几种常用的的手术范围

（一）颏下三角清扫术

颏下三角是指位于两侧二腹肌前腹与舌骨体之间的三角形间隙，间隙的底是下颌舌骨肌，该清扫术主要清除这一间隙内的淋巴、脂肪组织。

（二）颌下三角清扫术

颌下三角位于一侧二腹肌的前后腹与下颌骨水平支下缘组成的三角形间隙，底部是舌骨舌肌及下颌舌骨肌。该清扫术主要清除该间隙内的颌下腺及其周围的淋巴、脂肪组织，主要适用于一些颌下腺肿瘤。手术切口选择在下颌骨下缘2 cm处，平行于下颌骨下缘处，长约6～8 cm切口。术中注意保护面神经下颌缘支、舌神经和舌下神经。

（三）舌骨上清扫术

即Ⅰ区清扫术，包括颏下和颌下三角清扫，清扫范围为颌下、颏下区域的淋巴结缔组织、颌下腺体等，主要适用于该部位局部肿瘤的治疗，如颌下腺癌的治疗。手术过程同颏下＋颌下三角清扫术。

（四）肩胛舌骨上淋巴结清扫术

包括Ⅰ～Ⅲ区，清扫范围包括颈深上、颌下、颏下的淋巴结缔组织，其清扫上界为二腹肌后腹，下界为肩胛舌骨肌与颈内静脉交叉点，后界为颈丛神经皮支和胸锁乳突肌后缘。切口一般可设计为舌骨水平或甲状软骨水平，与颈部皮纹一致的弧形切口。分离皮瓣时注意避免损伤耳大神经、面神经下颌缘支。暴露下界为肩胛舌骨肌与颈内静脉交叉水平。于胸锁乳突肌内侧中上1/3部位找到副神经上段，注意保护胸锁乳突肌支和斜方肌支，解剖副神经至二腹肌水平。切除副神经后上方的Ⅱb区淋巴脂肪组织，向下清扫Ⅱa和Ⅲ区时应注意保护颈丛神经分支。

（五）颈前淋巴结清扫术

即Ⅵ区清扫术，也称中央区或前间隙淋巴结清扫术，主要清除颈前正中，自舌骨至胸骨切迹间的气管及环状软骨前、气管旁及甲状腺周围的淋巴结及其结缔组织。根据原发肿瘤确定手术切口，于气管食管沟找到喉返神经，保留其颈部全长，以便清扫过程中保护神经。断扎甲状腺下动、静脉，将所有位于气管食管沟和颈总动脉之间以及气管前的淋巴脂肪组织清除。

（六）颈侧区淋巴结清扫术

在根治性颈淋巴结清扫术（第四章）和改良性颈清扫术（第五章）中已有详细介绍，这里不再赘述。

（黄彩平　官青）

参考文献

[1] Robbins KT, Medina JE, Wolfe GT, et al.Standardizing neck dissection terminology.Official report of the academy committee for head and neck surgery and oncology[J]. Arch Otolaryngol Head Neck Surg, 1991, 117: 601–605.

[2] Clayman GL, Frank DK. Selective neck dissection of anatomically appropriate levels is as efficacious as modified radical neck dissection for elective treatment of the clinically negative neck in patients with squamous cell carcinoma of the upper respiratory and digestive tracts[J]. Arch Otolaryngol Head Neck Surg,1998, 124: 348–352.

[3] Marks JE, Breaux S, Smith PG, et al. The need for elective irradiation of occult lymphatic metastases from cancers of the larynx and pyriform sinus[J].Head Neck Surg, 1985, 8: 3–8.

[4] Pillsbury HC 3rd, Clark M. A rationale for therapy of the N0 neck[J]. Laryngoscope, 1997, 107: 1294–1315.

[5] Fletcher GH. Elective irradiation of subclinical disease in cancers of the head and neck[J]. Cancer, 1972, 29:1450–1454.

[6] Yuen AP, Wei WI, Wong SH. Critical appraisal of watchful waiting policy in the management of No neck of advanced laryngeal carcinoma[J]. Arch Otolaryngol Head Neck Surg, 11996, 122:742–745.

[7] Shah JP, Candela FC, Poddar AK. The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity[J]. Cancer, 1990, 66:109–113.

[8] Shan JP, Kraus D, Dubner S, et al. Patterns of regional lymph node metastasis from cutaneous melanoma of the head and neck[J]. Am J Surg, 1991, 162:320–323.

[9] Schmitz S, Machiels JP, Weynand B, et al. Results of selective neck dissection in the primary management of head and neck squamous cell carcinoma[J].European Archives of Oto-Rhino-Laryngology, 2009,266: 437–443.

[10] Coskun HH, Erisen L, Basut O. Selective neck dissection for clinically N0 neck in laryngeal cancer: Is dissection of level Ⅱb necessary?[J] Otolaryngology-Head and Neck Surg, 2004, 131: 655–659.

[11] Lim YC, Lee JS, Koo BS, et al. LevelⅡb lymph node metastasis in laryngeal squamous cell carcinoma[J].Laryngoscope, 2006, 116: 268–272 .

[12] Shepard PM, Olson J, Harari PM, et al. Therapeutic selective neck dissection outcomes[J]. Otolaryngology-Head and Neck Surg, 2010, 142: 741–746.

[13] Chepeha DB, Hoff PT, Taylor RJ, et al. Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck[J].Laryngoscope, 2002, 112: 434–438.

[14] Muzaffar K .Therapeutic selective neck dissection: A 25–year review[J]. Laryngoscope, 2003, 113: 1460–1465.