Incision: For exposing a single level or two levels a transverse incision corresponding to the level described
above can be taken, however for broad exposure, an longitudinal incision starting at the angle of mandible and extending down
to the manubrium sternii anterior to sternocleidomastoid muscle needs to be taken.
The skin, subcutaneous tissue and platysma are divided in the same direction till the superficial fascia is
reached. The traversing cervical veins and superficial nerves can be identified through the superficial fascia. After dividing
the superficial fascia longitudinally these veins can be ligated and transected. Avoid
transecting the mandibular branch of Facial nerve in the most cephalad aspect of incision.
A plane is then developed between the medial border of sternocleidomastoid and the strap muscles.
The Superior belly of Omohyoid muscle runs transversely between the strap muscles and the sternocleidomastoid.
The muscle can be divided between two ligatures. Palpate for the carotid pulse below the sternocleido mastoid and gently retract
it laterally. The middle cervical fascia should be dissected bluntly and divided medial to carotid pulse in the mid portion
of neck. The transverse branches of deep ansa cervicalis may need to be transected.
The strap muscles, trachea, larynx and thyroid are retracted medially while the neuro vascular bundle (the common
carotid artery, internal jugular vein and vagus nerve) is retracted laterally.
Middle thyroid vein needs to be tied in exposure of mid portion of neck.
For most of the dissection in middle neck this is the only vessel that needs to be tied.
The deep prevertebral Fascia is then divided in the midline and dissected laterally till the long muscles of
Using a periosteal elevator the longus colli can then be elevated on both sides of anterior longitudinal ligament
until the base of transverse processes on both the side. The disc is elevated and softer than the surrounding vertebral body
making its identification easier. The level can be confirmed by taking an intraoperative radiograph.
For extending the exposure superiorly superior thyroid artery and veins need to be tied and transected, and
for extending the exposure inferiorly the inferior thyroid artery and vein needs to be tied.
If the dissection needs to be extended upwards
a blunt dissection is best carried out with fingers. It is vital to identify five vital structures 1) the superior laryngeal
nerve. 2) The Hypoglossal nerve. 3) The Facial artery. 4) The lingual artery. 5) The Digastric muscle. The superior laryngeal
nerve should be carefully dissected; its caudad external branch is especially vulnerable owing to its close proximity to the
superior thyroid artery.
For extending the exposure inferiorly the inferior thyroid artery, which is a branch of thyro cervical trunk
or sub clavian, artery should be ligated and divided. The sympathetic trunk and stellate ganglion lies at the same level and
should not be injured. The cervical pleura corresponds to the first thoracic vertebrae, and recurrent laryngeal nerve which
is a branch of vagus nerve loops around the aorta on the left side and then ascends into the tracheoesophageal groove. The
prominent tubercle on C6 vertebrae may serve as guide to level identification but occasionally even the C7 vertebrae may have
a prominent tubercle and thus it may be safe to take an intra operative radiograph.
Airway obstruction secondary to retropharyngeal
edema or hematoma.
Hypoesthesia around the ear.
Recurrent laryngeal palsy
Vertebral Artery Injury
Superior Thyroid Artery injury.
Inferior Thyroid Artery Injury.
Thoracic duct injury.
Laryngeal edema and Hoarseness