical survey conducted several years from now could have fairly different
results.
Conclusions
A vast majority of head and neck oncologic surgeons have the following technique preferences
when performing a ND: preserve level 5 during a therapeutic ND (unless involved by
suspicious LNs), resect LNs en bloc, do not resect the IJV unless involved with tumor,
excise only a portion of the SCM involved with tumor, preserve cervical sensory rootlets,
perform a ND after parotidectomy and thyroidectomy, perform ND before transcervical
primary site resection for oropharynx, hypopharynx, and larynx carcinoma, do not perform
SMG transfer, and place one drain (instead of two) for NDs of levels 1–3, 1–4, and
2–4. There is variance among head and neck oncologic surgeons on the following aspects
of a ND: sequence of LN levels excised, instrument preference for various LN regions
and blood vessel types, preservation of venous blood vessels (besides IJV), preservation
versus resection of the SMG during level 1b dissection, performing a ND before or
after transoral primary site resection of oral cavity, oropharynx, hypopharynx, and
laryngeal carcinoma, the drain number (1 or 2) used for NDs of levels 1–5, and the
threshold criteria for drain removal. Age, surgical volume, efficiency, and completion
of a head and neck oncologic fellowship may influence some technique preferences when
performing a ND.
