Bilateral Modified Radical Neck Dissection for Metastatic Papillary Thyroid Carcinoma

1. Introduction

1. Patient positioning.
2. Surgical approach and marking.

2. Surgical Approach

1. Create extended Kocher incision.
2. Develop subplatysmal flaps.
3. Identify GAN and follow to Erb’s point.
4. Identify SAN and follow to insertion to trapezius muscle.
5. Mobilize level V compartment from lateral to medial.
6. Divide EJV.
7. Unwrap fascia around the SCM.
8. Circumferentially dissect and preserve carotid sheath contents.
9. Further mobilize lymph node specimen from lateral to medial, including levels V, IV, III, and II.
10. Identify and preserve (or ligate) thoracic duct (left side) or other minor lymphatic ducts (right).
11. Identify and preserve phrenic and brachial plexus nerves.
12. Divide transverse cervical nerve branches as necessary for complete mobilization of lymph node specimen.

3. Closure

1. Place a drain deep to the SCM for decompression of residual lymphatic fluid.
2. Close strap muscles.
3. Close platysma muscles.
4. Close dermis with 5-0 Prolene.
5. Apply Dermabond and Steri-Strips.
6. Remove drain once output is less than 30–50 cc and serosanguinous (usually postoperative day 2).