What are the steps for performing an axillary dissection surgery?

From the Guidelines

Axillary dissection surgery should be performed with a separate breast and axillary incision, using a transverse incision low in the axilla that stops at the posterior border of the pectoralis major muscle, to produce an excellent cosmetic result and good exposure. The steps for performing an axillary dissection surgery involve:

• Positioning the patient supine with the arm abducted to 90 degrees on an arm board
• Making a separate incision in the axilla, typically transverse and low, to avoid unsightly deformities, as recommended by the American College of Radiology, American College of Surgeons, College of American Pathologists, and Society of Surgical Oncology 1
• Identifying and preserving key anatomical structures, including the thoracodorsal and long thoracic nerves, as well as the medial pectoral nerve, to prevent complications such as scapular winging and latissimus dorsi dysfunction
• Removing lymphatic tissue and nodes from levels I and II, and sometimes level III, depending on the clinical indication, with the goal of accurate staging and removal of disease, while minimizing the risk of complications such as edema and nerve injury
• Maintaining hemostasis throughout the procedure using electrocautery and ligatures
• Placing a surgical drain to prevent seroma formation, as closed suction drainage is advisable, according to the standards for diagnosis and management of invasive breast carcinoma 1
• Closing the wound in layers using absorbable sutures for deep tissues and subcuticular closure or staples for skin
• Postoperatively, managing the drain, elevating the arm, and performing early but gentle range of motion exercises to prevent complications such as seroma, infection, lymphedema, and nerve injury, while also promoting recovery and preserving quality of life.

From the Research

Steps for Performing an Axillary Dissection Surgery

The steps for performing an axillary dissection surgery can be outlined as follows:

• Identification of the boundaries, anatomical landmarks, and neurovascular structures that traverse the axilla 2
• Preservation of these structures in their original anatomical planes, avoiding the division of the pectoralis minor muscle 2
• Dissection of levels I, II, and III of the axilla to provide accurate staging and maintain local control 2
• Removal of approximately 10 lymph nodes, as defined by national guidelines, to ensure adequate axillary lymph node dissection 3
• Consideration of the extent of axillary dissection necessary to provide accurate staging and maintain local control, as well as the potential benefits and risks of the procedure 4

Preoperative Evaluation

Preoperative evaluation is an important step in the process of axillary dissection surgery, and may include:

• Ultrasound-guided axillary lymph node biopsy to assess axillary lymph node status and prevent unnecessary completion axillary lymph node dissection 5
• Identification of patients who may benefit from axillary dissection, such as those with clinically node-positive breast cancer 6
• Consideration of the role of neoadjuvant chemotherapy in reducing the need for axillary dissection 6

Intraoperative Techniques

Intraoperative techniques for axillary dissection surgery may include:

• Complete axillary clearance, including levels I, II, and III 2
• Sentinel lymph node biopsy to identify the first lymph node to which cancer cells are likely to spread 6
• Removal of additional lymph nodes if the sentinel lymph node is found to be positive 6

Postoperative Management

Postoperative management of axillary dissection surgery may include:

• Monitoring for complications, such as infection, bleeding, and lymphedema 2
• Adjuvant therapy, such as chemotherapy and radiation, to reduce the risk of recurrence and improve survival 3
• Follow-up care to monitor for signs of recurrence and manage any long-term effects of the surgery 4