Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 100 • Axillary Node Dissection 1115

Axillary vein

Latissimus dorsi muscle

FIGURE 100–4

1116 Section XV • Miscellaneous Procedures

◆ The thoracodorsal artery and vein with the thoracodorsal nerve medially will be identiﬁ ed

in the lateral third of the axillary artery (Figure 100-5). The thoracodorsal trunk courses on

the medial aspect of the latissimus dorsi. Transection of the thoracodorsal nerve leads to

weakened shoulder adduction.

◆ Once the thoracodorsal trunk is identiﬁ ed, lateral dissection is safe as long as the

intercostalbrachial cutaneous nerve is visualized as it emerges from the axillary fat pad

approximately halfway up the latissimus dorsi muscle, coursing toward the arm.

◆ The intercostalbrachial cutaneous nerve may be identiﬁ ed coursing transversely below the

axillary vein and should be preserved if free of matted tumor-laden nodes to prevent

bothersome sensory dysesthesias along the medial aspect of the upper arm.

◆ Dissection medially should be cautious, with attention to the long thoracic nerve, which lies

on the serratus anterior muscle beneath the fascia (see Figure 100-5). Retraction of the

fascia off the chest wall will pull the long thoracic nerve off the chest wall and place it at

risk of injury. The nerve can be identiﬁ ed deep to the intercostalbrachial nerve or higher,

inferior to the axillary vein on the chest wall, where it is less likely to have been pulled

away from the serratus anterior into the axillary fat. The nerve should be protected and

preserved. The function can be conﬁ rmed by very gentle compression and demonstration of

contraction of the serratus muscle in the unparalyzed individual. Injury to the long thoracic

nerve causes a winged scapula.

◆ After the axillary boundaries and important structures are identiﬁ ed, resection of the axil-

lary contents is carried out from superior to inferior, maintaining visualization of the nerves

at risk. As the fatty tissue is swept inferiorly, lymphatics and blood vessels are ligated or

clipped and transected.

◆ The axillary contents are oriented to identify the apex of the axilla.

◆ The axilla devoid of lymphatics and the chest wall are visualized (see Figure 100-5). The

cavity is irrigated with warm saline. Any residual bleeding vessels are cauterized or ligated.

CHAPTER 100 • Axillary Node Dissection 1117

Axillary artery and vein

Latissimus dorsi muscle

Long thoracic nerve

Thoracodorsal artery and vein

FIGURE 100–5

1118 Section XV • Miscellaneous Procedures

3. CLOSING

◆ A closed-suction drain, such as a 10-mm Jackson-Pratt drain, is inserted through a separate

small stab incision inferior laterally and oriented toward the apex of the axilla

(Figure 100-6). The drain is secured with a 2-0 silk suture.

◆ The skin is closed in two layers with absorbable sutures, a deep layer of 3-0 Vicryl and a

subcuticular closure with 4-0 Monocryl (see Figure 100-6). Steri-Strips or Dermabond may

be used for skin approximation. A light dressing or special mastectomy bra is applied with

loose ﬂ uff gauze dressings.

Axillary drainage tube

FIGURE 100–6

CHAPTER 100 • Axillary Node Dissection 1119

STEP 4: POSTOPERATIVE CARE

◆ The drain is emptied 2 to 3 times per day, and drain output is recorded on a log.

◆ Drainage may be sanguinous immediately postoperatively but should be dilute.

◆ Continued postoperative frank bloody output indicates ongoing bleeding and warrants

return to the operating room.

◆ Drainage clears to serosanguinous, then clear and straw-colored.

◆ Cloudy ﬂ uid may indicate bacterial infection and should be cultured.

◆ Drains are removed when the output is less than 30 mL for 2 consecutive days. Drains

usually remain for 7 to 10 days.

◆ Seroma may form after drain removal.

◆ Aspirate it in clinic if it is large, suspicious for infection, or uncomfortable.

◆ Multiple aspirations may be required.

◆ Compression dressing may reduce the likelihood of reaccumulation.

◆ Some seromas are reabsorbed without aspiration if they are small.

◆ Dressings are removed after 48 hours.

◆ Pain out of proportion to the procedure may indicate a signiﬁ cant hematoma, for which

dressings should be removed sooner.

◆ Other indications include fever and excessive drainage.

◆ Taking a shower may be acceptable after 48 hours when dressings are removed.

◆ The surgical site is bathed with mild soap and water, patted dry, and re-dressed around

the drain site.

◆ The incision may be left open according to individual preference.

◆ Tub baths are usually not advised while drains are in place.

◆ Antibiotics are usually not needed but may be considered on an individual basis for the

following:

◆ Previous surgical biopsy

◆ Immunocompromised individuals

◆ Local wound conditions

◆ Limited exercises are initiated on postoperative day 1 and increased to range-of-motion and

strengthening exercises after the drains are removed.

◆ Consultation with American Cancer Society for Reach to Recovery is helpful.

◆ Consultation with occupational therapy for rehabilitation is useful.

◆ Individuals are monitored for lymphedema.

1120 Section XV • Miscellaneous Procedures

◆ Patient education about long-term precautions for protection of the affected extremity

include the following:

◆ Avoidance of blood pressure measurements and phlebotomy sticks on the affected extremity

◆ No intravenous infusion lines

◆ No constrictive clothing

◆ Use of electric razors for shaving

◆ Protective gloves for tasks that may lacerate the skin and lead to infection

◆ Early intervention with antibiotics for a hand or arm infection, often requiring

hospitalization for parenteral antibiotics

◆ Compression sleeve and glove may be indicated for cases of extensive nodal disease, combi-

nation surgery and radiotherapy, and evidence of lymphedema, as well as for prophylaxis

for air travel.

◆ Postoperative radiotherapy or chemotherapy is not initiated for 2 to 3 weeks.

◆ Scarring maybe reduced with application of a silicone sheet such as Biodermis.

STEP 5: PEARLS AND PITFALLS

◆ Discussion with the interdisciplinary team will sequence treatment in the most appropriate

manner.

◆ Preservation of the fascia of the serratus anterior muscle on the chest wall and identiﬁ cation

of the long thoracic nerve underlying it on the chest wall will reduce the risk of transection

and the winged scapula deformity.

◆ Dissection along the lateral aspect of the latissimus dorsi muscle reduces the likelihood of

injury to the thoracodorsal trunk and weakened shoulder adduction.

◆ Preservation of the medial pectoral nerve prevents atrophy of the pectoralis major muscle

and chest wall contour.

◆ Preservation of the intercostal brachial cutaneous nerves maintains sensation to the medial

aspect of the upper extremity and prevents bothersome dysesthesias.

◆ Preservation of fatty tissue and lymphatic channels from the arm around the axillary vein

reduces the risk of lymphedema.

◆ In obese patients, anatomic boundaries may be more difﬁ cult to identify and require time

and patience during the procedure.

◆ The pulse in the axillary artery is a landmark that can help orient the surgeon to stay

inferior.

CHAPTER 100 • Axillary Node Dissection 1121

SELECTED REFERENCES

1. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total

mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.

N Engl J Med 2002;347:1233-1241.

2. Grube BJ, Rose CM, Giuliano AE: Local management of invasive breast cancer: Axilla. In Harris JR,

Lippman ME, Morrow M (eds): Diseases of the Breast. Philadelphia, Lippincott Williams & Wilkins,

2004, pp 745-784.

3. Iglehart JD, Kaelin CM: Diseases of the breast. In Townsend C Jr, Beauchamp R, Evers B, Mattox K (eds):

Sabiston Textbook of Surgery. Philadelphia, Elsevier Saunders, 2004, pp 867-927.

4. Lyman GH, Giuliano AE, Somerﬁ eld MR, et al: American Society of Clinical Oncology guideline recom-

mendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005;23:7703-7720.

5. Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing breast-

conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227-1232.

1122

STEP 1: SURGICAL ANATOMY

◆ The surgical anatomy of the groin is depicted in Figure 101-1.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Accurate nodal staging may be accomplished by applying the techniques of sentinel lymph

node biopsy. The current recommendation for treatment of a histologically positive sentinel

lymph node is completion superﬁ cial inguinal node dissection. This operation is also indi-

cated for bulky groin disease, because this procedure is very effective treatment for local

disease control.

◆ Anesthesia: Either general anesthesia or epidural anesthesia may be used.

◆ Operative preparation: The patient is placed supine and prepared from 3 cm above the

umbilicus and groin, down to the ipsilateral toes and the perineum. The extremity is

prepped in its entirety and is externally rotated at the hip. A stack of sterile towels may be

placed behind the lateral aspect of the knee to facilitate a frog-leg position.

CHAPTER

101

Superﬁ cial Inguinal Node

Dissection

Celia Chao

CHAPTER 101 • Superﬁ cial Inguinal Node Dissection 1123

Great saphenous vein

Inguinal ligament

Anterior superior

iliac spine

Common iliac vessels

Line of incision

Sartorius muscle

FIGURE 101–2

Incision

FIGURE 101–1

1124 Section XV • Miscellaneous Procedures

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A longitudinal incision (Figures 101-2 and 101-3) is made overlying the groin, incorporat-

ing any previous biopsy scars (such as that from a sentinel lymph node biopsy) with an

elliptical incision. Superiorly, the incision starts approximately 3 cm superior medial to the

anterior superior iliac spine, extends past the inguinal ligament, and ends at the femoral

triangle (the point at which the sartorius muscle crosses over the superﬁ cial femoral vessels;

see Figures 101-2 and 101-3). A scalpel is used to incise the skin down to dermis.