Complications of Neck Dissection

More extensive neck dissections, especially in the central neck compartment, are associated with a higher risk of hypoparathyroidism and other complications.34-69 With complete resection of all fatty and lymph node tissue from the central neck, the recurrent laryngeal nerves and the vascular supply to the parathyroid glands are at risk, especially when combined with total thyroidectomy.14-47-62'69-94-96 Awareness of these potential problems emphasizes the importance of meticulous dissection and positive identification of the recurrent laryngeal nerves and parathyroid glands. Magnifying glasses (x2.5) and bipolar coagulation are helpful. The patient should not receive muscle relaxants. The recurrent laryngeal nerve should be dissected over its complete length with special care for the part caudal to the thyroid. Unilateral paralysis causes hoarseness, which is inconvenient to the patient. Bilateral injury is a life-threatening complication that may make an emergency tracheostomy necessary. Resection of the trachea and esophagus muscle wall is occasionally necessary in patients with extensive extracapsular tumor growth.

The modified neck dissection is designed to remove all of the metastatic lymph nodes in the lateral neck yet minimize morbidity. In experienced surgical hands, modified neck dissection is a safe procedure with minimal morbidity.10-36-94 Resection of the spinal accessory nerve results in paralysis of the trapezius muscle with a shoulder drop and decreased abduction of the arm. Besides loss of function, paralysis of the trapezius muscle is disfiguring. The choice of the incision as well as the preservation of the sternocleidomastoid muscle and the spinal accessory nerve is an important aspect for a favorable cosmetic result of a modified neck dissection. Injury to the phrenic nerve can result in paralysis of the diaphragm, whereas injury to the sympathic ganglion leads to Horner's syndrome. Resection of branches of the cervical sensory nerves can cause sensory loss of the shoulder. As previously stated, the identification of the thoracic duct on the left side can be difficult. When the duct is injured, chylous fluid collection or cyst occurs. The duct should therefore be ligated to prevent postoperative chylous fistula or chylotho-rax. When such a complication occurs, reoperation and ligation of the duct are often necessary. Both modified neck dissection and dissection of the superior mediastinum can cause a pneumothorax. A postoperative chest radiograph is recommended. When a pneumothorax is present, a chest catheter is placed under water seal.

Bilateral neck dissection can cause significant postoperative edema, and a temporary tracheostomy is rarely necessary. When one internal jugular vein is resected, the contralateral neck dissection should be delayed for at least 6 weeks to avoid this problem. Wound infections are uncommon (Figs. 22-3 and 22-4).

Hematoma Following Neck Dissection

FIGURE 22-4. Proposed strategy for management of regional lymph nodes in medullary thyroid carcinoma. Ipsilateral neck dissection is advocated if central neck nodes are involved with tumor. All patients with tumors larger than 2 cm should undergo standard ipsilateral neck dissection. Central neck dissection includes dissection of the superior mediastinum. See additional considerations in the section "Therapeutic Strategy."

FIGURE 22-4. Proposed strategy for management of regional lymph nodes in medullary thyroid carcinoma. Ipsilateral neck dissection is advocated if central neck nodes are involved with tumor. All patients with tumors larger than 2 cm should undergo standard ipsilateral neck dissection. Central neck dissection includes dissection of the superior mediastinum. See additional considerations in the section "Therapeutic Strategy."

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