2. Fork and double fork cuts are usually used. The blood supply of the flap at the lower end of the fork incision is good, which is beneficial to healing (). Double-fork incision can fully expose the cervical triangle, which is beneficial to extensive resection. The method is as follows:
⑴ First incision: From the point below the mastoid tip and a transverse finger behind the anterior edge of sternocleidomastoid muscle, make a slightly arc-shaped incision, which goes down first and then up, until it reaches the middle line of the neck. About1~1&; frac 12； Cm. The lowest branch of facial nerve is mandibular marginal nerve, which is located at the lower edge of mandible and corresponds to the surface of external maxillary artery and facial vein. Care should be taken not to cut off this nerve during incision, so as not to cause paralysis of the lower lip on the surgical side.
⑵ The second incision: At the junction of the first incision and the anterior edge of sternocleidomastoid muscle, it goes down vertically, crosses the sternocleidomastoid muscle and reaches a horizontal finger on the clavicle.
⑶ The third incision: it extends forward from the end of the second incision to the midpoint of sternum and backward to the lateral clavicle ().
3. The flap is separated under the platysma along the incision, ranging from the lower edge of mandible to the upper edge of clavicle, and from the midline of neck to the anterior edge of trapezius muscle. In order to maintain the blood supply of the diseased flap and reduce the scar contraction after operation, subcutaneous fat and platysma should be preserved, but platysma should be removed when the superficial lymph nodes in the neck have metastasized.
4. Ligation of external jugular vein The external jugular vein is located on the surface of sternocleidomastoid muscle, and the ligation should be cut off ().
5. Cut the lower end of sternocleidomastoid muscle along the upper edge of clavicle, and cut the deep fascia of neck to expose sternocleidomastoid muscle. After being separated from the deep tissue, the sternum and clavicle were cut above the clavicle 1 ~ 2 cm and ligated with thick silk thread.
6. Ligate the lower end of the internal jugular vein, so that the lower end of the internal jugular vein is fully free from the surrounding tissues, introduce thick silk thread from the deep part of the internal jugular vein with curved vascular forceps, and ligate it twice at the clavicle 1 ~ 2 cm and then cut it off. The upper and lower ends of the cut vein need to be ligated with silk thread again to avoid serious bleeding ().
7. Excise the lymphoid tissue in the posterior cervical triangle, turn the sternocleidomastoid muscle and internal jugular vein up to expose the scapulohyoid muscle, turn it up after ligation at the scapular end, and excise the lymphoid tissue and adipose tissue in the supraclavicular triangle from bottom to top along the upper edge of the clavicle. At this time, the transverse carotid artery should be ligated and cut off to avoid bleeding.
Then the lymphatic tissue of occipital triangle was removed along the anterior edge of trapezius muscle. Accessory nerve can be seen at the anterior edge of trapezius muscle, and it should be removed because there is abundant lymphoid tissue around the nerve.
All the above operations were performed along the anterior fascia of vertebra. After the separated neck muscles, veins and lymph nodes are upturned, the anterior fascia and its deep scalene muscle, brachial plexus nerve and phrenic nerve can be seen, and injuries should be avoided during operation.
8. Treating the tumors in the carotid triangle of the head and neck is most likely to cause lymph node metastasis around carotid sheath, so the lymph node resection there should be as thorough as possible. The severed sternocleidomastoid muscle and internal jugular vein are separated along the carotid sheath until the hyoid bone is horizontal and reaches the muscles around the hyoid bone forward. Carotid artery and vagus nerve should be avoided during operation. If the metastatic lymph nodes have adhered to the carotid artery, they can be separated along the arterial wall to avoid peeling off the carotid artery wall ().
9. Treatment of submental triangle and submandibular triangle: the deep fascia is cut along the lower edge of mandible, from the mandibular angle to the midline of the neck, and separated from top to bottom at the midline, so that the lymph nodes in the submental triangle are excised and connected with the cervical tissue blocks excised from bottom to top. Cut off the digastric muscle to expose the submandibular gland. Ligate the submandibular gland with silk thread and then cut it off. When cutting off the digastric muscle, you should avoid cutting off the hypoglossal nerve () behind the digastric muscle.
10. After cutting off the sternocleidomastoid muscle and the upper end of the internal jugular vein, most of the tissues and lymph nodes in the cervical triangle were dissociated, and the sternocleidomastoid muscle was cut and ligated at 1 ~ 2 cm below the tip of the mastoid, then the upper end of the internal jugular vein was separated, cut and sutured, and then the lymph nodes in the cervical triangle were removed (). Place a negative pressure drainage tube () from the submandibular region to the supraclavicular region. Suture the skin and compress the wound.
If radical neck lymph node dissection and total laryngectomy are performed at the same time, total laryngectomy can be started after the cervical lymphatic tissue block is relieved. 1. Make an arc incision from the outer edge of the affected mandibular angle along the anterior edge of sternocleidomastoid muscle to the suprasternal fossa. If bilateral functional neck lymph node dissection is performed at the same time, the same arc incision is made on the opposite side, and the two arc incisions are connected into a ∨ shape.
2. Peel off the skin flap. Separate the flap from the underside of platysma muscle, forward to the midline of the neck and backward to the anterior edge of trapezius muscle.
3. Ligate the external jugular vein, separate the upper and lower ends of sternocleidomastoid muscle, use two gauze strips to pass through the upper and lower ends of the muscle, and pull back. Expose and cut off the ligated external jugular vein.
4. Clean the lymph tissue in the anterior cervical region, separate the internal jugular vein and vagus nerve from above the clavicle, cut off the scapulohyoid muscle, and separate the carotid sheath. On the premise of preserving the internal carotid artery, vein and vagus nerve, the fat, lymphatic tissue, fascia and interstitial tissue in the anterior cervical region were cleaned from bottom to top; The submandibular gland, digastric muscle and hypoglossal nerve are preserved to the submandibular triangle.
5. Clean the lymph tissue behind the neck, pull the sternocleidomastoid muscle to the front of the neck, clean the fat, lymph tissue and fascia behind the neck from the supraclavicular fossa, and keep the transverse cervical artery and accessory nerve.
If the contralateral side also needs functional neck lymphadenectomy, it should be treated according to the same surgical steps. Total laryngectomy or laryngectomy can also be performed at the same time.