Cervical Lymph Node Dissection

Unfortunately, in the majority of cases, patients do not experience any warning symptoms. Often, there are no visible neck swellings either. Therefore, clinical examination and, most importantly, ultrasound imaging are essential to identify affected lymph nodes.

Ultrasound is a critical preoperative examination that the surgeon must have. Radiologists usually provide information on whether there are any suspicious or pathologically enlarged lymph nodes.

Suspicious lymph nodes may undergo fine-needle aspiration (FNA) for cytological examination to confirm malignancy. In many cases, however, the ultrasound findings alone are sufficient to proceed directly to surgery without FNA.

For confirmed thyroid cancer cases, optional preoperative lymph node mapping may be performed by specialized radiologists to provide detailed anatomical information.

There are two main types:

• Central lymph node dissection
• Lateral lymph node dissection (unilateral or bilateral)

Cervical lymph node dissection (especially lateral) is among the most complex surgeries in the neck. The specialized surgeon must carefully and precisely remove the lymph nodes, which are literally “entangled” among vital anatomical structures. Therefore, on one hand, a thorough oncologic clearance must be achieved, while on the other hand, important and delicate neck structures must be carefully preserved. These include the parathyroid glands, the recurrent laryngeal nerves, the carotid arteries, the internal jugular veins, the thoracic duct (on the left), the minor thoracic duct (on the right), as well as crucial nerves such as the vagus, phrenic, hypoglossal, accessory nerves, the brachial plexus, and the cervical plexus.

Certainly, a cervical lymph node dissection should ideally be performed by a surgeon specialized in endocrine surgery. On one hand, the primary goal is to achieve a complete and thorough removal of malignant tissue, ensuring the oncologic effectiveness of the procedure. On the other hand, it is essential to minimize the risk of serious complications reported in the literature, such as hematoma, nerve injury, tracheal or esophageal damage, parathyroid injury, pneumothorax, air embolism, chyle leak, surgical site infection, and skin flap necrosis.

For a central cervical lymph node dissection, the procedure is similar to a total thyroidectomy. In the case of a lateral cervical lymph node dissection, which is a more complex surgery, there are some differences. General anesthesia is required and is safe. The duration of the surgery can range from 3 hours to longer, depending on the extent of the disease and the surgical challenges in each patient. The surgical incision is slightly larger to provide the surgeon with proper anatomical access to the suspicious lymph nodes, while also ensuring the best possible cosmetic result. The placement of a drainage tube is more likely than in standard thyroidectomy procedures, but it is usually removed painlessly within 1–2 days. The need for blood transfusion is extremely rare.

After surgery, patients can speak, eat lightly, and begin moving on the same day. Pain is generally minimal and is usually managed with simple analgesics, such as acetaminophen, which most patients do not need to continue at home. Hospitalization typically lasts 1–2 days in the majority of cases.

Cervical lymph node dissection is an oncologic procedure, where the surgeon’s primary goal is the thorough removal of malignant tissue. At the same time, we place great importance on secondary goals, such as achieving the best possible cosmetic outcome and ensuring a fast, painless recovery for our patient. This is achieved by applying principles of minimally invasive surgery without compromising the radicality of the procedure.

Comprehensive preoperative ultrasound mapping of the neck, often with repeated imaging during surgery using portable sonography, provides essential information for a more complete and successful lymph node dissection in cases of malignancy.

Maximum surgical precision and effectiveness are achieved with modern tools such as radiofrequency and ultrasonic devices (Ultracision), instead of traditional scalpels. These technologies allow for a more thorough removal of metastatic lymph nodes, better hemostasis, and reduced postoperative pain. Patient speech is safeguarded through the use of neuromonitoring. This revolutionary and highly useful technique alerts the surgeon to protect the vocal cords, providing a high degree of safety. In lateral lymph node dissections, the anatomical course of not only the laryngeal nerves but also the vagus nerves is revealed, giving the surgeon a more complete view for vocal cord protection.

At our Center, we use either intermittent or continuous neuromonitoring. In continuous monitoring, the nerve signals for the vocal cords are tracked throughout the surgery. Video-laryngoscopy is also employed to verify vocal cord mobility, adding another layer of safety.

During this highly demanding surgery, specialized equipment with precision magnifying lenses (surgical loops)  gives the surgeon a detailed view of the surgical field. Careful dissection, sometimes combined with marking techniques, ensures and protects the adjacent parathyroid glands.

The incision is made with meticulous care, following the natural skin folds of the neck, ensuring the best possible cosmetic outcome. No suture removal is required, as the technique allows for a plastic closure of the wound at the end of the surgery.

This technique has been significantly refined by Dr. Karvounis to minimize the visibility of scars without compromising the thoroughness of the procedure. Special dermatological creams may be recommended to support skin healing, resulting in a fine, barely visible scar or, in some cases, no visible scar at all, depending on skin type and healing.

If the histological examination after surgery confirms the presence of malignant lymph nodes, this does not necessarily indicate a serious concern. The most common type of thyroid cancer, papillary thyroid carcinoma, is generally highly treatable and responds very well to therapy, even when lymph nodes are involved.

The need for additional radioactive iodine (¹³¹I) therapy is assessed in consultation with the treating endocrinologist, based on the histology results and other prognostic factors. In many cases, radioactive iodine is administered in tablet form, without the need for chemotherapy or external radiation, as is required for some other cancers.

This treatment is accompanied by a scintigraphic evaluation and simple precautions, such as avoiding close contact with pregnant women and infants for a few days. In rarer forms, such as medullary thyroid carcinoma, the therapeutic approach is individualized.

The most important step, however, remains the timely and complete surgical removal of the tumor. This is the fundamental basis for successful management of any thyroid malignancy.

The procedure is carefully planned to minimize discomfort for the patient while ensuring the highest standard of medical care. With the support of our experienced medical team, each case is approached individually, with full responsibility and scientific accuracy.

The process begins with an initial surgical evaluation, either in-person at the clinic or through a detailed telephone consultation. In many cases, patients are asked to send medical examinations via email for an initial assessment.

For proper preoperative preparation of a lateral cervical lymph node dissection, the following steps are essential:

• ENT evaluation of vocal cord mobility, ideally performed by a specialized phoniatrist in collaboration with our clinic
• Detailed ultrasound mapping of the cervical lymph nodes by an experienced radiologist
• Timely coordination with the clinic’s administration to schedule the surgery and allocate sufficient operating time, as this is a lengthy and demanding procedure

Proper preparation, a specialized surgical team, and personalized care for each patient are the foundation for a safe and effective surgical approach.

Dr. Evangelos Karvounis, MD, PhD, FACS, is an award-winning endocrine surgeon, Doctor of the Medical School of Athens, and a Fellow of the American College of Surgeons. He currently serves as Director of Endocrine Surgery at Euroclinic Athens. The experienced endocrine surgeon is available to answer any questions regarding cervical lymph node dissection. Contact him today by phone or by completing the contact form to schedule a consultation for proper diagnosis and individualized treatment.