OT notes · General Surgery

Excision biopsy of cervical lymph node

Usual anaesthesia
Local infiltration (general for children, deep nodes or uncooperative patients)
Position
Supine, pillow or folded sheet under shoulders, head on a head ring turned to the opposite side
Setting
elective

Operative note template for excision biopsy of a cervical lymph node, with a filled example for a level III node under local anaesthesia after an inconclusive FNAC.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding and haematoma
  • wound infection or a discharging sinus
  • injury to the spinal accessory nerve (shoulder weakness) for posterior triangle nodes
  • injury to the cervical or marginal mandibular branch of the facial nerve (lip weakness)
  • injury to the internal jugular vein
  • chyle leak from thoracic duct injury on the left low neck
  • biopsy may not give a diagnosis and may need repeating
  • only part of a matted mass may be removed

Pre-operative details for this operation

  1. Node selectedside, neck level (I to VI), size in cm, consistency, matting
  2. FNAC resultdate and report; reason excision is still needed (inconclusive, suspected lymphoma)
  3. Head and neck examination for a primaryoral cavity, oropharynx, larynx and nasopharynx examined; findings
  4. Other investigationschest X-ray, HIV status (offered), USG neck, CBC
  5. Anti-tubercular treatment already started?NoYes (date)
  6. Node marked on skin before anaesthesiaYes

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationLocal with sedationGeneraldrug, strength, volume; if GA, reason
  2. PositionSupine, shoulder roll, head ring, face turned to opposite side

Operative findings

  1. Node removednumber, size in cm, capsule intact or not
  2. Cut surface / appearanceFleshyCaseousMatted with surrounding tissuePus
  3. Other nodes / mattingextent of matted mass; complete or partial removal
  4. Structures seen and protectedinternal jugular vein, spinal accessory nerve, facial nerve branches, thoracic duct

Procedure (steps)

  1. Skin preparation, draping and local infiltration
  2. Skin incisionTransverse in skin crease over the nodelength; for upper anterior nodes, 1 to 1.5 inches below the mandible
  3. Platysma / subcutaneous tissue divided
  4. Deep fascia opened, sternomastoid retractedNot neededDone
  5. Node held for tractionFigure-of-eight 2-0 silk traction sutureBabcock forcepsavoid crushing the node
  6. Node dissected all around, hilar vessels clamped and ligatedsuture used
  7. Matted massNot presentAccessible part removed, one whole node shelled out
  8. HaemostasisCauterySuture ligature

Closure, drains and dressing

  1. DrainNoneDrain for large cavity
  2. Deep fascia / subcutaneous tissueabsorbable suture and size
  3. SkinInterrupted non-absorbableSubcuticular absorbablematerial and size
  4. Dressing

Specimens and implants

  1. Node for histopathologyhow sent (fresh to lab / formalin), label with side and level
  2. Node tissue for Xpert MTB/RIF and AFB microscopy and cultureSentNot requiredsent fresh without formalin
  3. Pus / caseous materialNot presentSent for AFB and culture

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Wound watchswelling or bleeding; inform surgeon
  2. Dietnormal diet when comfortable (after LA, straight away)
  3. Analgesiadrug, dose, frequency
  4. Nerve checkshoulder shrug and lower lip symmetry; record
  5. Dischargesame day or next day
  6. Suture removalday
  7. Follow-up for reportsHPE, Xpert, culture; date of review

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Ms. A.N., 28 years, 6 weeks of a 2.5 cm firm, mobile node at right level III with evening fever; FNAC showed reactive changes only, chest X-ray normal.

Case details

Date: 20/06/2026. Elective, day care. Minor OT.

In OT 11:00. Local infiltration 11:10. Skin incision 11:15. Closure completed 11:50.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., informed and available.

Anaesthetist: none (local anaesthesia by surgeon); anaesthesia team not involved. Scrub nurse: Sr E.

Indication and pre-op

Indication: persistent right level III lymphadenopathy with non-diagnostic FNAC. Tuberculosis and lymphoma to be excluded.

Oral cavity, oropharynx and indirect laryngoscopy normal. HIV non-reactive. Hb 11.2 g/dl. ATT not started.

Consent: procedure-specific consent under LA taken in Hindi. Possibility of non-diagnostic biopsy and nerve injury explained.

Node marked with skin marker. WHO checklist sign in and time out done. No antibiotic prophylaxis (clean procedure).

Anaesthesia and position

Supine, pillow under shoulders, head on head ring turned to left.

Parts painted with povidone-iodine and draped. 5 ml of 2% lignocaine infiltrated around the node.

Procedure

3 cm transverse incision in a skin crease over the node. Platysma divided. Investing fascia opened and anterior border of sternomastoid retracted backwards.

Findings: single 2.5 x 2 cm firm node lying on the internal jugular vein, not matted. Two smaller nodes below it, left alone.

Figure-of-eight traction suture of silk 2-0 placed in the node. Node dissected all around, kept off the internal jugular vein. Hilar vessels clamped and ligated with polyglactin 910 (Vicryl) 3-0.

Node removed intact with capsule. Cut surface shows a small yellowish caseous area.

Haemostasis with cautery.

Closure

No drain. Investing fascia and platysma closed with Vicryl 3-0. Skin closed with interrupted polyamide (Ethilon) 4-0. Dry dressing.

Specimens

Node cut in two by Dr A. on a sterile tray. One half in formalin for HPE. Other half in a sterile container without formalin, sent fresh for Xpert MTB/RIF, AFB microscopy and culture. Both labelled 'right level III node'.

End of procedure

Estimated blood loss 10 ml.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No complications. Shoulder shrug normal and lower lip symmetrical at end.

Patient walked to day-care ward. Pulse 78/min, BP 116/74 mmHg.

Post-op orders

Normal diet.

Tab paracetamol 1 g 6-hourly for 2 days.

Discharge the same evening if wound dry.

Suture removal at the review visit if the wound has healed.

Review with HPE, Xpert and culture reports on day 7. Do not start ATT until reports are seen.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 20/06/2026, 12:00.

Must document for this operation

  • Side and neck level of the node removed, with its size. If the report is non-diagnostic or cancer, the next surgeon must know exactly which node was taken.
  • Whether the node came out whole with its capsule. The pathologist needs an intact node to classify lymphoma, and a partial biopsy explains a non-diagnostic report.
  • How the specimen was divided and where each part was sent. Tissue in formalin cannot be cultured, so the note shows whether TB tests were possible.
  • Head and neck examination done for a primary cancer before the biopsy. Open biopsy of a metastatic node contaminates the field for a later neck dissection, so the note must show a primary was looked for.
  • Nerves at risk seen and their function at the end. Accessory nerve injury after a neck node biopsy is a known cause of complaint, and the note is the first record of nerve status.
  • Whether anti-tubercular treatment had started before the biopsy. Culture is less likely to grow once ATT has started, which affects how the result is read.

Common mistakes in these notes

  • Writing 'lymph node excised' with no side, level or size.
  • Putting the whole node in formalin when TB is suspected.
  • No record of the FNAC (fine needle aspiration cytology) result that justified the open biopsy.
  • Not recording shoulder shrug after a posterior triangle node biopsy.
  • Leaving out that only part of a matted mass was removed.

Indian practice and paperwork

  • INDEX-TB guidelines advise excision biopsy of a lymph node when FNAC is inconclusive or malignancy is suspected, with tissue sent for Xpert MTB/RIF, microscopy and culture for Mtb with drug susceptibility testing, and histopathology. Specimens should be taken before ATT is started. (INDEX-TB Guidelines on extra-pulmonary tuberculosis for India (ICMR / Central TB Division, 2016), section 12.2, p. 55)
  • Bio-Medical Waste Management Rules 2016 put excised human tissue in Yellow category (a) human anatomical waste, and discarded formalin is chemical waste. Record where each part of the specimen went. (DGHS/CPCB Guidelines for Management of Healthcare Waste as per BMW Rules 2016)
  • NABH requires informed consent in a language the patient understands, taken by the person doing the procedure. (NABH Hospital Accreditation Standards 5th ed. (April 2020), PRE.4(c) and PRE.4(e))

Sources

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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