A structured data header for neck dissection documentation: a feasibility proposal for surgical reporting

Abstract

Every neck dissection tells a story. The surgeon's operative note captures that story in prose-which structures were preserved, which were sacrificed, and why. For decades, this narrative tradition has served clinicians well. These operative notes are useful not just for the surgeons or patients but also are used for audit, research, coding and digital analysis. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification and terminology of the Modified Radical Neck Dissection (MRND) is widely accepted worldwide primarily because it contains all the relevant information which will aid in the communication and rehabilitation of the patient. However, it also has a drawback in which effective communication cannot be achieved without detailed wordings and we also had this practical discussion in the operating theatre while teaching the post graduate residents.