Lymph Node

Lymph Node Dissection

Definition

Lymph node dissection (lymphadenectomy) is the surgical removal of lymph nodes in order to assess the spread of cancer.

Purpose

The lymph system is the body's primary defense against infection. It consists of the spleen, tonsils, thymus, lymph nodes, lymph vessels, and the clear, slightly yellow fluid called lymph. These components produce and transport cells and proteins that help rid the body of infection.

The lymph vessels are similar to veins, only instead of carrying blood as veins do, they circulate lymph to tissues in the body. There are about 600 small, bean-shaped collections of tissue found along the lymph vessels. These are called lymph nodes. They produce cells and proteins that fight infection. They also clean and filter foreign cells, such as bacteria or cancer cells, out of the lymph.

Cancer cells can break off from the original tumor and metastasize (spread) through the lymph system to distant parts of the body, where secondary tumors are formed. The purpose of a lymph node dissection is to remove the lymph nodes that have trapped cancer cells so that the extent of spread can be determined. Lymph node dissection is done for many different types of cancers, including cancers of the head and neck, breast, prostate, testes, bladder, colon, and lung.

About 200 lymph nodes are in the head and neck and another 30 to 50 are in the armpit. More are located in the groin area. Lymph nodes are sometimes called lymph glands, although they are not true glands. When someone talks about having swollen glands, they are referring to swollen lymph nodes.

Normally lymph nodes are no larger than 0.5 in (1.3 cm) in diameter and are difficult to feel. However, when lymph nodes trap bacteria or cancer cells, they can increase in size to greater than 2.5 in (6 cm). Most often, hot and painful swollen nodes are caused by trapped bacteria. Swollen lymph nodes caused by cancer are usually painless.

Precautions

As with any surgery, women who are pregnant should inform their doctors before a lymph node dissection.

Description

Lymph node dissection is usually done by a surgeon in a hospital setting, under general anesthesia. An incision is made and tissue is pulled back to reveal the lymph nodes. The surgeon is guided in what to remove by the location of the original cancer. Sample lymph nodes may be sent to the laboratory for examination. If the excised nodes do contain malignant cells, this would indicate that the cancer has spread beyond the original site, and recommendations can then be made regarding further therapy.

Preparation

Tests may be done before the operation to determine the location of the cancer and which nodes should be removed. These tests may include lymph node biopsies, CT (computed tomography) scans, and MRI scans. In addition, standard pre-operative blood and liver function tests are performed. The patient will meet with an anesthesiologist before the operation, and should notify the anesthesiologist about all drug allergies and all medication (prescription, non-prescription, or herbal) that he or she is taking.

You should have nothing to eat after midnight, but you may have clear liquids up until 4 hours prior to the surgery.

Aftercare

How long a person stays in the hospital after lymph node dissection depends on how many lymph nodes were removed, their location, and whether surgery to remove the primary tumor or other structures was performed at the same time. Drains are sometimes inserted under the skin to remove the fluid that accumulates after the lymph nodes have been removed, and patients are usually able to return home with the drains still in place. Some patients are able to leave the same day or the day following the procedure.

An accumulation of lymph fluid that causes swelling, a condition known as lymphedema, is a side effect of lymph node dissection. If swelling occurs, patients should notify their doctor. Treatment for lymphedema in people with cancer is different than treatment of lymphedema that arises from other causes. In cancer patients, it is essential to alleviate swelling without spreading cancer cells to other parts of the body, therefore an oncologist (cancer specialist) should be consulted before beginning any treatment.

Risks

People who have lymph nodes removed are at increased risk of developing lymphedema, which can occur in any part of the body where lymph accumulates in abnormal quantities. When the amount of fluid exceeds the capacity of the lymph system to move it through the body, it leaks into the tissues and causes them to swell. Removing lymph nodes and lymph vessels through lymph node dissection increases the likelihood that the capacity of the lymph transport system will be exceeded.

Lymphedema can occur days or weeks after lymph node dissection. Radiation therapy also increases the chance of developing lymphedema, so those people who have radiation therapy following lymph node dissection are at greatest risk of experiencing this side effect. Lymphedema slows healing, causes skin and tissue damage, and when left untreated can result in the development of hard or fibrous tissue. People with lymphedema are also at risk for repeated infection, because pools of lymph in the tissues provide a perfect spot for bacteria to grow. In severe cases, untreated lymphedema can develop into a rare form of cancer called lymphangiosarcoma.

Other risks associated with lymph node dissection are the same as for all major surgery: potential bleeding, infection, and allergic reaction to anesthesia.

Pathology Results

Results of testing the lymph nodes are usually available within 5-7 business days of the procedure. This is not within our control. We will discuss your results with you at your postop visit.

After Your Surgery:

Activity:

We encourage resuming walking and light activity immediately, as soon as you are sure you are not going to have issues with dizziness or lightheadedness. You may resume driving when it is comfortable to walk up and down stairs. Don’t plan on any strenuous activities, like sports or going to the gym, until your postop appointment. Your surgeon may have specific instructions to add to this; usually these are outlined to you before surgery. The bottom line: if it hurts, don’t do it!

Driving should not be attempted until you are off pain medications and able to go up and down stairs comfortably. You should be able to slam on the brakes to avoid an accident without causing any pain.

Eating:

The basic rule is take in what your body is telling you. Unless you have been given a specific diet plan, you may eat what you wish, even the day of surgery. Beware of nausea or queasiness the day of surgery, though. Some find it easier to digest bland foods, light foods, or predominantly liquids that evening. As you feel better, however, you can eat whatever seems good to you. Make sure you stay hydrated, and avoid excessive caffeine. Also, no alcohol if you are taking prescription pain medications.

Elimination:

Constipation is very common after surgery. We recommend staying well hydrated, and using Miralax, prune juice, or Milk of Magnesia for a few days until things are back to normal. If you are at all prone to constipation, or if you need several days of pain medicine, it may help to add Benefiber, Metamucil or similar bulk fiber agents for a few days as well. Do not let more than 48 hours go by without a bowel movement without starting the above medications. If they fail to help within another 24 hours, call our office.

Diarrhea is common if you are taking antibiotics. If you have this problem, we would suggest either probiotics while you are on the antibiotics, or eating yogurt with active cultures. If diarrhea occurs more than 4-6 times daily for more than 48 hours, call us.

You should be able to urinate within 6-8 hours of leaving the facility. If you are unable to do so, call our office. Make sure your doctor is aware of any chronic difficulties with urination (like prostate trouble) before surgery.

Wound care:

Usually surgical wounds will have either glue or steri-strips (butterfly tapes) on them, often covered with gauze. Glue, steri-strips, or waterproof plastic dressings can all get wet the day after surgery (unless your surgeon advises differently). Wounds with visible staples or sutures can get wet in the shower after 48 hours. Do not submerge your wound (tub bathing or swimming) for one week. While soap will not harm the wound, do not scrub it. Do not apply peroxide or other chemicals unless you have been told to do so by your doctor. After 48 hours, change or remove gauze dressings or Band-aids. Do not leave soiled or wet dressings on the wound beyond 48 hours. Most wounds can then remain uncovered, unless you have been told otherwise. Light gauze covering to prevent chafing is acceptable if you wish. You may notice a slight drainage (usually pink or reddish in color) from the incision site. This is normal and not a cause for concern. Light pinkness immediately surrounding the incision, and not spreading over time, is normal. Bruising is common and may extend for up to an inch. Spreading redness, progressive swelling with bruising, and malodorous drainage are not normal and should prompt a call to our office.

Drains:

If you are sent home with surgical drains, you will likely be given instructions at the time of discharge for care of them, and a log sheet to record the output. It is important to note the daily output of the drain(s) so we will know when to remove them. Drains that empty into a suction bulb or attached bag can get wet in the shower. If there is gapping of the skin around the drain, Neosporin or similar ointment may be used to protect the area while you shower. Do not submerge the drain site underwater, such as tub bathing or swimming. Slight pinkish or yellowish drainage from around the tube is normal while it is in place, as is a small amount of redness at the site. Gauze over the site may help protect your clothing from staining. Foul smelling or copious drainage around the drain, or spreading redness around the drain, is not normal and should prompt a call to our office. If the drain reservoir fails to hold suction when you squeeze it, or if the drainage suddenly drops to near zero, call our office .

Normal care of drains includes emptying the fluid in the reservoir every 8 hours and recording the amount per 24 hour period. Bring this record to your postoperative appointment. The fluid may need to be emptied more frequently if the drainage is heavy. Fluid will often be red at first, then pink, then yellow as the wound heals. Stringy material in the tubing or reservoir is normal.

Medication:

Prescription pain medications are there to help you recover comfortably, but stop them as soon as you are able. Side effects of nausea, vomiting, dizziness, fatigue, poor appetite, and above all constipation, are common. If you have these issues, try to use ibuprofen and Tylenol instead (see below). Do not use alcohol or drive if you are taking prescription pain medications.

Unless you are told differently by your surgeon or primary doctor, you can take 400 mg ibuprofen every 4-6 hours, or 800 mg every 8 hours, for the first 3-5 days after surgery, for a maximum dose of about 2400 mg/day (refer to the label for specific dosing based on age and weight). It is best if you can take some food with this medication.

Tylenol is also acceptable to help with the baseline pain after surgery. It can be taken in conjunction with ibuprofen, and with your prescription (unless your prescription already contains acetaminophen--which is Tylenol). Be very careful not to exceed the dosage on the bottle. Taking more than 3 grams/day is not advisable.

Blood thinners should only be restarted after surgery according to the plan discussed with you by your surgeon or prescribing doctor before surgery. If this was not made clear to you, call our office.

All other medications should be resumed once you get home. Vitamins and supplements are not necessary to help you heal, unless you have a known deficiency. You may resume them after you get home if you wish. We would suggest sleep aids not be used while you are on narcotic pain medications.

Difficulties:

Please call us if any problems or questions arise. We can be reached any time, including evenings and weekends, by calling our office number (703) 359-8640.

When to Call Your Doctor:

  • Fever over 101°F or chills
  • Increasing pain, redness, or drainage at an incision site
  • Vomiting or nausea that lasts more than 12 hours
  • Prolonged diarrhea
  • Chest pain or shortness of breath
  • Inability to urinate within 8 hours of discharge