A new device for the identification of lymph nodes removed during different types of neck dissection

doi:10.4236/health.2010.29161

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Vol.2, No.9, 1093-1096 (2010) Health

doi:10.4236/health.2010.29161

A new device for the identification of lymph nodes

removed during different types of neck dissection

Imre Gerlinger1*, Tamás Ferenc Molnár2, Tamás Járai1, Péter Móricz1, Gábor Ráth1,

Gyula Göbel1

1Department of Otorhinolaryngology & Head and Neck Surgery, Medical School, University of Pécs, Pécs, Hungary;

*Corresponding Author: i.gerlinger@freemail.hu

2Department of Otorhinolaryngology & Surgery, Medical School, University of Pécs, Pécs, Hungary

Received 9 January 2010; revised 21 January 2010; accepted 1 February 2010.

ABSTRACT

Meticulous mapping of the lymph node status is

a general principle in present-day head and

neck surgery. The removal of a certain number

of lymphatic levels during neck dissection may

well be therapeutic in intent, but it is also

mandatory for correct tumour staging. We pre-

sent a precise lymph node mapping during dif-

ferent types of neck dissection in the course of

major head and neck surgery by a sterile plastic

tray moulded in the shape of the neck. This de-

vice makes lymph node mapping simpler, safer,

quicker and methodically more structured than

any of the present methods. It facilitates the

work of the pathologist and the flow of reliable

information along the surgeon－pathologist-

oncologist chain. With this device, a more stru-

ctured, methodical means of lymph node re-

moval has become possible.

Keywords: Head and Neck Surgery; Lymph Node

Mapping; Neck Dissection

1. INTRODUCTION

In 1906, George Crile published a report on what is now

considered the first surgical procedure for the en bloc

resection of cervical nodes [1]. Until the 1950s, his

radical neck dissection technique underwent only modest

technical improvements and there was little clarification

of the indications for the procedure. During the 1960s,

the ideas of Suarez and Ballantyne led to advances in the

technique of conservative neck dissection [2]. For the

first time the non-lymphatic structures (the spinal acces-

sory nerve, the internal jugular vein and the sternoclei-

domastoid muscle) were preserved, and only the lymph

nodes between the aponeurotic compartments of the neck

were removed [3]. Today, a variety of different types of

neck dissection are available that are considered on- co-

logically, functionally and cosmetically effective in the

therapeutic or prophylactic treatment of the neck in pa-

tients with head and neck cancers. These less radical

surgical procedures are often performed bilaterally, and

may be followed by postoperative radiotherapy with a

very similar recurrence ratio as observed after radi-

cal/modified radical neck dissections [4,5].

Meticulous mapping of the lymph node status is a

general principle in present-day head and neck surgery.

The removal of a certain number of lymphatic levels

during neck dissection may well be therapeutic in intent,

but it is also mandatory for correct tumour staging [6].

Te decisions concerning the prognosis, postoperative

adjuvant therapy at the individual level and the audit at

the departmental level are impossible without proper

TNM staging [7].

As in other manual specialities, the identification,

handling, collecting and appropriate labelling of the in-

dividual lymph nodes according to their origin during

different types of neck dissection is a time-consuming

procedure all participants concerned. This seemingly

minor problem is customarily solved by the usage of

labelled individual vials or small bottles.

The routine of individual ENT surgeons practising

neck dissections is determined by a long list of factors,

but it is clear that lymph node mapping is not ideally

standardized and integrated into the daily routine [6].

Deficiencies and substandard attitudes towards the im-

portance of the mapping can not be dealt with here, but it

is perfectly obvious that after a neck dissection, careful

attention and an extra workload are needed on the part of

all the theatre staff. Their number, quality and level of

enthusiasm are frequently underestimated potential sour-

ces of the misplacing and mishandling of specimens.

Over noisy verbal instructions given in the course of

I. Gerlinger et al. / HEALTH 2 (2010) 1093-1096

1094

sampling with reference to the designation of the indi-

vidual specimen in question can also be distractive. Even

the necessary communication between the surgeon/scrub

nurse and the circulating staff during identification is

another possible source of misunderstanding. The rou-

tine of the postoperative filling of the pathological re-

quest forms by the junior staff and their re-checking of

the designation of the vials are likewise not the strongest

elements in the information chain. In spite of being a

seemingly unrelated area of trouble-shooting, the inter-

departmental transfer can be another source of problems.

Lymph node mapping is time and energy consuming

activity in every phase starting with removal of one or

more lymphatic levels from their anatomical surround-

ings until the specimens land on the microscope plate of

the pathologist. We have modified a tool invented and

originally introduced for mediastinal lymphnode map-

ping during lung cancer surgery and applied it for the

systematic collection of different types of neck dissect-

tion specimen [6].

2. MATERIAL AND METHOD

A plastic tray shaped in accordance with the outline of

the anatomy of the neck with the designated lymph node

position represents the anatomical field of the origin of

the individual specimens. The small built-in containers it

holds, also made of plastic, contain a fluid (water, alco-

hol or formaline) and are fitted with airtight rubber caps

(Figure 1). The invidual lymph node stations are de-

noted in accordance with the standard [6]. The whole

complex can be handled by the surgeon, the assistant or

the scrub nurse at the time of the surgical removal of the

lymphatic levels as it is sterile. Sterilization is achieved

with formaldehid steam, no disturbing interference with

any other intraoperative activity.

The method was evaluated by personal interviews

with the personnel concerned (4 ENT surgeons, 6 theatre

nurses, 6 theatre assistants and 2 pathologists) during a

2-months test period. Application of the tool was appro-

Figure 1. The original plastic tray containing built-in vials

closed by rubber caps. The device measured 34 cm in diameter

and can easily be handled by the assistant or the scrub nurse.

ved in advance by the Ethical Committee of Pécs Uni-

versity, Medical School.

3. RESULTS

The prototype of the tool was applied between Decem-

ber 1st 2006 and Janury 31st 2007 in 14 consecutive cases,

without any adverse event. The type of neck dissections

was as follows: radical neck dissections: 2 cases, modi-

fied radical neck dissections: 2 cases and selective neck

dissections: 10 cases. The theatre staff did not consider

the extra workload caused by the usage of the tool to be

excessive. Their most important observation related to

the ease of following the Health and Safety Regulations

as their exposure to biohazard was obviously reduced.

The positive comments from the pathologists empha-

sized the simplicity and reliability of processing the

lymph nodes.

4. DISCUSSION

In 1991, the Committee for Head and Neck Surgery and

Oncology created by the American Academy of Oto-

laryngology Head and Neck Surgery, in conjunction with

the Education Committee of the American Society for

Head and Neck Surgery [8], developed a classification

system based on the following concepts: 1) radical neck

dissection is the fundamental procedure with which all

neck dissections has to be compared; 2) modified radical

neck dissection denotes the preservation of one or more

non-lymphatic structures; 3) selective neck dissection

denotes the sparing of one or more lymph node levels;

and 4) extended neck dissection denotes the removal of

more lymphatic and/or non-lymphatic structures. The

terminology for the current classification of neck dissec-

tions is detailed in Table 1 [9].

For the categorization of neck dissections, we must

first adopt a common nomenclature for the lymph node

groups of the neck. The classification recently proposed

by Som et al. [10] is simple and clear. It includes seven

levels and proposes precise imaging-based anatomical

landmarks for use in classifying metastatic cervical ade-

nopathy. The lymph node groups that correspond to the

neck levels and subgroups are outlined in Table 2. This

classification defines in a more precise manner the ana-

tomical zones or levels of the neck previously classified

by Shah et al. [11] and by Robbins et al. [8]. We took

this classification into account while planning our device

in order to simplify neck node identification during neck

dissections.

Meticulous mapping of the lymph node status of the

neck demands the systematic use of neck dissection

classification. Our preliminary experience indicates that

I. Gerlinger et al. / HEALTH 2 (2010) 1093-1096

1095

Table 1. Terminology of the current classifiation of neck dis-

sections.

Type of neck

dissection

Lymph node levels

removed

Structures

preserved

Comprehensive

Radical I, II, III, IV, V None

Modified radical

Type 1 I, II, III, IV, V SAN

Type 2 I, II, III, IV, V SAN, IJV,

Type 3 I, II, III, IV, V SAN, IJV, SCM

Selective

Suprahyoid I, II SAN, IJV, SCM

Supraomohyoid I, II, III SAN, IJV, SCM

I, II, III, IV SAN, IJV, SCM

Extended suprao-

mohyoid I, II, III, IV, V SAN, IJV, SCM

Posterolateral suboccipital and

retroauricular nodes

Lateral II, III, IV SAN, IJV, SCM

Anterior VI SAN, IJV, SCM

Anterolateral II, III,IV,VI SAN, IJV, SCM

I, II, III, IV, V None

Extended neck

dissection

and one or more

additional lymph node

groups (such as the

paratracheal nodes or

anterior compartment

lymph nodes)

and structures that

are not routinely

removed by radi-

cal neck dissec-

tion (such as the

carotid artery, the

hypoglossal nerve,

the vagus nerve)

are removed

SAN: spinal acessory nerve; IJV: internal jugular vein; SCM: sterno-

cleidomastoid muscle

the new device has already demonstrated obvious ad-

vantages in five different areas: 1) it reduces operating

theatre movement as there is no need for the separate

step of passing the individual lymph nodes to the circu-

lating staff for further handling; 2) unnecessary verbal

communication is avoided as the identification of indi-

vidual lymph node levels is self-explanatory; 3) the

quality of the lymph nodes reaching the pathologist is

improved as tissue trauma during grasping and transfer

is minimized; 4) the risk of exposure of the handling

staff to dangerous materials (specimens and formalin) is

lower than on the use of individual vials/small bottles;

and 5) from an educational point of view, it is important

that the device as it makes the cancer surgeon and train-

ees more aware of lymph node staging. With this device,

Table 2. Lymph node groups corresponding to levels I-VII and

the various subzones.

Level Lymph node group

Ia Submental nodes

Ib Submandibular nodes

IIa Upper jugular, anterior to n. IX

IIb Upper jugular, posterior to n. IX (submuscular recess)

III Middle jugular nodes

IVa Lower jugular nodes (behind sternal head of

sternocleidomastoid muscle

IVb Lower jugular nodes (behind clavicular head of

sternocleidomastoid muscle)

Va Posterior triangle nodes (spinal accessory group)

Vb Posterior triangle group (transverse cervical artery

group, supraclavicular group)

VI Anterior (central) compartment lymph nodes

(paratracheal, perithyroideal, Delphian)

VII Superior mediastinal nodes

a more structured, methodical means of lymph node re-

moval has become possible, and the importance of lymph

node mapping gets the emphasis it deserves.

5. CONCLUSIONS

The reported device makes lymph node collection and

identification simpler, safer and quicker. Industrial pro-

duction is planned, with the whole complex made as one

integrated plastic tray. The removable vials will be re-

placed by designated capped bays.

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