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NETTERS SURGICAL ANATOMY AND APPROACHES

CONOR P. DELANEY

MICHAEL S. BENNINGER TONY CAPIZZANI

TOMMASO FALCONE STEPHEN R. GROBMYER

JIHAD KAOUK MATTHEW KROH SEAN P. LYDEN

JOHN H. RODRIGUEZ - MICHAEL J. ROSEN

CHRISTOPHER T. SIEGEL * ALLAN SIPERSTEIN

SCOTT R. STEELE • R. MATTHEW WALSH

NETTER’S 2

SURGICAL ANATOMY AND APPROACHES

Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS, FRCSI (Hon)

Chairman Digestive Disease and Surgery Institute Cleveland Clinic

Victor W. Fazio Endowed Professor of Colorectal Surgery Cleveland Clinic Lerner College of Medicine Cleveland, Ohio

Illustrations by Frank H. Netter, MD

Contributing Illustrators

Carlos A. G. Machado, MD

Kristen Wienandt Marzejon, MS, MFA

James A. Perkins, MS, MFA

John A. Craig, MD

Paul Kim, MS

Sara M. Jarret, MFA

Elsevier

1600 John F. Kennedy Blvd.

Ste 1800 Philadelphia, PA 19103-2899

NETTER’S SURGICAL ANATOMY AND APPROACHES, SECOND EDITION

Copyright © 2021 by Elsevier, Inc. All rights reserved.

ISBN: 978-0-323-67346-4

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Permission to use Netter Art figures may be sought through the website NetterImages.com or by emailing Elsevier’s Licensing Department at H.Licensing@elsevier.com

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2014.

Library of Congress Control Number: 2020939762

Publisher: Elyse O’Grady

Senior Content Development Specialist: Marybeth Thiel

Publishing Services Manager: Catherine Jackson

Senior Project Manager: Daniel Fitzgerald

Designer: Patrick Ferguson

Printed in China.

For my colleagues who have contributed to this book.

And their inspiring excellence, attention to detail, and care for optimizing

The standard of patient care

About the Artists

Frank H. Netter, MD

Frank H. Netter was born in 1906 in New York City. He studied art at the Art Students’ League and the National Academy of Design before entering medical school at New York University, where he received his MD degree in 1931. During his student years, Dr. Netter’s notebook sketches attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating articles and textbooks. He continued illustrating as a sideline after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a full-time commitment to art. After service in the United States Army during World War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraordinary collection of medical art so familiar to medical professionals worldwide.

In 2005, Elsevier, Inc. purchased the Netter Collection and all publications from Icon Learning Systems. Over 50 publications featuring the art of Dr. Netter are available through Elsevier, Inc. (in the United States: https://www.us.elsevierhealth.com/ and outside the United States: www.elsevierhealth.com)

Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the most famous medical works ever published. The Netter Atlas of Human Anatomy, first published in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions students the world over.

The Netter illustrations are appreciated not only for their aesthetic qualities, but, more important, for their intellectual content. As Dr. Netter wrote in 1949, “… clarification of a subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are what inform his paintings and make them so intellectually valuable.

Frank H. Netter, MD, physician and artist, died in 1991.

Learn more about the physician-artist whose work has inspired the Netter Reference collection: https://netterimages.com/artist-frank-h-netter.html.

Carlos Machado, MD

Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main artist contributing to the Netter collection of medical illustrations.

Self-taught in medical illustration, cardiologist Carlos Machado has meticulously updated some of Dr. Netter’s original plates and has created many original paintings of his own in the style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise and keen insight into the physician–patient relationship informs his vivid and unforgettable visual style. His dedication to researching each topic and subject he paints places him among the premier medical illustrators at work today.

Learn more about his background and see more of his art at: https://netterimages.com/ artist-carlos-a-g-machado.html.

Preface

The Atlas of Human Anatomy by Frank H. Netter, MD, has been the pinnacle of demonstrating the anatomy of the human body for generations of students. To those who would wish to perform or understand surgical procedures, however, there has been no direct link between the beautiful images created by Dr. Netter and the surgical procedures being performed. In Netter’s Surgical Anatomy and Approaches, we try to address a request by many Netter users to tie these anatomical diagrams to the procedures they perform, while advancing the book from the description and images used in the first edition.

This book portrays the curriculum of basic and common general surgical procedures in chapters that describe the relevant anatomy for each procedure. In his very first edition, Dr. Netter stated that “anatomy of course does not change, but our understanding of anatomy and its clinical significance does.” Consequently, in some cases we have been able to pair the anatomy demonstrated in his illustrations with a modern intraoperative photograph or radiographic image, particularly focusing on the new approaches required for minimally invasive surgery. For many chapters, new Netter-style illustrations have been created to demonstrate key anatomical points for an operative procedure or to show a key surgical perspective or orientation that is not captured in the original Netter images. The result is a volume that covers the most important and common areas in surgery, as well as exploring complex areas such as transplantation and advanced cancer surgery.

A book like this would not be possible without the help of many people. Being fortunate to work at an institution like the Cleveland Clinic, I elected to enlist the support of my colleagues from many different surgical specialties. It is only with the guidance and assistance of the editorial team of Michael S. Benninger, MD, Tony R. Capizzani, MD, FACS, Tommaso Falcone, MD, FRCSC, FACOG, Stephen R. Grobmyer, MD, Jihad Kaouk, MD, Matthew Kroh, MD, Sean P. Lyden, MD, John H. Rodriguez, MD, FACS, Michael J. Rosen, MD, Christopher T. Siegel, MD, PhD, Allan Siperstein, MD, Scott R. Steele, MD, MBA, R. Matthew Walsh, MD, and the direction and guidance of the ever-patient Dan Fitzgerald and Marybeth Thiel at Elsevier that this project has been completed.

On behalf of my co-editors and myself, we hope you enjoy this second edition of Netter’s Surgical Anatomy and Approaches

Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS, FRCSI (Hon)

EDITOR

Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS, FRCSI (Hon)

Chairman

Digestive Disease and Surgery Institute

Cleveland Clinic

Victor W. Fazio Endowed Professor of Colorectal Surgery

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

SECTION

EDITORS

Michael S. Benninger, MD

Chairman

Head and Neck Institute

Cleveland Clinic

Professor of Surgery

Lerner College of Medicine of CWRU

Cleveland, Ohio

The Neck

Tony R. Capizzani, MD, FACS

Assistant Professor

General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Vascular Access, Emergency and Trauma Procedures

Tommaso Falcone, MD, FRCSC, FACOG

Chief of Staff, Chief Academic Officer, Medical Director

Cleveland Clinic London

Professor of Obstetrics, Gynecology and Reproductive Biology

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

Urology and Gynecology

Contributors

Stephen R. Grobmyer, MD

Chairman

Oncology Institute

Cleveland Clinic Abu Dhabi

Abu Dhabi, United Arab Emirates

Breast and Oncology

Jihad Kaouk, MD

Director

Center for Robotics and Minimally Invasive Surgery

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Urology and Gynecology

Matthew Kroh, MD

Chairman

Digestive Disease Institute

Cleveland Clinic Abu Dhabi

Abu Dhabi, United Arab Emirates

Upper Gastrointestinal

Sean P. Lyden, MD

Professor and Chairman

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Vascular

John H. Rodriguez, MD, FACS

Director of Surgical Endoscopy

Advanced Laparoscopic and Bariatric Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Upper Gastrointestinal

Michael J. Rosen, MD

Professor of Surgery

Lerner College of Medicine

Cleveland Clinic

Cleveland, Ohio

Hernia

Christopher T. Siegel, MD, PhD

Associate Professor of Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic Lerner College of Medicine

Cleveland Clinic

Cleveland, Ohio

Hepatobiliary

Organ Transplantation

Allan Siperstein, MD

Professor and Chair

Endocrine Surgery Department

Cleveland Clinic

Cleveland, Ohio

Endocrine

Scott R. Steele, MD, MBA

Chairman

Department of Colorectal Surgery

Rupert B. Turnbull, M.D. Endowed Chair in Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Lower Gastrointestinal

R. Matthew Walsh, MD

Professor and Chairman

General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatobiliary

CONTRIBUTORS

Robert Abouassaly, MD

Associate Professor

Glickman Urological & Kidney Institute

Cleveland Clinic

Louis Stokes Cleveland VA Medical Center

Cleveland, Ohio

Radical Prostatectomy

Kareem Abu-Elmagd, MD, PhD, FACS

Director

Center for Gut Rehabilitation & Transplantation (CGRT)

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Intestinal and Multivisceral Transplantation

Usman Ahmad, MD, FACS

Assistant Professor of Surgery

Staff Surgeon

Thoracic Surgery

Cleveland Clinic

Cleveland, Ohio

Esophagectomy

Abdul Q. Alarhayem, MD

Clinical Fellow

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Radiocephalic, Brachiocephalic, and Brachiobasilic Fistula

Michael Antiporda, MD

Fellow

Advanced Gastrointestinal and Minimally Invasive Surgery

Providence Portland Medical Center

Portland, Oregon

Gastrectomy

Sofya H. Asfaw, MD, FACS

Assistant Professor of Surgery

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Chest Tube Placement

Federico Aucejo, MD

Associate Professor of Surgery

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

Toms Augustin, MD, MPH, FACS

Assistant Professor

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Distal Pancreatectomy

Jocelyn M. Beach, MD

Assistant Professor of Surgery

Section of Vascular Surgery

Dartmouth-Hitchcock Medical Center

Lebanon, New Hampshire

Carotid Subclavian Bypass/Transposition and Vertebral Transposition

Cassandre Benay, MD

General Surgery

Hopital de LaSalle

Montreal, Quebec, Canada

Thyroidectomy and Parathyroidectomy

Eren Berber, MD

Staff Surgeon

Endocrine and General Surgery

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Riccardo Bertolo, MD

Urologist

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Laparoscopic Transperitoneal Radical Nephrectomy

Radical Prostatectomy

Radical Cystectomy

Vladimir Bolshinsky, MBBS, DipSurgAnat, FRACS

Clinical Associate

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Low Anterior Resection With Total Mesorectal Excision and Anastomosis

Paul C. Bryson, MD

Associate Professor of Otolaryngology—Head and Neck Surgery

Laryngology Section Head

Department of Otolaryngology

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

Tracheostomy

Tony R. Capizzani, MD, FACS

Assistant Professor

General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Tracheal Intubation and Endoscopic Anatomy

Central Line Anatomy

Francis J. Caputo, MD

Associate Professor and Program Director

Department of Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Aortic Aneurysm Repair and Thoracoabdominal

Aneurysm Repair

Femoral Tibial Bypass

Walter S. Cha, MD

Staff Surgeon

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Common Bile Duct Surgery and Choledochoduodenostomy

Bradley J. Champagne, MD

Professor of Surgery

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Chair of Surgery

Fairview Hospital—Cleveland Clinic

Cleveland, Ohio

Right Colectomy

Julietta Chang, MD

Bariatric Surgeon

Department of Surgery

Marian Regional Medical Center

Santa Maria, California

Surgical Management of Achalasia

James M. Church, MB, ChB, MMedSci, FRACS

Staff Surgeon

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Perianal Abscess and Fistula in Ano

Giuseppe D’Amico, MD

Staff Surgeon

Hepato-Pancreato-Biliary/Liver and Intestinal

Transplantation Surgery

General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Liver Transplantation

Gerardo Davalos, MD

Research Scholar

Surgery

Duke University

Durham, North Carolina

Truncal and Selective Vagotomy

Robert DeBernardo, MD

Section Head Gynecologic Oncology

Laura J Fogarty Endowed Chair for Uterine

Cancer Research

Director of the Peritoneal Surface Malignancy

Program

Associate Professor of Surgery Lerner College of Medicine

Woman’s Health Institute

Cleveland Clinic

Cleveland, Ohio

Oophorectomy for Benign and Malignant Conditions

Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS, FRCSI (Hon)

Chairman

Digestive Disease and Surgery Institute

Cleveland Clinic

Victor W. Fazio Endowed Professor of Colorectal Surgery

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

Low Anterior Resection With Total Mesorectal Excision and Anastomosis

Teresa Diago-Uso, MD

Assistant Professor of Surgery

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Living Donor Liver Transplantation

Deceased Donor Organ Recovery

Risal Djohan, MD

Vice Chairman

Plastic Surgery

Cleveland Clinic

Cleveland, Ohio

Breast Reconstruction

Nathan Droz, MD

Vascular Surgery Fellow

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Visceral Bypass

Bijan Eghtesad, MD

Staff Surgeon

Hepato-Pancreato-Biliary/Liver

Transplantation Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Liver Transplantation

Deceased Donor Organ Recovery

Kevin El-Hayek, MD, FACS

Section Head

Endoscopic Surgery

Division of General Surgery

Section Head

Hepato-Pancreato-Biliary Surgery

Division of Surgical Oncology

Metro Health System

Assistant Professor of Surgery

Case Western Reserve University

Cleveland, Ohio

Gastric Emptying Procedures

Pancreatoduodenectomy

Aldo Fafaj, MD

General Surgery

Digestive Disease and Surgery

Cleveland Clinic

Cleveland, Ohio

Laparoscopic Inguinal Hernia Repair

Behzad S. Farivar, MD

Assistant Professor of Surgery

Department of Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Carotid Subclavian Bypass/Transposition and Vertebral Transposition

Jeffrey M. Farma, MD

Professor

Surgical Oncology

Fox Chase Cancer Center

Philadelphia, Pennsylvania

Inguinal and Pelvic Lymphadenectomy

Alisan Fathalizadeh, MD, MPH

Associate Staff Surgeon

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Gastric Emptying Procedures

Molly Flannagan, MD, FACS

Assistant Professor of Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Emergency Thoracotomy for Trauma

Masato Fujiki, MD

Assistant Professor of Surgery, Transplantation

Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Living Donor Liver Transplantation

Intestinal and Multivisceral Transplantation

Juan Garisto, MD

Urologist

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Radical Cystectomy

Keith Glover, MD

Resident

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Femoral Endarterectomy and Femoral Popliteal

Bypass

David A. Goldfarb, MD

Professor of Surgery, CCLCM

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Kidney Transplantation

Emre Gorgun, MD

Director

Endoluminal Surgery Center

Department of Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Ileal Pouch Anal Anastomosis

Stephen R. Grobmyer, MD

Chairman

Oncology Institute

Cleveland Clinic Abu Dhabi

Abu Dhabi, United Arab Emirates

Mastectomy: Partial and Total

Morgan Gruner, MD

OB-GYN Resident Physician

Department of Subspecialty Care for Women’s

Health

Cleveland Clinic

Cleveland, Ohio

Oophorectomy for Benign and Malignant Conditions

Alfredo D. Guerron, MD

Assistant Professor of Surgery

General Surgery

Duke University Health System

Durham, North Carolina

Truncal and Selective Vagotomy

Georges-Pascal Haber, MD, PhD

Chairman

Department of Urology

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Retroperitoneal Lymph Node Dissection

David M. Hardy, MD, RPVI, FACS

Assistant Professor

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Carotid Endarterectomy

Above-Knee and Below-Knee Amputation

Koji Hashimoto, MD, PhD

Director

Living Donor Liver Transplantation

Associate Professor of Surgery

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Living Donor Liver Transplantation

Barbara J. Hocevar, MSN, RN, CWOCN

Assistant Director, WOC Nursing Education

R. B. Turnbull, Jr. MD, School of WOC Nursing

Education

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Abdominal Wall Marking and Stoma Site Selection

Kristen Holler, DO

Critical Care Fellow

Anesthesiology Institute

Cleveland Clinic

Cleveland, Ohio

Tracheal Intubation and Endoscopic Anatomy

Stefan D. Holubar, MD, MS

Director of Research

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Abdominoperineal Resection

Farah A. Husain, MD

Division Chief

Bariatric Services

Associate Professor

Department of Surgery

Oregon Health & Science University

Portland, Oregon

Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Daniel J. Kagedan, MD, MSc, FRCSC

Surgical Oncology Fellow

Department of Surgical Oncology

Roswell Park Comprehensive Cancer Center

Buffalo, New York

Retroperitoneal Sarcoma

Matthew F. Kalady, MD Professor of Surgery

Colorectal Surgery

Vice-Chairman

Colorectal Surgery

Cleveland Clinic

Director

Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia

Co-Director

Comprehensive Colorectal Cancer Program

Cleveland, Ohio

Left and Sigmoid Colectomy

Jihad Kaouk, MD

Director

Center for Robotics and Minimally Invasive

Surgery

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Radical Prostatectomy

Radical Cystectomy

Hermann Kessler, MD, PhD

Professor of Surgery

Section Head

Minimally Invasive Surgery

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Abdominoperineal Resection

Leena Khaitan, MD, MPH

Professor of Surgery Department of Surgery

Director

Metabolic and Bariatric Surgery

Center Digestive Health Institute

Director

Esophageal and Swallowing Center

Digestive Health Institute

University Hospitals

Cleveland Medical Center

Cleveland, Ohio

Minimally Invasive Antireflux Surgery

Amit Khithani, MD, DABS

Faculty Surgeon

Surgical Oncology and Hepatopancreatobiliary

Surgery

Department of Surgery

Kendall Regional Medical Center

Miami, Florida

Pancreatoduodenectomy

Lee Kirksey, MD, MBA

Vice Chairman

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Radiocephalic, Brachiocephalic, and Brachiobasilic

Fistula

Eric A. Klein, MD

Chairman

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Retroperitoneal Lymph Node Dissection

Venkatesh Krishnamurthi, MD

Director

Kidney/Pancreas Transplant Program

Glickman Urological & Kidney Institute

Transplant Center

Cleveland Clinic

Associate Professor of Surgery

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

Pancreas and Kidney Transplantation

Matthew Kroh, MD Chairman

Digestive Disease Institute

Cleveland Clinic Abu Dhabi

Abu Dhabi, United Arab Emirates

Surgical Management of Achalasia

David M. Krpata, MD

Assistant Professor

Cleveland Clinic Lerner College of Medicine

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Surgical Approach to Chronic Groin Pain Following Inguinal Hernia Repairs

Jamie A. Ku, MD

Staff

Head and Neck Institute

Cleveland Clinic

Cleveland, Ohio

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Choon Hyuck David Kwon, MD, PhD

Professor of Surgery

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

David J. Laczynski, MD

Vascular Surgery Resident

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Above-Knee and Below-Knee Amputation

Judith Landis-Erdman, BSN, RN, CWOCN

Wound Ostomy Continence Nursing Team

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Abdominal Wall Marking and Stoma Site Selection

Kelsey E. Larson, MD

Assistant Professor of Surgery

General Surgery

University of Kansas

Kansas City, Kansas

Sentinel Lymph Node Biopsy

Pierre Lavertu, MD

Director of Head and Neck Surgery

Department of Otolaryngology—Head and Neck Surgery

University Hospitals Case Medical Center

Professor

Case Western Reserve University School of Medicine

Cleveland, Ohio

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Tripp Leavitt, MD

Resident Physician

Plastic Surgery

Cleveland Clinic

Cleveland, Ohio

Breast Reconstruction

Sungho Lim, MD

Fellow

Department of Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Aortic Aneurysm Repair and Thoracoabdominal Aneurysm Repair

Jeremy M. Lipman, MD, MHPE

Program Director

General Surgery Residency

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Transverse Colectomy

Victoria Lyo, MD, MTM

Assistant Professor of Surgery

Foregut, Metabolic, and General Surgery

Division

University of California Davis

Sacramento, California

Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Gary N. Mann, MD

Associate Professor

Surgical Oncology

Roswell Park Comprehensive Cancer Center

Buffalo, New York

Retroperitoneal Sarcoma

Jeannine L. Marong, PA-C

Advanced Practice Coordinator of Trauma

Services

Hillcrest Hospital

Mayfield Heights, Ohio

Arterial Line Anatomy

Christopher Mascarenhas, MD, FACS

Assistant Professor

Division of Colon and Rectal Surgery

Columbia University Irving Medical Center

New York, New York

Left and Sigmoid Colectomy

Evan R. McBeath, MD

Otolaryngologist

Wood County Hospital

Bowling Green, Ohio

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Chad M. Michener, MD

Associate Professor of Surgery

Obstetrics, Gynecology and Women’s Health Institute

Cleveland Clinic Lerner College of Medicine

Vice Chair

Department of Obstetrics and Gynecology, Main Campus

Obstetrics, Gynecology and Women’s Health Institute

Cleveland Clinic

Cleveland, Ohio

Hysterectomy for Benign and Malignant Conditions

Charles Miller, MD

Enterprise Director of Transplantation

Director

Transplantation Center

Professor of Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

Eric T. Miller, MD

Transplantation and Urological Surgery

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Kidney Transplantation

Pancreas and Kidney Transplantation

Laparoscopic Donor Nephrectomy

Edwina C. Moore, BMedSci, MBBS, FRACS

Endocrine Surgeon

Cleveland Clinic

Cleveland, Ohio

Laparoscopic Adrenalectomy

Amit Nair, MS, MD, FRCS

Clinical Scholar

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

Robert Naples, DO

General Surgery Resident

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Splenectomy

Ahmed Nassar, MD

Transplant Surgery Fellow

Emory University

Atlanta, Georgia

Common Bile Duct Surgery and Choledochoduodenostomy

Eileen A. O’Halloran, MD, MS

Complex General Surgical Oncology Fellow

Surgical Oncology

Fox Chase Cancer Center

Philadelphia, Pennsylvania

Inguinal and Pelvic Lymphadenectomy

Keita Okubo, MD, PhD

Clinical Research Fellow

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

F. Ezequiel Parodi, MD

Associate Professor

Division of Vascular Surgery

University of North Carolina School of Medicine

Durham, North Carolina

Visceral Bypass

Will Perry, MD, BS

Resident

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Carotid Endarterectomy

Clayton C. Petro, MD

Assistant Professor of Surgery

Center for Abdominal Core Health

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Open Retromuscular Hernia Repair

Lee Ponsky, MD, FACS

Professor of Urology

Chief, Urologic Oncology

Leo and Charlotte Goldberg Chair of Advanced

Surgical Therapies

Master Clinician of Urologic Oncology Urology

Institute

University Hospitals Cleveland Medical Center

Case Western Reserve University School of Medicine

Cleveland, Ohio

Laparoscopic Transperitoneal Radical Nephrectomy

Ajita Prabhu, MD

Assistant Professor of Surgery

Lerner College of Medicine

Center for Abdominal Core Health

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Open Flank and Lumbar Hernia Repair

Debra Pratt, MD

Medical Director

Fairview Breast Program

Cleveland Clinic Cancer Center Moll Pavilion

Cleveland, Ohio

Central Duct Excision and Nipple Discharge

Cristiano Quintini, MD

Director

Liver Transplantation

Professor of Surgery

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

Hepatectomy

Liver Transplantation

Living Donor Liver Transplantation

Siva Raja, MD, PhD

Associate Professor of Surgery

Staff Surgeon

Thoracic Surgery

Cleveland Clinic

Cleveland, Ohio

Esophagectomy

Kevin M. Reavis, MD

Foregut and Bariatric Surgeon

Gastrointestinal and Minimally Invasive Surgery

The Oregon Clinic

Portland, Oregon

Gastrectomy

Saranya Reghunathan, MD

Department of Otolaryngology

Cleveland Clinic

Cleveland, Ohio

Tracheostomy

Beri M. Ridgeway, MD

Institute Chair

OB/GYN and Women’s Health Institute

Cleveland Clinic

Cleveland, Ohio

Reconstructive Surgery for Pelvic Floor Disorders

John H. Rodriguez, MD, FACS

Director of Surgical Endoscopy

Advanced Laparoscopic and Bariatric Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Surgical Management of Achalasia

David R. Rosen, MD

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Transverse Colectomy

Steven Rosenblatt, MD

Associate Professor of Surgery

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic Lerner College of Medicine

Cleveland Clinic

Cleveland, Ohio

Splenectomy

Laparoscopic Inguinal Hernia Repair

Kazunari Sasaki, MD

Assistant Professor of Surgery

Transplantation Center

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

Graham Schwarz, MD

Program Director

Microsurgery and Breast Reconstruction

Fellowship

Department of Plastic Surgery

Cleveland Clinic

Cleveland, Ohio

Axillary Lymphadenectomy and Lymphaticovenous

Bypass

Sherief Shawki, MD, MSc, MBBCH

Staff Surgeon

Colon & Rectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Assistant Professor of Surgery

Colon & Rectal Surgery

Lerner Medical School of Medicine

Cleveland, Ohio

Suture Rectopexy and Ventral Mesh Rectopexy

Christopher T. Siegel, MD, PhD

Associate Professor of Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic Lerner College of Medicine

Cleveland Clinic

Cleveland, Ohio

Hepatectomy

Living Donor Liver Transplantation

Robert Simon, MD

Associate Staff

Division General and Hepatopancreaticobiliary

Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Cholecystectomy

Allan Siperstein, MD

Professor and Chair

Endocrine Surgery Department

Cleveland Clinic

Cleveland, Ohio

Thyroidectomy and Parathyroidectomy

Laparoscopic Adrenalectomy

Christopher J. Smolock, MD

Staff Vascular Surgeon

Department of Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Femoral Endarterectomy and Femoral Popliteal Bypass

Sean P. Steenberge, MD, MS

Resident

Vascular Surgery

Cleveland Clinic

Cleveland, Ohio

Femoral Tibial Bypass

Rachael C. Sullivan, MD, MS

Staff Physician

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Upper and Lower Extremity Fasciotomy

Andrew Tang, MD

Resident

Thoracic and Cardiovascular Surgery

Cleveland Clinic

Cleveland, Ohio

Esophagectomy

Patrick Tassone, MD

Fellow in Head & Neck Oncologic and Reconstructive Surgery

Head and Neck Institute

Cleveland Clinic

Cleveland, Ohio

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Luciano Tastaldi, MD

Clinical Research Fellow

Center for Abdominal Core Health

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Open Flank and Lumbar Hernia Repair

Lewis J. Thomas IV, MD

Urologic Oncology Fellow

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Retroperitoneal Lymph Node Dissection

Michael A. Valente, DO, FACS, FASCRS

Associate Professor

Residency Program Director

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Appendectomy

Stephanie A. Valente, DO, FACS

Breast Surgical Oncologist

Director

Breast Surgery Fellowship

General Surgery

Cleveland Clinic

Associate Professor of Surgery

Department of General Surgery

Cleveland Clinic Lerner College of Medicine

Case Western Reserve University

Cleveland, Ohio

Axillary Lymphadenectomy and Lymphaticovenous

Bypass

Valery Vilchez, MD

Surgery Resident

Department of General Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Distal Pancreatectomy

Cynthia E. Weber, MD

Bariatric Surgery Fellow

Surgery

University Hospitals’ of Cleveland

Cleveland, Ohio

Minimally Invasive Antireflux Surgery

Alvin C. Wee, MD, MBA

Surgical Director

Kidney Transplantation

Glickman Urological & Kidney Institute

Cleveland Clinic

Cleveland, Ohio

Kidney Transplantation

Laparoscopic Donor Nephrectomy

James S. Wu, MD, PhD

Staff Surgeon

Department of Colon and Rectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Abdominal Wall Marking and Stoma Site Selection

Chad A. Zender, MD, FACS

Assistant Professor

Department of Otolaryngology—Head and Neck Surgery

Case Western Reserve University School of Medicine

Cleveland, Ohio

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Massarat Zutshi, MD

Staff Surgeon

Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic

Cleveland, Ohio

Hemorrhoids and Hemorrhoidectomy

Sphincter Repair and Sacral Neuromodulation

SECTION 1 The Neck 1

Section Editor: Michael S. Benninger

Chapter 1 Selective (Supraomohyoid)

Neck Dissection, Levels I-III 3

Patrick Tassone, Chad A. Zender, Evan R. McBeath, Pierre Lavertu, and Jamie A. Ku

Chapter 2 Tracheostomy 13

Paul C. Bryson and Saranya Reghunathan

SECTION 2 Endocrine 19

Section Editor: Allan Siperstein

Chapter 3 Thyroidectomy and Parathyroidectomy 21

Allan Siperstein and Cassandre Benay

Chapter 4 Laparoscopic Adrenalectomy 35

Allan Siperstein and Edwina C. Moore

SECTION 3 Upper Gastrointestinal 47

Section Editors: Matthew Kroh and John H. Rodriguez

Chapter 5 Esophagectomy 49

Andrew Tang, Usman Ahmad, and Siva Raja

Chapter 6 Minimally Invasive Antireflux Surgery 63

Cynthia E. Weber and Leena Khaitan

Chapter 7 Truncal and Selective Vagotomy 77

Gerardo Davalos and Alfredo D. Guerron

Contents

Chapter 8 Gastrectomy 87

Michael Antiporda and Kevin M. Reavis

Chapter 9 Gastric Emptying Procedures 95

Kevin El-Hayek and Alisan Fathalizadeh

Chapter 10 Roux-en-Y Gastric Bypass and Sleeve Gastrectomy 107

Victoria Lyo and Farah A. Husain

Chapter 11 Surgical Management of Achalasia 115

Matthew Kroh, John H. Rodriguez, and Julietta Chang

SECTION 4 Hepatobiliary 127

Section Editors: Christopher T. Siegel and R. Matthew Walsh

Chapter 12 Cholecystectomy 129

Robert Simon

Chapter 13 Common Bile Duct Surgery and Choledochoduodenostomy 139

Walter S. Cha and Ahmed Nassar

Chapter 14 Hepatectomy 151

Federico Aucejo, Kazunari Sasaki, Charles Miller, Eren Berber, Keita

Okubo, Cristiano Quintini, Choon

Hyuck David Kwon, Christopher T. Siegel, and Amit Nair

Chapter 15 Distal Pancreatectomy 173

Valery Vilchez and Toms Augustin

Chapter 16 Pancreatoduodenectomy 181

Kevin El-Hayek and Amit Khithani

Chapter 17 Splenectomy 189

Steven Rosenblatt and Robert Naples

SECTION 5 Organ Transplantation 195

Section Editor: Christopher T. Siegel

Chapter 18 Liver Transplantation 197

Giuseppe D’Amico, Cristiano Quintini, and Bijan Eghtesad

Chapter 19 Living Donor Liver Transplantation 205

Koji Hashimoto, Choon Hyuck

David Kwon, Kazunari Sasaki, Charles Miller, Keita Okubo, Cristiano Quintini, Teresa DiagoUso, Masato Fujiki, Christopher

T. Siegel, Amit Nair, and Federico Aucejo

Chapter 20 Intestinal and Multivisceral Transplantation 217

Masato Fujiki and Kareem Abu-Elmagd

Chapter 21 Kidney Transplantation 225

Eric T. Miller, David A. Goldfarb, and Alvin C. Wee

Chapter 22 Pancreas and Kidney Transplantation 233

Eric T. Miller and Venkatesh Krishnamurthi

Chapter 23 Laparoscopic Donor Nephrectomy 243

Eric T. Miller and Alvin C. Wee

Chapter 24 Deceased Donor Organ Recovery 251

Teresa Diago-Uso and Bijan Eghtesad

SECTION 6 Lower Gastrointestinal 261

Section Editor: Scott R. Steele

Chapter 25 Appendectomy 263

Michael A. Valente

Chapter 26 Abdominal Wall Marking and Stoma Site Selection 275

Barbara J. Hocevar, Judith LandisErdman, and James S. Wu

Chapter 27 Right Colectomy 281

Bradley J. Champagne

Chapter 28 Left and Sigmoid Colectomy 289

Christopher Mascarenhas and Mathew F. Kalady

Chapter 29 Transverse Colectomy 301

David R. Rosen and Jeremy M. Lipman

Chapter 30 Low Anterior Resection With Total Mesorectal Excision and Anastomosis 311

Vladimir Bolshinsky and Conor P. Delaney

Chapter 31 Abdominoperineal Resection 329

Stefan D. Holubar and Hermann Kessler

Chapter 32 Hemorrhoids and Hemorrhoidectomy 339

Massarat Zutshi

Chapter 33 Perianal Abscess and Fistula in Ano 349

James M. Church

Chapter 34 Suture Rectopexy and Ventral Mesh Rectopexy 361

Sherief Shawki

Chapter 35 Ileal Pouch Anal Anastomosis 369

Emre Gorgun

Chapter 36 Sphincter Repair and Sacral Neuromodulation 379

Massarat Zutshi

SECTION 7 Hernia 385

Section Editor: Michael J. Rosen

Chapter 37 Laparoscopic Inguinal Hernia Repair 387

Aldo Fafaj and Steven Rosenblatt

Chapter 38 Surgical Approach to Chronic Groin Pain Following Inguinal Hernia Repairs 399

David M. Krpata

Chapter 39 Open Flank and Lumbar Hernia Repair 411

Luciano Tastaldi and Ajita Prabhu

Chapter 40 Open Retromuscular Hernia Repair 417

Clayton C. Petro

SECTION 8 Vascular 429

Section Editor: Sean P. Lyden

Chapter 41 Carotid Endarterectomy 431

David M. Hardy and Will Perry

Chapter 42 Carotid Subclavian Bypass/ Transposition and Vertebral Transposition 441

Jocelyn M. Beach and Behzad S. Farivar

Chapter 43 Aortic Aneurysm Repair and Thoracoabdominal Aneurysm

Repair 449

Sungho Lim and Francis J. Caputo

Chapter 44 Visceral Bypass 463

Nathan Droz and F. Ezequiel Parodi

Chapter 45 Radiocephalic, Brachiocephalic, and Brachiobasilic Fistula 473

Abdul Q. Alarhayem and Lee Kirksey

Chapter 46 Femoral Endarterectomy and Femoral Popliteal Bypass 479

Christopher J. Smolock and Keith Glover

Chapter 47 Femoral Tibial Bypass 487

Sean P. Steenberge and Francis J. Caputo

Chapter 48 Above-Knee and Below-Knee Amputation 499

David M. Hardy and David J. Laczynski

SECTION 9 Vascular Access, Emergency and Trauma Procedures 509

Section Editor: Tony R. Capizzani

Chapter 49 Tracheal Intubation and Endoscopic Anatomy 511

Kristen Holler and Tony R. Capizzani

Chapter 50 Chest Tube Placement 525

Sofya H. Asfaw

Chapter 51 Emergency Thoracotomy for Trauma 533

Molly Flannagan

Chapter 52 Central Line Anatomy 545

Tony R. Capizzani

Chapter 53 Arterial Line Anatomy 553

Jeannine L. Marong

Chapter 54 Upper and Lower Extremity Fasciotomy 561

Rachael C. Sullivan

SECTION 10 Breast and Oncology 579

Section Editor: Stephen R. Grobmyer

Chapter 55 Mastectomy: Partial and Total 581

Stephen R. Grobmyer

Chapter 56 Breast Reconstruction 587

Tripp Leavitt and Risal Djohan

Chapter 57 Central Duct Excision and Nipple Discharge 603

Debra Pratt

Chapter 58 Sentinel Lymph Node Biopsy 609

Kelsey E. Larson

Chapter 59 Axillary Lymphadenectomy and Lymphaticovenous Bypass 617

Stephanie A. Valente and Graham Schwarz

Chapter 60 Inguinal and Pelvic Lymphadenectomy 625

Eileen A. O’Halloran and Jeffrey M. Farma

Chapter 61 Retroperitoneal Sarcoma 631

Daniel J. Kagedan and Gary N. Mann

SECTION 11 Urology and Gynecology 637

Section Editors: Jihad Kaouk and Tommaso Falcone

Chapter 62 Hysterectomy for Benign and Malignant Conditions 639

Chad M. Michener

Chapter 63 Oophorectomy for Benign and Malignant Conditions 653

Morgan Gruner and Robert DeBernardo

Chapter 64 Reconstructive Surgery for Pelvic Floor Disorders 663

Beri M. Ridgeway

Chapter 65 Laparoscopic Transperitoneal Radical Nephrectomy 675

Riccardo Bertolo and Lee Ponsky

Chapter 66 Radical Prostatectomy 685

Riccardo Bertolo, Jihad Kaouk, and Robert Abouassaly

Chapter 67 Radical Cystectomy 699

Riccardo Bertolo, Juan Garisto, and Jihad Kaouk

Chapter 68 Retroperitoneal Lymph Node Dissection 711

Eric A. Klein, Georges-Pascal Haber, and Lewis J. Thomas IV

Index 721

Video Contents

1.1 Neck Dissection

2.1 Tracheostomy

3.1 Thyroidectomy and Parathyroidectomy

6.1 Laparoscopic Nissen Fundoplication

7.1 Laparoscopic Truncal Vagotomy

8.1 Laparoscopic Total Gastrectomy With D2 Lymphadenectomy

9.1 Per-Oral Pyloromyotomy (POP) and Laparoscopic Pyloromyotomy

10.1 Linear Stapled Gastric Bypass (Antecolic, Antegastric)

10.2 EEA Stapled Gastrojejunal Anastomosis (Antecolic, Antegastric)

10.3 Sleeve Gastrectomy

12.1 Laparoscopic Cholecystectomy

13.1 Laparoscopic Transcystic Common Bile Duct Exploration

14.1 Laparoscopic Right Hepatectomy

14.2 Laparoscopic Left Hepatectomy

14.3 Robotic Left Hepatectomy

16.1 Laparoscopic Pancreaticoduodenectomy

17.1 Laparoscopic Splenectomy

19.1 Laparoscopic Living Donor Right Hepatectomy

19.2 Open Living Donor Left Hepatectomy

20.1 Intestinal Graft Procurement

20.2 Multivisceral Transplantation

21.1 Kidney Transplantation

22.1 Simultaneous Pancreas and Kidney Transplantation

23.1 Left Laparoscopic Donor Nephrectomy

25.1 Appendectomy

27.1 Right Colectomy

28.1 Left and Sigmoid Colectomy

30.1 Low Anterior Resection With Total Mesorectal Excision and Anastomosis

35.1 Single Incision Total Abdominal Colectomy (First Stage Restorative Proctectomy/Ileal Pouch Anal Anastomosis)

35.2 Completion Proctectomy/J-Pouch Construction

40.1 Open Transversus Abdominis Release (TAR)

43.1 Abdominal Aortic Aneurysm

61.1 Retroperitoneal Sarcoma

66.1 Robotic Prostatectomy

The Neck

section editor : Michael S. Benninger

1 Selective (Supraomohyoid) Neck

Dissection, Levels I-III

Patrick Tassone, Chad A. Zender, Evan R. McBeath, Pierre Lavertu, and Jamie A. Ku

2 Tracheostomy

Paul C. Bryson and Saranya Reghunathan

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Patrick Tassone, Chad A. Zender, Evan R. McBeath, Pierre Lavertu, and Jamie A. Ku

VIDEO

1.1 Neck Dissection

INTRODUCTION

Neck dissection has been a standard method of removing at-risk or involved cancerous lymph nodes in the head and neck for more than 100 years. Crile first described the radical neck dissection in the early 1900s, but modifications by Bocca and others helped reduce the morbidity associated with lymph node removal, allowing for nerve and structure preservation when oncologically sound. This chapter discusses one of these modifications in detail, the selective or supraomohyoid neck dissection. A selective neck dissection, including levels I through III, is typically used for malignancies of the oral cavity in patients with N0 disease. When a larger nodal burden is present, an extended (levels I-IV) selective neck dissection or a modified radical neck dissection (levels I-V) is indicated. Lesions in the oral cavity that approach or cross the midline require treatment of both sides of the neck.

NECK ANATOMY FOR SURGICAL PLANNING

Understanding the regional lymphatic drainage pathways is critical when planning which type of neck dissection will be employed (Fig. 1.1 ). A supraomohyoid neck dissection is performed when treating patients who are at risk for micrometastasis in levels I, II, and III. The boundaries of levels I (submental and submandibular), II (upper jugular nodal chain), and III (midjugular nodal chain) are defined as follows:

Level Ia: Bounded laterally by the medial aspects of the anterior belly of the digastric muscles, and ending medially at a line drawn from the mandible to the hyoid bone at the anatomic midline.

Level Ib: Bounded by the lateral aspect of the anterior belly of the digastric muscle, the medial aspect of the posterior belly of the digastric and stylohyoid muscles, and the inferior border of the mandibular body superiorly.

Level IIa: Bounded anteriorly and superiorly by the posterior belly of the digastric and stylohyoid muscles, posteriorly by the vertical plane defined by the spinal accessory nerve and sternocleidomastoid muscle (SCM), and inferiorly by the horizontal plane defined by the inferior border of the hyoid bone.

Level IIb: Bounded anteriorly by the jugular vein and inferiorly by the vertical plane defined by the spinal accessory nerve, posteriorly by the posterior border of the SCM, and superiorly by the skull base.

Level III: Bounded superiorly by the horizontal plane defined by the inferior border of the hyoid bone, inferiorly by the horizontal plane defined by the inferior border of the cricoid cartilage and/or the omohyoid muscle as it crosses the internal jugular vein, anteriorly by the lateral border of the sternohyoid muscle, and posteriorly by the posterior border of the SCM.

The patient is positioned on the table with his neck extended, typically on a shoulder roll, and head turned away from the operative side.

Mandibular nodes

Submandibular nodes

Submental nodes

Suprahyoid node

Superior deep lateral cervical (internal jugular) nodes

Superior thyroid nodes

Jugulo-omohyoid node

Anterior deep cervical (pretracheal and thyroid) nodes (deep to infrahyoid muscles)

Anterior superficial cervical nodes (anterior jugular nodes)

Jugular trunk

Superior flap dissected up along deep surface of anterior facial vein and facial (external maxillary) artery, thus elevating ramus marginalis mandibulae of facial nerve out of operating field.

Vessels ligated and distal end of vascular stump sutured to undersurface of flap

Supraclavicular nodes*

Subclavian trunk and node

Superior lateral superficial cervical (external jugular) node

Accessory nerve (XI)

Jugulodigastric node

Posterior lateral superficial cervical (spinal accessory) nodes

Intercalated node

Inferior deep lateral cervical (scalene) node

Thoracic duct

Transverse cervical chain of nodes

*The supraclavicular group of nodes (also known as the lower deep cervical group), especially on the left, are also sometimes referred to as the signal or sentinel lymph nodes of Virchow or Troisier, especially when sufficiently enlarged and palpable. These nodes (or a single node) are so termed because they may be the first recognized presumptive evidence of malignant disease in the viscera.

Parotid gland

Platysma muscle

Facial (external maxillary) artery and anterior facial vein

Ramus marginalis mandibularis of facial nerve

Mandible

Hyoid bone

Fascia over strap muscles

Anterior jugular vein

Platysma muscle

Transverse cervical nerves

Sternocleidomastoid muscle

Supraclavicular nerves

Operative field exposed

FIGURE 1.1 Patient positioning and anatomy in neck dissection.

Posterior facial vein

Common facial vein

Great auricular nerve

External jugular vein

Accessory nerve

Trapezius muscle

Platysma muscle