The axillary lymph node dissection

Storyboards

Albert Fung, MScBMC Candidate

Segment 1: Introduction

Level III nodes Level II nodes Level I nodes

The axillary lymph nodes are categorized as level I, level II and level III nodes.

Level II nodes Level I nodes

In the axillary lymph node dissection procedure, only level I and II nodes are removed.

Pectoralis minor muscle

These nodes lie lateral and deep to the pectoralis minor muscle...

Axillary fat pad

Pectoralis minor muscle

...and are enveloped within fatty tissue, known as the axillary fat pad. The fat pad will be removed along with the axillary lymph nodes.

Axillary vein Thoracodorsal bundle

Medial pectoral nerves Long thoracic nerve

The fat pad also contains the axillary vein, the thoracodorsal bundle, the long thoracic nerve, and medial pectoral nerves.

These structures must be preserved throughout the procedure.

Segment II: Incision

Underarm dimple

Anterior axillary fold

Axillary hairline

To begin the procedure, locate the anterior axillary fold, the underarm dimple, and the axillary hairline.

Axillary vein

Underarm dimple

The dimple indicates the location of the axillary vein.

Make an incision anterior to the dimple, following the hairline.

Using a electrocautery, dissect the subdermal fat...

Pectoralis major muscle

...to reveal the lateral border of the pectoralis major muscle.

Clavipectoral fascia

Raise the muscle. Posterior to the muscle is the clavipectoral fascia.

Axillary fat Subdermal fat

Cutting open the fascia reveals the axillary fat, which appears smoother and less lobular than subdermal fat.

Segment III: The axillary vein

Axillary vein

The next step is to locate the axillary vein, which lies at the superior border of the surgical field.

Axillary vein
Axillary artery Brachial plexus

Do not dissect regions superior to this vein, as this will risk damage to the axillary artery and brachial plexus.

To locate the vein, dissect the superior border carefully with a hemostat.

Dissect through the clavipectoral fascia...

...and pull the axillary fat in an inferior-lateral direction.

Superficial branches

Superficial branches of the vein may be visible; do not tie off these branches until the thoracodorsal bundle is identified.

Clean off the fat from the vein using rough dissection.

Segment IV: The thoracodorsal bundle

Throacodorsal bundle

Next, identify the thoracodoral bundle.

Throacodorsal nerve

Throacodorsal vein Throacodorsal artery

The bundle consists of the thoracodorsal vein, artery and nerve. The nerve is located medial to the vein and artery.

Latissimus dorsi muscle

The bundle inserts into the latissimus dorsi muscle, about four fingers width from the axillary vein.

To locate the bundle, venture deep into the axillary fat pad.

Identify the vein, artery and nerve to confirm the bundles identity.

Once located, perform rough dissection to clean off the medial side of the bundle.

The goal is to create a tunnel through the axillary fat pad.

Next, raise the fat pad medially.

Dissect the skin off the fat pad; this skin flap should not be too thin.

Latissimus dorsi muscle

Continue dissecting, until revealing the latissimus dorsi muscle.

Tendinous portion

Latissimus dorsi muscle

The tendinous portion of the muscle indicates that the axillary vein is nearby.

Locate the lateral side of the thoracodorsal bundle, and clean off the fat. The bundle is now isolated from the fat pad.

Segment V: The long thoracic nerve

Pointer vessel

The thoracodorsal vein sometimes contains a branch that leads towards the chest wall.

Long thoracic nerve

Pointer vessel

This pointer vessel helps locate the long thoracic nerve...

Long thoracic nerve Serratus anterior muscle

...which lies superficial of the serratus anterior muscle. Note that the thoracodorsal bundle and the long thoracic nerve lie on the same plane.

To locate the nerve, pull the fat pad in a lateral direction, and return to the tunnel opening.

Dissect medial to the thoracodorsal bundle...

...and palpate the chest wall to locate the long thoracic nerve.

The nerve should feel like a guitar string on the chest wall.

Insert a finger to spread the tissue above the nerve. This isolates the nerve without displacing it.

Segment VI: The inferior border

Pull the fat pad superiorly, to inspect the inferior border.

Corner vessels

The border contains numerous corner vessels.

Clip them to prevent bleeding.

Dissect the fat pad off the inferior border once all vessels are secured.

Segment VII: The pectoralis minor and axillary apex

Pectoralis minor muscle

At this point, the fat pad is only connected to the pectoralis minor muscle.

Medial pectoral vessels

Inspect the medial pectoral vessels near the muscle border...

...and clip them to prevent bleeding.

Next, raise the arm to provide better access to the pectoralis minor muscle.

Insert a finger into the tunnel entrance, placing it above the long thoracic nerve. This protects the nerve from the following dissection steps.

Dissect the fat off the lateral border of the pectoralis minor muscle...

...then raise the muscle, revealing the fat underneath. The level II axillary nodes lie within this fat.

Dissect medially...

...until the medial border of the pectoralis minor muscle is revealed.

The fat pad is now separated from the pectoralis minor muscle.

The final step is to proceed to the apex.

Use rough dissection to remove fatty tissue in this area.

The fat pad is excised, and sent to the pathology lab.

Fatty tissue remaining between the thoracodorsal nerve and long thoracic nerve should also be removed.

Segment VIII: Wound closure

To close the wound, irrigate the surgical field...

...and create a stab incision at the inferior border.

Insert a lymphatic drain...

...and suture the subdermal fat.

Use a surgical stapler to close the skin.