Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 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 fluid 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 significant 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.

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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, combination 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 identification 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 difficult 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.

C H A P T E R 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, Somerfield MR, et al: American Society of Clinical Oncology guideline recommendations 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 breastconserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227-1232.

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STEP 3: OPERATIVE STEPS

1.INCISION

A longitudinal incision (Figures 101-2 and 101-3) is made overlying the groin, incorporating 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 superficial femoral vessels; see Figures 101-2 and 101-3). A scalpel is used to incise the skin down to dermis.

C H A P T E R 101 • Superficial Inguinal Node Dissection 1125

Psoas muscle

Genitofemoral nerve

Lateral femoral cutaneous

nerve

Iliacus muscle

Inguinal ligament

Tensor fasciae latae muscle

Femoral sheath

Sartorius muscle

Rectus femoris muscle

Pectineus muscle

Adductor longus muscle

Great saphenous vein

Gracilis muscle

FIGURE 101–3

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2. DISSECTION

Electrocautery is used to dissect down to subcutaneous tissue. Medial and lateral skin flaps are created. Superiorly, the skin flaps should be thinner because nodal-bearing tissue may be more superficial; as the dissection moves inferiorly toward the midthigh, the flap can become thicker. The medial aspect of the dissection extends to the pubic tubercle and extends laterally to include the entire length of the inguinal ligament. The boundaries of the dissection include the medial border of the adductor magnus muscle and the lateral border of the sartorius muscle.

All fatty tissues, which include lymph node–bearing tissue (see Figure 101-1) both above and below the inguinal ligament, down to the external oblique fascia and the inguinal ligament are swept inferiorly. Medially, fatty nodal tissue is reflected away from the spermatic cord or round ligament, and all tissues overlying the femoral vessels, including the femoral sheath, are carefully dissected en bloc into the specimen. Laterally, tissue anterior to the sartorius fascia are swept toward the specimen. Distally, as the saphenous vein dives behind the sartorius muscle at the apex of the femoral triangle, the vein is divided (approximately 4 cm beyond the saphenofemoral junction). The tissue is swept superiorly until the foramen ovalis is encountered. Using a right-angled clamp, the surgeon ligates the saphenous vein at the saphenofemoral junction and secures the vein with a 2-0 silk ligature. Posteriorly, the limits of dissection include tissue anterior to the fascia of the adductor muscles and pectineus.

The origin of the sartorius is identified and divided off the anterior superior iliac spine. The sartorius muscle is mobilized medially and transposed to cover the femoral vessels (Figures 101-4 and 101-5). The lateral femoral cutaneous nerve arises underneath the lateral aspect of the inguinal ligament and extends obliquely over the origin of the sartorius. Care should be taken to identify and preserve this sensory nerve to the lateral thigh. Blood vessels entering the sartorius muscle are preserved as the muscle is mobilized medially to cover the exposed femoral vessels in a tension-free manner. The proximal aspect of the muscle has to be rotated for the coverage to be tension free. The tendinous end of the muscle is sutured to the inguinal ligament with 3-0 absorbable sutures using interrupted vertical mattress stitches. The sartorius muscle will protect the femoral vessels from exposure and subsequent bleeding, in case of skin edge necrosis, wound infection, and tissue breakdown, especially after adjuvant radiotherapy.

3. CLOSING

The wound is irrigated and two closed-suction drains are placed, one exiting medially and one exiting laterally. If the blood supply to the skin edges appears marginal, the edges should be trimmed back to healthy tissue. The incision is closed in two layers. The deeper fascial layer is reapproximated with 2-0 or 3-0 interrupted absorbable sutures, and the skin can be closed using skin staples.

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STEP 4: POSTOPERATIVE CARE

Postoperatively, the patient may ambulate with elastic support on the leg, as tolerated. However, when the patient is at rest, the extremity should be elevated to decrease limb edema. The drains can be removed when the drainage decreases to 30 mL or less per 24 hours.

Lymphedema can occur in more than 50% of patients who have undergone superficial lymph node dissection. Prophylactic measures, such as elevating the leg and wearing elastic stockings, are important means to decrease the severity and incidence of this potential complication.

STEP 5: PEARLS AND PITFALLS

The most common acute postoperative complication is cellulitis and/or wound infection. Although prophylactic preoperative antibiotics are recommended, the infection rates can range up to 30%.

The rate of lymphocele or seroma formation ranges from 3% to 23%. The use of closedsuction drains for a longer period of time can decrease the incidence of fluid formation under the flaps; however, prolonged use has to be balanced with the increased potential for wound infection.

The incidence of extremity lymphedema can be decreased with the use of elastic stockings, limb elevation, and exercise.

The incidence of thromboembolic events, such as deep vein thrombosis and pulmonary embolus, was reported to be 13.6% in a study of patients who underwent inguinal node dissection for melanoma. Prophylaxis with intermittent pneumatic compression devices and low-dose anticoagulants may minimize this complication.

SELECTED REFERENCES

1. Karakousis CP, Heiser MA, Moore RH: Lymphedema after groin dissection. Am J Surg 1983;145:205-208. 2. Arbeit JM, Lowry SF, Line BR, et al: Deep venous thromboembolism in patients undergoing inguinal

lymph node dissection for melanoma. Ann Surg 1981;194:648-655.

3. Johnson TM, Sondak VK, Bichakjian CK, et al: The role of sentinel node biopsy for melanoma: evidence assessment. J Am Acad Dermatol 2006;54:19-27.

4. Health Care Center for the Homeless. Available on the Internet: www.hcch.org