This is a photograph of a patient who is about 10 days post-op following a left modified radical neck dissection for regionally recurrent thyroid cancer. In this case the patient also had recurrence in the left thyroid bed. The previous thyroidectomy incision was incorporated into a longer oblique incision extending toward the left ear.
The patient is brought to the operating room and given a general anesthetic. An incision is made extending from the collar bone near the mid-line toward the lower portion of the ear. An incision this large is required for full exposure of all the regions of the neck. It allows for optimal safety and removal of the lymph nodes in in levels 2- 5. As we have mentioned earlier, formal systematic removal of these lymph-nodes as a single specimen is important to minimize persistent/recurrent disease and gives the best chance of rendering the patient disease free. Simple removal of the malignant lymph node identified during the pre-op evaluation (“berry picking”) is not recommended. Though this can be done through a smaller incision with less risk and quicker recovery, it offers little if any benefit to the patient. The extent of lymph-node involvement in this situation is almost always more extensive than is apparent by clinical evaluation.
Regional disease in the lateral neck is essentially always limited to the lymph-nodes. It is very uncommon for other structures such as muscle or blood vessels or important nerves to be involved with the malignant process. This allows us to perform a “modified “ neck dissection. This modification means we are only removing lymph nodes. Larger muscles, blood vessels and nerves are left in place. This minimizes post-op complications while giving the greatest benefit. On rare occasions when disease invades local structures more aggressive resection maybe required.
The operation proceeds from level 2 inferiorly to level 4, then laterally to level 5. Depending on a variety of factors, the operation last 2 to 4 hours. The wound is closed with plastic surgery techniques including skin glue. There are no bandages, generally patients can shower the next day. The patient is observed overnight (23hr stay) and discharged the next day. We use drains in most patients. The drain may be removed the first post-op day before discharge from the hospital, but most patients go home with it for a few days.
After discharge, patients are encouraged to be up and active as their comfort level allows. The only restrictions are no two-handed lifting, athletics, or exercise. Patients are seen 3-5 days post-op for drain removal then again at about 10 days post-op for a formal evaluation. At that visit we will discuss the pathologic findings from the operation and make plans for further treatment and follow-up. After this visit, patients that work at sedentary jobs are allowed to return to work. Those that have physically demanding jobs, usually return to work in 3-4 weeks.
After recovery, patients are seen by their endocrinologist, RAI is usually recommended and patients are continued on suppressive doses of thyroid medication. We’ll consider risks of surgery and specific post-op issues and the next page.