Axillary clearance

Extent of operation

• Standard ALND removes nodes at levels I and II
• If level II contains gross disease, proceed to level III
• Boundaries:
  • Lateral: thoracodorsal bundle
  • Medial: chest wall
  • Superior: axillary vein
  • Inferior: Angular vein
  • Anterior: anterior axillary fold
  • Posterior: posterior axillary fold

Key structures:

• Intercostobrachial, long thoracic, thoracodorsal nerves
• Axillary vein
• Medial pectoral nerve

Pre-op:

• Some say best to do it without any neuromuscular block, so that motor nerves can be identified and tested if necessary, with a nerve stimulator

Technique:

• Supine with arm out and myself standing between body and arm, IV Abx, prep, drape, VTE prophylaxis (TEDs only)
• Mark out borders of axilla - pec major/minor, latissimus dorsi
• Incision over skin fold from pec major to lat dorsi at bottom of hair-bearing skin - can be extended into lazy S as needed
  • Dissection down, using diathermy, initially with small Langenbach, changing to larger as we get deeper
  • Pass through clavipectoral fascia, until serratus anterior and pectoralis major are identified
• Pectoral dissection (levels I and II)
  • Incise axillary fascia and dissect along the underside of pec major, sweeping fatty tissue down to clear the inferior edge. Aware of neurovascular bundle containing medial pectoral nerve - needs to be pushed medially, and that can be followed up to axillary vein too.
  • Identify pec minor (fibres running cranio-caudally, as opposed to transverse fibres of serratus anterior). Elevate pec minor and continue to dissect under it, until the axillary vein is reached.
  • Ensure to preserve the lateral pectoral nerve, emerging just medial to the origin of the pec minor and travelling on the underside of pec major. If lymphatics are seen they can be ligated, but uncommon to see.
• Axillary vein dissection
  • Located inferior and superficial to artery, inferior to brachial plexus (whitish)
  • Continue dissection on the vein medially (as far as pec minor insertion, on coracoid process) and laterally (until subscapular/thoracodorsal vein is found)
  • All small tributaries entering the antero-inferior aspect of the axillary vein can be clipped or ligated and divided. Any structure that crosses over the vein can be divided. Leave the subscapular vein, entering from posteroinferiorly, alone.
  • If going to divide pec minor, divide near insertion.
  • Another way of finding the axillary vein is to identify the underarm dimple and trace it towards the chest wall
• Level III dissection
  • Always palpate level III and clear it if positive
  • Divide pectoralis minor near its insertion
  • Aim to remove nodes as far as the crossing of the clavicle over the axillary vein
  • If doing level III, also clear the interpectoral nodes (Milan technique)
• Thoracodorsal nerve
  • Entering the posterior aspect of the axillary vein, identify the subscapular vein, a sizeable tributary ~2cm lateral to the chest wall, which is coursing straight down towards subscapularis. The subscapular artery lies about 1cm deep to the lateral thoracic vein, a sizable tributary of the axillary vein. The thoracodorsal vein is a tributary of the subscapular vein.
  • A gentle squeeze of the nerve with DeBakey forceps should result in contraction of latissimus dorsi.
  • The angular vein is a tributary of the thoracodorsal vein, which marks the inferior border of the dissection specimen. This confluence can be found on a transverse plane level with the third intercostal space where it meets the sternum.
  • The angular vein is the inferior limit of dissection - follow the thoracodorsal bundle down to it.
  • Follow the angular vein medially to reach the long thoracic nerve, too.

• Lateral chest wall
  • Look for long thoracic nerve - a palpable structure deep to serratus fascia running down axilla along anterior/mid axillary line to innervate serratus anterior (one source says 8cm posterior to pec minor, at the same horizontal level as the thoracodorsal nerve). Release the axillary packet from the nerve just laterally, to allow the nerve to drop back onto chest wall, and avoid tenting the nerve up too much here.
  • Dissect areolar and lymphatic tissues off intercostal muscles and ribs going from lateral to medial. If pec minor was needed to be divided earlier, now divide the lower end of pec minor, near its origin, when you get to it, leaving the excised muscle attached to specimen.
  • It's quite likely that the intercostobrachial nerve will need to be divided, if it enters the specimen
• Finished dissection:
• Tidying up
  • Meticulous haemostasis
  • Irrigation with water
  • Blakes on a Redivac
  • Close in layers (interrupted 3/0 Vicryl, then 3/0 Monocryl)
  • Pressure dressing

Post-op

• Drain - usually keep until <30mL/day for two consecutive days
• Physiotherapy day 1 - ROM exercises to avoid a 'frozen shoulder'

Complications

• Intra-op bleeding
  • Concern for avulsion of axillary vein trib
  • Usual bleeding things
  • Direct pressure swab on stick
  • Attempt proximal and distal control with vascular clamps
  • Repair defect 4/0 Prolene
• Lymphoedema
  • ALND + RTx 30%
  • ALND 25%
  • SLNB + RTx 11%
  • SLNB 8%
• Reduced shoulder flexion and abduction in the short term, but mostly back to normal by one year
• Arm pain/numbness - 30% get this at 1 year