Lymph Node Dissection

 

 

 

What Is Lymph Node Dissection?

A Lymph Node Dissection is a systematic approach to removing entire groups of Lymph Nodes from the neck.

 

 

 

 

 

A neck dissection can be performed as an;

• ELECTIVE PROCEDURE - This is the removal of the lymph nodes without any evidence that there is obvious cancer in the neck. An elective neck dissection will be considered if there is a high risk that there is microscopic (hidden or not clinically apparent) cancer in the lymph nodes (more than 20%).
• THERAPEUTIC NECK DISSECTION- This is the removal of lymph nodes in the neck with known cancerous lymph nodes in the region based on a biopsy or a high level of suspicion based on their appearance on imaging studies.

The extent of the neck dissection will depend on a number of factors. Perhaps most important is the site of the primary cancer.

There is a pattern to which level certain cancers spread when they enter the lymphatic system. For example, cancers of the oral cavity are known to spread to Levels I, II and III; therefore, an elective neck dissection for a cancer of the oral cavity should include these lymph node groups on the side of the primary cancer. The different lymph node groups of the neck are described below and the general patterns include:

• Level I, II, III: oral cavity
• Level II, III, IV: oropharynx, hypopharynx, larynx
• Level V: scalp, facial skin
• Level VI: thyroid, larynx
• Level VII: thyroid

Surgeons use different terms to describe neck dissections:

• RADICAL NECK DISSECTION: This refers to the removal of lymph node groups I to V, as well as the sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. This used to be the standard neck dissection years ago but has been replaced with neck dissections that spare some or all of these structures.
• MODIFIED RADICAL NECK DISSECTION: This is the removal of lymph node groups I to V, while sparing one or more of the three structures taken in the radical neck dissection (sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve). In old nomenclature, depending on what structure was removed, surgeons would call them Type I, Type II or Type III modified radical neck dissections. These days, they should be described as a modified radical neck dissection with sacrifice of the internal jugular vein and sternocleidomastoid muscle (this implies that the spinal accessory nerve was preserved). A modified radical neck dissection that preserves all three structures is also called a COMPREHENSIVE NECK DISSECTION, indicative of the removal of lymph nodes from Levels 1 though 5. 
• SELECTIVE NECK DISSECTION: This is the removal of a select group of lymph nodes in the neck, with or without sacrifice of additional non-lymphatic structures. Most neck dissections in current times are really selective neck dissections. Some common selective neck dissections are given names such as the following:
• SUPRAOMOHYOID NECK DISSECTION: This is the removal of lymph node Groups I, II and III.
• LATERAL NECK DISSECTION: This is the removal of lymph node Groups II, III and IV.
• POSTEROLATERAL NECK DISSECTION: This is the removal of lymph node Groups II, III, IV and V.

If a major neck structure is removed as part of a selective neck dissection, it should be indicated. For example, a lateral neck dissection with sacrifice of the internal jugular vein is still a selective neck dissection.

• CENTRAL COMPARTMENT LYMPH NODE DISSECTION: The central compartment (Level VI) is not included in the typical “neck dissection.” Level VI is systematically removed in cases of thyroid cancer and larynx cancer.
• SALVAGE NECK DISSECTION: This is a neck dissection in a previously treated neck, whether previously treated by radiation, chemotherapy or surgery. This is performed for a persistent tumor in the neck lymph nodes despite treatment. A salvage neck dissection is typically more difficult than a primary neck dissection because of previous treatment scarring and effects. Also, it usually indicates that the cancer cells are more aggressive and resistant to treatment than they typically are.
• REMOVAL OF SKIN, CAROTID ARTERY: In some cases of very advanced tumors, your surgeon might require removing skin as part of the neck dissection. Even more rarely, the common CAROTID ARTERY (or internal carotid artery) might be involved by tumor. This is the artery that supplies blood to your brain. If the carotid artery is almost completely surrounded by tumor, this is usually considered unresectable as there are major risks to attempted removal of the tumor with a low chance of getting it all out. If your cancer team does anticipate partial or total resection of the common carotid artery as a reasonable option for your treatment plan, and you understand the risks, you will likely have some pre-operative tests to see if the opposite carotid artery is strong enough to supply oxygen to both sides of the brain. Then, in most cases, a vascular surgeon will be available to help with the resection and subsequent reconstruction of the carotid artery if that is deemed necessary.

 

PREPARATION FOR SURGERY

Before traveling to Cyprus, as part of your surgery preparation you will complete a detailed specific questionnaire, which will allow our doctors to determine your eligibility for Minimally Invasive Lymph Node Surgery.

Ten days prior to your arrival in Cyprus, you will receive all the necessary pre operative instructions, to prepare yourself both physically and mentally for your chosen procedure.

Before your departure your records will be reviewed thoroughly by our surgeon. This includes X-rays and a complete medical and surgical history as well as your specific issues. In addition, you may be asked to consult with a physical therapist to discuss recovery, hip rehabilitation and important precautions you must take postoperatively. The physical therapist may even give you exercises you can begin prior to your surgery in order to aid with recovery.

After traveling to Cyprus, a new set of X-rays will be taken as well as an in person physical examination. Two of the tests you may have are a CT scan and an Ultrasound.

The surgeon and anesthetist will also go through you medical and surgical issues with you. During this visit, your surgeon will discuss your procedure and answer any questions.

Preparation for the hospital

Here are a few things to keep in mind as you pack and prepare for the hospital and recuperation:

Clothing
Getting dressed in the morning helps you feel better, so be sure to bring some comfortable clothing to the hospital:

• Loose shorts or pants
• Loose tops or T-shirts
• Underwear and socks
• Short robe or pajamas
• Toiletries

Morning of surgery

Bring all your medicines in their original containers with you to the hospital. You will meet with the anesthesiologist. This doctor will talk to you about general anesthesia. This is a controlled sleep while the surgery is being done so you will not feel any pain or remember the surgery. You will have an IV or intravenous line put in to give you fluid and medicine during your surgery. When it is time for you to go to surgery, your family will be asked to wait in the waiting area. Your doctor will talk to your family there after your surgery is done.

 

RECOVERY AFTER SURGERY

When you wake up after your surgery, you will be in the recovery room. You will stay there until you are awake and your pain is under control. Most patients return to their room after a few hours, but some will need to stay overnight for observation.

You will receive oxygen through a thin tube called a nasal cannula that rests below your nose. A nurse will be monitoring your body temperature, pulse, blood pressure, and oxygen levels.

You will have an analgesia pump device to deliver pain medication into your IV or epidural space (in your spine). You will also have compression boots on your lower legs to help your circulation. They will be taken off when you are able to walk.

You will most likely be tired and a bit sore for a few days. You may have pain not only from your incision, but also from muscle soreness in your upper back and shoulders. This is from the positioning in the operating room during the surgery. You will have liquid pain medicine in the hospital and a prescription for pain pills at home.

You may have a sore throat. This is a result of the placement of anesthesia tubes during surgery. Throat lozenges and spray usually help. 

Your neck may be slightly swollen as well. You may feel like you have a lump in your throat when you swallow. This will improve after a few days but may continue for a week or so. 

Hospital discharge and home instructions

The recovery course will depend on the extent of additional surgery and the reconstruction performed along with the neck dissection. Some surgery might require staying in the hospital for one to two weeks.

With a neck dissection alone, you should be ready to go home after two to three days—and that’s only to allow the drain output to decrease.

Before leaving the hospital, our surgeon and staff will help you adjust to recovery in every way possible. You will receive specific instructions and precautions from your surgeon and nursing staff and they will show you safe techniques of simple activities like getting in and out of bed, bathing, going to the bathroom etc.

You will be able to leave the hospital when you are:

• Able to eat a regular diet and drink fluids
• Passing gas or you have had a bowel movement
• Passing urine
• Not having a fever or other signs of infection
• Walk for short distances

 

LIFE AFTER SURGERY

These guidelines give you an overview of what you may expect as part of your care after you leave the hospital. Be sure to follow your surgeon’s discharge instructions if they are different from what is listed here:

• Most people take 1 to 2 weeks off to recover. 
• You may resume most of your normal activities the day after surgery. However, wait for at least 10 days (or until your surgeon gives you permission) to engage in strenuous activities such as high-impact exercise.
• You should not drive for at least a week.
• There are no other restrictions. 

If you notice sudden swelling in your neck contact our surgeon immediately. Your calcium level may drop after surgery. This is related to disturbance of the parathyroid gland, which regulate calcium balance. This will be monitored through blood tests. You may notice numbness and tingling of your fingers or around your mouth. You will have instructions about taking calcium replacement if needed.

Medications

Your medicines: Take the medicines you were taking before surgery, unless your surgeon has made a change.

• For pain

Your surgeon will order a prescription pain medicine for you after surgery. As your pain lessens, over the counter pain medicines such as acetaminophen or ibuprofen can be used. They can also be used instead of your prescription for mild pain.

• For constipation

Prescription pain medicines can cause constipation. Your doctor may order a stool softener to prevent this. You should be back to your normal bowel routine in about 2 weeks. If the stool softener does not work, take Milk of Magnesia. If you still are not getting relief, call your surgeon.

 

FOLLOW-UP

Follow-up after surgery is extremely important and our surgeons at Salus are committed to providing all the post surgical care you need.