Axillary lymph node dissection is indicated for the management of clinically positive nodes secondary to breast cancer or melanoma. It is also the current standard of care after a positive axillary sentinel node for melanoma and selected cases of breast cancer. Axillary node dissection is also considered for breast cancers when the sentinel lymph node cannot be identified.
The skin of the axilla should be inspected for signs of infection. The skin is shaved, preferably with electric clippers. Most surgeons administer a perioperative dose of parenteral antibiotics.
General anesthesia is administered via endotracheal tube. If muscle depolarizing agents are used for induction, they should be short acting to allow recovery of the motor nerves for evaluation during the procedure.
The patient is placed with the operative side close to the edge of the table. The arm is abducted and placed upon a support at a right angle to the body. Some surgeons wrap the arm in sterile drapes so that the arm is freely mobile to facilitate exposure (figure 1).
Incisions may vary slightly depending on the disease process being addressed. For melanoma, transverse incisions are preferred to allow easier access to the level III axillary nodes (figure 1). For breast cancer, curvilinear incisions in a skin fold inferior to the hair-bearing area are generally preferred. If a previous sentinel node biopsy incision exists, this should be excised.
The incision is extended through the subcutaneous tissues and clavipectoral fascia to expose the pectoralis major muscle medially and the latissimus dorsi muscle laterally. The medial border of the pectoralis major muscle is cleared to allow medial retraction of the muscle (figure 2). The interpectoral, or Rotter’s nodes, are swept laterally and included with the specimen. The pectoralis minor muscle is then exposed and the lateral edge cleared to facilitate medial retraction and exposure of the deeper nodes. The medial pectoral bundle is identified and traced back to identify the axillary vein. The inferior border of the vein is cleared between the chest wall and latissimus dorsi muscle (figure 3). The axillary vein is the superior extent of dissection for breast cancer, but for melanoma, some authors suggest continuing the dissection superior to identify the coracobrachialis muscle and carefully dissecting the fibrofatty tissue overlying the brachial plexus down to be included with the specimen, taking care to maintain the fascial covering overlying the brachial plexus.
As the dissection of the vein proceeds, the thoracodorsal bundle is identified (figure 4). Usually, there is a vein superficial to the thoracodorsal vein that will require division and ligation. The thoracodorsal bundle, including the ...