Axillary Dissection

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Technical Considerations:
    • General Axillary dissection in melanoma includes:
      • Levels I, II, and III lymph nodes (Figure)
    • The arm, shoulder, and chest:
      • Are prepped and included in the surgical field
    • Incision:
      • I generally use a slightly S-shaped incision:
        • Beginning anteriorly along the superior portion of the lateral edge of the pectoralis major muscle:
          • Traversing the axilla over the fourth rib and extending inferiorly along the anterior border of the latissimus dorsi muscle
      • The incision should be constructed:
        • So that previous scars can be excised en bloc with the specimen
    • Skin Flaps:
      • Skin flaps are raised:
        • Anteriorly to the lateral border of the pectoralis muscle and the midclavicular line
        • Inferiorly to the sixth rib
        • Posteriorly to the anterior border of the latissimus dorsi muscle
        • Superiorly to just below the pectoralis major insertion
      • The medial side of the latissimus dorsi muscle:
        • Is dissected free from the specimen, exposing the thoracodorsal vessels and nerve
      • The lateral edge of the dissection:
        • Then proceeds cephalad to the axillary vein
      • In a lateral to medial fashion:
        • The thoracodorsal neurovascular bundle is skeletonized and preserved:
          • These maneuvers generally allow the next portion of the dissection to proceed from medial to lateral
      • The fatty and lymphatic tissue adjacent to the pectoralis major muscle:
        • Is dissected free around to its undersurface:
          • Where the pectoralis minor muscle is encountered
      • The interpectoral groove is exposed
    • Lymph Node Dissection:
      • The medial pectoral nerve is generally preserved
      • The interpectoral nodes are dissected free and lymphoareolar tissue swept from Rotter’s space
      • At this point, the dissection generally proceeds in a lateral to medial fashion, with lymph node bearing tissue swept medially:
        • The thoracodorsal bundle is again visualized:
          • The long thoracic nerve is identified and preserved
      • The fatty tissue between the two nerves is separated from the subscapularis muscle and included with the specimen
      • The upper axilla is exposed:
        • By bringing the patient’s arm over the chest by adduction and internal rotation
      • If nodes are bulky:
        • The pectoralis minor muscle may be divided to facilitate exposure
      • Dissection of the upper axillary lymph nodes should be sufficiently complete:
        • That the thoracic outlet beneath the clavicle, Halsted’s ligament, and subclavius muscle are seen
      • Fatty and lymphatic tissues are dissected downward over the axillary vein
      • The apex of the dissected specimen may be tagged
      • The specimen is removed from the lateral chest wall
    • Wound Closure:
      • One #15 French closed-suction drain:
        • Is usually placed percutaneously through the inferior flap into the axilla
      • An additional drain may be inserted through the inferior flap depending on body habitus
      • The skin is closed with interrupted 3-0 undyed absorbable sutures and running 4-0 subcuticular absorbable sutures
    • Postoperative Management:
      • Suction drainage is generally continued until output is less than 20mL to 30 mL per day for 2 consecutive days:
        • By approximately 4 weeks, the suction catheters are usually removed, regardless of the amount of drainage, to reduce the likelihood of infection
      • Subsequent fluid collections are removed by needle aspiration, or on occasion by percutaneous drainage
Lymphatic anatomy of the axilla showing the three groups of axillary lymph nodes defined by their relationship to the pectoralis minor muscle. The highest axillary nodes (level III) medial to the pectoralis minor muscle should be included in an axillary lymph node dissection for melanoma.
Access to the upper axilla. The arm is draped so that it can be brought over the chest wall during the operation. This facilitates retraction of the pectoralis muscles upward to reveal the level III axillary lymph nodes. (From Balch CM, Milton GW, Shaw HM, et al., eds. Cutaneous Melanoma. Lippincott; 1985.)
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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