Vol.2, No.9, 1093-1096 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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.
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 surgeonpathologist-
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
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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].
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.
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.
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
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 1. Terminology of the current classifiation of neck dis-
Type of neck
Lymph node levels
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
Suprahyoid I, II SAN, IJV, SCM
Supraomohyoid I, II, III SAN, IJV, SCM
Extended suprao-
mohyoid I, II, III, IV, V SAN, IJV, SCM
Posterolateral suboccipital and
retroauricular nodes
Anterior VI SAN, IJV, SCM
Anterolateral II, III,IV,VI SAN, IJV, SCM
I, II, III, IV, V None
Extended neck
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.
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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