Modified Radical Neck Dissection (MRND) — Surgical Steps

• Spinal accessory nerve (SAN)
• Internal jugular vein (IJV)
• Sternocleidomastoid muscle (SCM)

Step-by-Step Technique

Step 1 — Incision and Skin Flap Elevation

• A suitable cervical incision is made (modified apron, MacFee, or Schobinger incision).
• Subplatysmal skin flaps are raised superiorly and inferiorly to expose the operative field.
• The mandibular branch of the facial nerve is identified and protected at its crossing over the lower border of the mandible.

Step 2 — Identification and Mobilization of the Spinal Accessory Nerve (SAN)

• The SAN is first identified in the posterior triangle near the Erb point (junction of upper and middle thirds of SCM, where cutaneous branches of the cervical plexus emerge).
• The nerve lies superficially within the fibrofatty contents of the posterior triangle; careful spreading of tissue (± nerve stimulator) reveals it.
• The nerve is isolated and dissected from Erb's point medially → to its entry into the anterior border of the trapezius laterally.

Step 3 — Dissection Along the Anterior Border of the SCM

• The anterior border of the SCM is incised from its mastoid attachment superiorly to its sternal/clavicular attachments inferiorly.
• The SCM is retracted laterally, and fibrofatty soft tissue anterior to the muscle is dissected away, dividing small arcades of vessels between the muscle and the specimen.
• In the upper portion, the SAN is identified entering the deep surface of the SCM, then traced superiorly until the posterior belly of the digastric is seen.
• The posterior belly of the digastric is retracted superiorly to expose the superior end of the IJV near the jugular foramen.
• The posterior border of the SCM is freed from underlying fibrofatty tissue from mastoid attachment to clavicular attachment.
• The SAN is now completely mobilized — from the anterior border of the trapezius to the skull base — except for its intramuscular course through the SCM.

Step 4 — Dissection of the Posterior Triangle (Level V)

• The fibrofatty tissue of the posterior triangle is separated from the entire anterior border of the trapezius muscle.
• Contents are mobilized in a lateral to medial direction.
• Tissue superficial to the SAN as it crosses the posterior triangle is divided immediately above the nerve; the divided tissue passes with its deep component beneath the nerve and the elevated SCM.

Step 5 — Sweeping the Specimen Medially / IJV Dissection

• After fibrofatty contents are dissected and swept over the carotid artery, vagus nerve, and IJV, the SCM can be retracted laterally.
• The specimen is dissected off the IJV (preserved), staying on the fascial investment of the vein.
• The contents of all five levels are now mobilized en bloc.

Step 6 — Dissection of Level I (Submandibular/Submental Triangle)

• The anterior belly of the contralateral digastric is the medial limit.
• The submandibular gland (SG) is dissected; the lingual nerve, submandibular duct (isolated, divided, ligated), and hypoglossal nerve are identified and protected.
• The submandibular ganglion is divided, allowing the lingual nerve to retract superiorly.
• The proximal facial artery (coursing deep to the SG) is ligated as the final attachment.
• All contents within the muscular boundaries of the submandibular triangle are excised — not just the gland.

Step 7 — En Bloc Removal of the Specimen

• The specimen, encompassing all five lymph node levels, is removed en bloc with the SAN, IJV, and SCM preserved (Fig. 118.7F in Cummings).
• If any non-lymphatic structure is directly invaded by tumor intraoperatively, it may be sacrificed — the operation remains a "modified" RND as long as at least one of the three structures is preserved.

Step 8 — Wound Closure

• Drains (closed suction) are placed through separate stab incisions in the most dependent areas of the dead space.
• Wound is closed in two layers: platysma anteriorly + subcutaneous tissue laterally (first layer), then skin (second layer).

Important Anatomical Landmarks

Types of MRND (by structures preserved)

Key Indication

Repair of Perforated Peptic Ulcer — Surgical Steps

Pre-operative Essentials

• IV fluid resuscitation + broad-spectrum antibiotics (cover enteric gram-negatives, anaerobes, mouth flora)
• NG tube decompression
• Urgent surgery — delay from perforation to operation directly increases mortality (up to 30% in some series)
• Selective antifungal coverage in frail/immunosuppressed patients

Surgical Steps (Open / Laparoscopic)

Step 1 — Access / Incision

• Open: Upper midline (epigastric) laparotomy — rapid, reliable access to the gastroduodenal region
• Laparoscopic: 3–4 port technique; preferred in hemodynamically stable patients if surgeon is experienced — associated with less postoperative pain and fewer wound infections with equivalent leak rates and mortality

Step 2 — Identification and Assessment of the Perforation

• The perforation is usually located on the anterior surface of the first part of the duodenum (most common site)
• Assess:
  • Size of perforation (<1 cm, 1–2 cm, or >2 cm)
  • Tissue quality at the edges — friable vs. healthy
  • Duration of peritonitis (fresh vs. >24 hours)
  • Any suspicion of malignancy (gastric ulcers must be biopsied)
• Inspect the rest of the abdomen for a second "kissing" posterior bleeding ulcer

Step 3 — Peritoneal Lavage

• 5–10 litres of warm saline lavage throughout the peritoneal cavity
• Peritoneal fluid sent for culture and sensitivity (including fungal)
• Thorough irrigation of all quadrants, paracolic gutters, and sub-diaphragmatic spaces to reduce contamination load

Step 4 — Repair of the Perforation (Graham/Roscoe Patch Closure — Standard Technique)

Graham's Original Method (Omental Plug/Patch)

1. Do NOT attempt primary closure of a friable-edged small duodenal perforation — sutures pull through and can enlarge the hole
2. Select a well-vascularized, tension-free pedicle of omentum
3. Place 2–3 interrupted seromuscular Lembert sutures through healthy duodenum on either side of the perforation (bridging sutures) — sutures are left untied
4. Lay the omental patch over/into the perforation
5. Tie the sutures gently but snugly over the omental patch to secure it — this creates better apposition between duodenum and omentum than using "tails" of a primary closure suture
6. Additional sutures may be placed circumferentially between healthy duodenum and omental patch if needed

Modified Graham Patch (preferred by many)

1. Close the perforation first with interrupted sutures (primary closure of the defect if edges are healthy and come together without tension)
2. Place omentum over the now-closed perforation
3. Secure the omentum by tying the same suture knots a second time over the omentum

Leak Test

• Submerge the repair site under irrigation fluid
• Inject air ± methylene blue via the NG tube
• Confirm no bubbles/leak before proceeding

Step 5 — Drain Placement

• Place at least one closed-suction drain (e.g., Jackson-Pratt) adjacent to the repair site
• Leakage at the repair site is not uncommon — the drain allows controlled management

Step 6 — Abdominal Closure

• Standard layered closure of the abdominal wall
• NG tube left in situ postoperatively

Special Situations

Large Perforations (>2 cm)

• Healthy omentum or jejunal serosa (Roux-en-Y limb) to close the defect
• Pyloric exclusion (oversew pylorus with absorbable suture OR non-cutting linear stapler) + gastrojejunostomy (Billroth II or Roux-en-Y) to bypass the duodenum — pyloric exclusion sutures dissolve over weeks, restoring anatomy once healed
• Duodenostomy tube through the perforation with wide peritoneal drainage
• Antrectomy + Billroth II/Roux-en-Y if healthy duodenal stump tissue is available sufficiently away from the ampulla
• Consider feeding jejunostomy for nutritional access

Perforated Gastric Ulcer

• Mandatory biopsy (or resection) — all perforated gastric ulcers must be biopsied to exclude malignancy
• Stable patient: Partial (distal) gastrectomy with Billroth I or II reconstruction — preferred
• Unstable/high-risk patient: Wedge excision and closure, or patch closure with biopsy + truncal vagotomy and drainage

Adding a Definitive Acid-Reduction Procedure

• Highly selective vagotomy (HSV) added to patch closure — considered in chronic symptoms or failed medical therapy
• Truncal vagotomy + drainage (TV+D) — acceptable but carries risk of disabling side effects
• Not performed in hemodynamically unstable patients

Post-operative Management

• Continue IV antibiotics → transition to oral
• NG tube until bowel function returns
• PPI therapy
• H. pylori eradication post-operatively in all positive patients (triple/quadruple therapy)
• NSAID cessation

Summary Algorithm

Perforated Peptic Ulcer
        ↓
Resuscitation + Antibiotics + NG tube
        ↓
Laparoscopy (stable) OR Open (unstable/hostile abdomen)
        ↓
Peritoneal lavage (5–10 L)
        ↓
Assess perforation:
  Size < 2 cm → Graham/modified Graham omental patch
  Size > 2 cm → Pyloric exclusion + GJ / Roux-en-Y patch
  Gastric ulcer → Resect or biopsy + patch
        ↓
Leak test (air/methylene blue)
        ↓
Drain placement + Closure
        ↓
Post-op: PPI + H. pylori eradication + NSAID cessation