An operative lymph-node biopsy remains a useful procedure despite the increasing diagnostic accuracy of fine-needle aspiration cytology. Open biopsy allows examination of the whole node, including its structural organization, thereby reducing the incidence of false-negative results. It also provides adequate material for histological, immunocytochemical, and bacteriological examination.

The usual indication for open biopsy is a patient presenting with one or more enlarged glands. These are most commonly located superficially in the neck, axillae, and groins, and hence often appear suitable for excision under local anaesthesia through a small incision. However, procedure it is precisely this approach, especially in the neck, which may result in the complications associated with this procedure. The temptation is to place the procedure at the end of the list to be done by an inexperienced surgeon or even to perform the procedure at the bedside without adequate lighting or diathermy. Nodes in both the posterior and anterior triangles of the neck are always more deeply placed than is suggested by clinical examination.

The surgeon should personally see the patient on the ward preoperatively, in order to select the most appropriate node for biopsy and to determine the best position for the limbs or neck. The patient must be positioned by the surgeon before he scrubs to ensure the best exposure and lighting of the operative site. Lignocaine with adrenaline can be advantageously infiltrated at this stage, to allow a few minutes for the adrenaline to reduce skin edge bleeding. The incision should be generous and carefully placed along Langer's lines.

While removal of an intact node is preferable it is not mandatory. Problems frequently arise when access is difficult and the node is large, fixed to adjacent structures, or is one of several matted together. Under these circumstances the surgeon risks damaging significant blood vessels or nerves if an attempt is made to remove the gland intact. Instead an incision biopsy should be performed. This invariably yields adequate material, provided the biopsy is taken from the more centrally placed nodes within the mass. When the central nodes are affected by lymphoma, the more peripheral nodes may show only reactive hyperplasia. The wound can usually be closed with a subcuticular absorbable suture.

The tissue should be sent fresh for histological examination, not fixed in formalin: some immunochemical procedures yield better results on fresh frozen sections. If indicated, a portion of the specimen should be sent for bacteriological examination.