Neck Dissection: Indications, Extension, Operative Technique

Abstract

Lymph node involvement is common in patients with thyroid carcinoma and is related to the biology of the tumor (differentiated thyroid carcinoma/medullary thyroid carcinoma). Knowledge of surgical anatomy, classifications, and operative technique for neck nodal dissection is essential. Some concerns still exist regarding the indications, the extension, and the optimal surgical technique of lymph node dissection both for central and lateral neck dissection. In differentiated thyroid carcinomas, central neck dissection is mandatory in case of macroscopic central neck nodal involvement, while in patients with clinically node negative tumors the role of prophylactic central neck dissection remains matter of debate. In patients with medullary thyroid carcinoma, central neck dissection is mandatory at first surgery, even in the absence of overt involvement. Regarding the lateral neck dissection, guidelines recommend that it should be performed with therapeutic intent in all patients with differentiated thyroid carcinoma or medullary thyroid carcinoma and lateral neck nodal metastases. Indications to prophylactic lateral neck dissection in medullary thyroid carcinoma remain controversial. The extension of lateral neck dissection is still debated, but most of endocrine surgeons perform a selective lateral neck dissection including levels IIa–III–IV–Vb. Fascial functional neck dissection has been proposed in order to obtain an adequate oncological surgical resection reducing the risk of sequelae and complication of radical neck dissection. Surgical technique and possible complication are described.