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Standard Axillary Lymphadenectomy

 

STANDARD AXILLARY LYMPHADENECTOMY

In 1997, a standard axillary lymphadenectomy or an axillary dissection is an integral part of the staging protocol of patients diagnosed with invasive breast carcinoma. Recently, a less invasive version of this lymphadenectomy, the axillary sentinel lymphadenectomy, has emerged as a potential replacement for this technique (Refer to section: Sentinel Axillary Lymphadenectomy).

Indications

Any patient diagnosed with invasive breast cancer which requires an accurate staging of the disease..

The Technique

  • Position

The patient is in supine position, the affected arm extended perpendicular to the body. The chest, axilla and arm are prepped and draped.

  • Instruments

A standard major instrument tray is used including Lahey Clamps.

  • Instructions to the anesthesiologist

The anesthesiologist is instructed not to paralyze the patient in order for the surgeon to accurately identify the neural structures of the axilla.

  • STEP 1: Making the Incision

The axillary incision is made in the axilla as shown. It should be 5 cm long in a normal-size patient, longer in obese patients. The axilla is entered at its lowest level.

  • STEP 2: Entering the Axilla and Identifying the Anatomical Landmarks

The first anatomical structure to identify is the lateral border of the pectoralis major muscle. The border of the latissimus dorsi muscle and the axillary vein are identified.

  • STEP 3: Initiating the Axillary Dissection

The axillary vein is dissected meticulously from its lateral to medial aspect. The dissection continued inferiorly. Three neural trunks will be exposed.

1. The Long Thoracic Nerve runs along the chest wall. It innervates the Serratus Anterior muscle. The best access to this nerve is located at the junction of the chest wall and below and posterior to the axillary vein. The lymph node bearing tissue should be retracted medially.

2. The Thoraco-Dorsal Nerve runs parallel to the subscapular vein for two to three centimeters and then, dives posteriorly. It innervates the Latissimus Dorsi muscle.

3. The Intercostal Brachial Nerve is not always identified with accuracy. It is a sensory neural bundle for the inferior aspect of the arm. It is found under the axillary vein and usually runs parallel to it.

  • STEP 4: Completing the Axillary Dissection

Once the previously mentioned neural structures have been identified, the axillary dissection is completed by resecting the tissue below the axillary vein, lateral to the chest wall and the long thoracic nerve, medial to the latissimus dorsi muscle, and between the long thoracic nerve and the thoraco-dorsal nerve.

Hemostasis is obtained with medium hemoclips.

  • STEP 5: Placing the Blake Drain

A Blake Drain (flat) is placed in the wound via a separate stab wound.

  • STEP 6: Closing the Incision

The incision can be closed with a subcuticular 4.0 PDS or Maxon or skin staples.

Technical Notes

1. Number of Resected Lymph Nodes: The average number of axillary lymph nodes resected is between 15 to 25. Some studies have reported that it is approximately between 10 to 25.

2. Persistent Postoperative Drainage: The Blake Drains are left in place on the average of six days. However, some patients have drains in place for as long as 15 to 21 days. An European biological sealant is being introduced to decrease the incidence of postoperative seroma. Its efficacy is not know at this time.

3. Numbness Under (inferior aspect) the Arm: In the majority of cases, most surgeons are trying to spare the intercostal brachial nerve and its branches, but it is frequently severed.

4. Axillary Specimen Handling: The surgeon should always orient the specimen with silk sutures indicating LEVEL I and LEVEL III before sending it to the pathologist.

5. Excessive Postoperative Local Pain: A well performed axillary dissection does not generate significant pain postoperatively. If the patient complains of unusual pain, the following should be checked: 1) Clogged Blake drain with resulting seroma, 2) Seroma, 3) Excessive tension of the skin suture anchoring the drain, 4) Wound infection, 6) Hematoma.


 

1997 - TransMed Network