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