The surgical team comprises: 

An operating surgeon, an assistant surgeon (resident/registrar, another surgeon, or a certified first-assistant), scrub nurse, circulating nurse, and the anesthetist.

There are no specific preoperative preparatory requirements for patients undergoing neck dissection other than planning of the incisions for neck dissection, particularly if the primary tumor is undergoing resection simultaneously. Also, preparation of the neck dissection incisions must take into consideration any reconstructive effort required to repair the surgical defect created after the excision of the primary tumor. General endotracheal anesthesia is essential for performing a neck dissection, and the use of paralytic agents should be discussed between the surgeon and anesthetist. The patient placement is in the supine position with the head elevated to 30 degrees. The neck is hyper-extended with the use of a shoulder roll, and rotated to the opposite side.[15]

Incision: There are many historical incisions including the Latyshevsky and Freund, Mac Fee, Crile, Kocher, Schobinger, and Hockey stick, but in modern head & neck surgery, the operation is performed via a single incision placed in an existing neck skin crease midway down the neck. Trifurcate incisions were popular in the past, and can still be used in the case of bulky posterior neck disease, but care should be taken to not place the trifurcation over the carotid artery.[16][17]

Raising skin flaps: The skin incision is deepened through the subcutaneous tissue and then through the platysma muscle. The posterior flap is then raised in the subplatysmal plane by applying traction to the flap with skin hooks and counter-traction of the deeper soft tissues. The flap is elevated up to the anterior border of the trapezius muscle. (Figure I).

 Identifying Marginal mandibular nerve: Careful identification of the marginal mandibular branch of the facial nerve is crucial. Avoidance of paralytics is advocated at this point in the operation by some surgeons. Posteriorly, the greater auricular nerve and the external jugular vein overlying the sternocleidomastoid muscle come into view as the elevation of the flap continues. The greater auricular nerve and the external jugular vein should be identified carefully and preserved. We advise the use of the scalpel or scissors to dissect around the mandibular branch rather than electrocautery as it may cause temporary damage to the nerve.  This nerve lies just anterior to the submandibular fascia and superficial to the posterior facial vein. The vein is ligated, and its upper stump retracted cephalad, protecting the marginal branch of the facial nerve (the Hayes Martin maneuver). Alternately, the facial vein and marginal mandibular nerves can be skeletonized and preserved individually. This can greatly increase vessel length available for microvascular reconstruction and should be discussed between the ablative and reconstructive surgeons preoperatively if it is oncologically sound to perform this dissection. The peri-facial nodes can be dissected out at this point if indicated.

Superior Dissection: The fibrous fatty tissue of the submental triangle is dissected off the anterior bellies of the digastric muscles and the mylohyoid. The fascia is then dissected off the anterior belly of the digastric muscle, and the specimen is retracted posteriorly, removing the fibrous fatty tissue containing lymph nodes lateral to the mylohyoid muscle. When the dissection reaches the posterior border of the mylohyoid, this is retracted anteriorly, exposing the lingual nerve and the submandibular gland duct are divided. Finally, the facial artery is ligated as it crosses forward, under the posterior belly of the digastric muscle. Alternately, the facial artery and vein can be dissected through the substance of the submandibular gland to increase the length of these vessels available for microvascular anastomosis, or if a submental flap is planned. The tail of the parotid gland is elevated off of the SCM and deep structures, and the sternocleidomastoid muscle is then incised close to its insertion in the mastoid process. The fibro-fatty tissue medial to the muscle is incised, exposing the splenius capitis and the levator scapulae muscles. Otherwise, incising the fascia below the digastric muscle and gentle inferior traction of the specimen allows identification of the hypoglossal nerve, the upper end of the internal jugular vein, and the spinal accessory nerve. At this point in the dissection, the internal jugular vein and the spinal accessory nerve are identified and preserved, reflecting the lymph node-bearing tissue inferiorly with the surgical specimen.

Inferior dissection: The dissection is continued posteriorly and inferiorly along the anterior border of the trapezius muscle. The spinal accessory nerve and the transverse cervical vessels are divided as they cross the anterior the border of the trapezius muscle. During this step of the operation, it is important to preserve the branches of the cervical plexus that innervate the levator scapulae muscle, unless the extent of the disease in the neck precludes it. The sternocleidomastoid muscle and the superficial layer of the deep cervical fascia are incised above the superior border of the clavicle. The omohyoid muscle is divided, and the external jugular vein can either be preserved or divided, depending upon the vascular needs of the reconstructive surgeon. The fibro-fatty tissue in this region is then gently pushed in an upward direction, exposing the brachial plexus, the scalenus anterior muscle, and the phrenic nerve (Fig. 1-6). Posteriorly, the dissection is continued to join the previous dissection along the anterior border of the trapezius.

Medial dissection: The dissection is continued medially to expose the vagus nerve, the common carotid artery, and the internal jugular vein. Inferiorly, the phrenic nerve is identified and protected by not violating the deep fascia of the floor of the neck overlying the brachial plexus and muscles. The surgeon must remain very vigilant on the left side to be able to identify thoracic duct, which arches downward and forward from behind the common carotid to open into the internal jugular vein, the subclavian vein, or the angle formed by the junction of these two vessels. The duct is located anterior or superficial to the anterior scalene muscle and the phrenic nerve. To prevent a chyle leak, the surgeon must also remember that the thoracic duct may have multiple connections at its upper end and that at the base of the neck it usually receives a jugular, a subclavian, and perhaps other minor lymphatic trunks, which must be individually ligated or clipped.

The internal jugular vein can almost always be spared with meticulous technique, but if resection is necessary, it is important to obtain circumferential control of the vessel proximally and distally with vessel loops before cross-clamping and dividing it. If the tumor mass is located low in the jugulodigastric region or the mid-jugular region, the internal jugular vein is first ligated and divided superiorly. The dissection then continues in an inferior direction, separating the specimen from the vagus nerve, the carotid artery, and the superior thyroid vessels. If instead, the disease is located high in the jugulodigastric region, the internal jugular vein is divided inferiorly, and the dissection continues in a superior direction along the common carotid artery; this is especially useful when the tumor is extensive and may require removal of the external carotid artery or the hypoglossal nerve. Mobilization of the surgical specimen from below allows easier dissection from the internal carotid artery and, if possible, the external carotid and the hypoglossal nerve.

Closure: Incision closure is in three layers: the first layer approximates the platysma anteriorly and the subcutaneous tissue laterally, and the second layer approximates the subcuticular layer. The skin can then be closed with sutures, staples, or dermal glue. One or two suction drains should remain in place, placed in the most dependent areas (the lateral gutter and inferior aspect near the thoracic inlet). The drain(s) should not rest immediately over the carotid artery or in the area of the thoracic duct, or atop any named nerve.

1. Infection.

2. Air leak.

3. Postoperative bleeding.

4. Chylous fistula. The reported incidence varies between 1% and 2.5%. Management depends on the time of onset of the fistula, on the amount of chyle drainage in 24 hours, and the presence or absence of accumulation of chyle under the skin flaps. When the daily output of chyle exceeds 600 mL in a day or 200 to 300 mL per day for 3 days, especially when the chyle fistula becomes apparent immediately after surgery, conservative closed wound management is unlikely to succeed; these are indications for surgical exploration.

5. Synchronous bilateral radical neck dissections, in which both internal jugular veins undergo ligation, can result in the development of facial edema, cerebral edema, or both; blindness; and hypoxia.

6. Carotid artery rupture. The most feared and often lethal complication after neck surgery is exposure and rupture of the carotid artery. Therefore, every effort must be made to prevent it. If the skin incisions have the proper design, the carotid seldom becomes exposed in the absence of a salivary fistula. If the carotid becomes exposed, it should be covered promptly with well-vascularized tissue.

7. The most notable sequelae observed in patients who have undergone a radical neck dissection are related to the removal of the spinal accessory nerve. The resulting denervation of the trapezius muscle causes destabilization of the scapula with progressive flaring at the vertebral border, drooping, and lateral and anterior rotation. The loss of trapezius function decreases the patient’s ability to abduct the shoulder above 90 degrees at the shoulder. These physical changes result in a syndrome of pain, weakness, and deformity of the shoulder girdle commonly associated with the radical neck dissection. Careful performing of a modified radical neck dissection greatly reduces the severity, likelihood, and duration of these complications.[18][19]

Currently, head and neck surgeons throughout the world use a variety of different cervical lymph node dissections for the surgical treatment of the neck in patients with cancer of the head and neck region. In contrast to the measured pace of refinements to the technique of neck dissection, the role of neck dissection in the management of regional disease across the entire gamut of histologies, from squamous cell carcinoma to cutaneous melanoma, to papillary thyroid carcinoma, is evolving rapidly.[20]

Strategies to improve the quality of head and neck cancer care do exist.[21][22]

The most important aspects of success involve interprofessional care of the patient. Nurses provide coordination of care, managing documentation, and follow-ups and reporting when untoward complications occur to the clinical team. The clinical team, assisted by the nursing staff, must make sure protocols are followed to avoid infections, hydration issues, and calorie intake. Interprofessional cooperation will assist in making sure patients obtain the best outcomes. Modern care of the cancer patient is by definition, multi-disciplinary. Tumor Boards, where all subspecialties and allied health practitioners meet to discuss and plan treatment for new cancer diagnoses are now the norm and the expectation.