Harmonic scalpel is particularly useful when a VA-CCD is carried out because it can easily coagulate and cut all the lymphatic vessels, reducing the operating time and the risk of lymphatic leaks.

For what concerns the patient position and the composition of the surgical staff we refer to the chapter describing MIVAT.

For VA-CCD general anaesthesia with orotracheal intubation is required.

VA-CCD is accomplished, during MIVAT, through the same skin access, a small (1.5–2 cm) skin incision performed in the midline, usually just below (1 cm) the cricoid cartilage. Such a cranial position of the skin incision, that is of utmost importance to perform MIVAT because it permits a good exposure and a safe control of the superior vessels peduncle, does not represent an obstacle to approach the lymph nodes located in the upper mediastinum. In fact an optimal preparation of the upper and lower subcutaneous flaps, consents to open the cervical linea alba as far as possible and permits the small skin access to move on the deepest planes, under the skilled use of the retractors, letting the endoscopic instruments and the camera easily reach both the upper six level lymph nodes and the lower ones. In such a way it is possible to perform a complete VI level neck dissection removing all the lymph nodes and the fatty tissue from the bone hyoid superiorly, the innominate artery inferiorly, the pre-vertebral fascia dorsally, and between carotid arteries laterally [25].

The dissection is carried out by a blunt technique using the same two dedicated instruments called spatulas, previously mentioned for MIVAT. VA-CCD is carried out under endoscopic vision, selectively clipping and cutting, or directly cutting with an ultrasound knife system (Ultracision®), the lymphatic vessels. It is very important to accurately control the tip of the instrument to avoid any injury of the recurrent nerves and trachea. The magnification (two- to threefold) of the endoscope permits a quite easy identification of the nerves and parathyroid glands (Fig. 15.2).

Nonetheless, as highlighted above in our introduction, the endoscope enables the identification of enlarged lymph nodes and consequently not only influences the surgeon’s decision making but, during the procedure, allows a more accurate dissection (Fig. 15.3).

After checking the haemostasis the strap muscles are sutured along the midline as well as the platysma. The skin is closed by means of a not re-absorbable subcuticular running suture or by a skin sealant. Usually no drainage is left inside.