Case Competition 2023 Case 8 Removal of an axillary lymphnode
Authors: Roskilde
A 65-year-old male with a palpable lump in his right axilla. Admitted from the department of hematology to perform a lymphadenectomy diagnose for lymphoma. The patient had lost 6 kilos of weight through the last 3 months and his health was beginning to deteriorate.
Before and after
Patient examination
A palpable enlarged, hard lymphnode was found in the patients right axilla, measuring 3x3x3 cm. Alle other lymphnode stations including the neck, contralateral axilla, the groin were without signs of enlarged nodes.
Pre-Operative Considerations
When removing a lymphnode in the axilla, one has to consider that the scar tissue may develop into a contracture. Therefore a lazy-s incision should be performed from the pectoral muscle, going diagonal just below the hair area, and advance near the latisimus dorsi muscle. In case there is to be performed a later radical lymphnode dissection, one should remove the incision in 1-2mm margins and use the same lasy-s incision (often elongating the incision to reach all of the lymphnodes). Another important aspect is to send the tissue just in saline solution (NaCl solution), as the pathologist need to assess for lymphoma using microscopy. The lymph node may not be sent in formalin (formaldehyde), as this solution damage the tissue for assessment.
Step 1: Pre-operative drawing
The pectoral muscle is marked anteriorly. The latissimus muscle is marked posteriorly. The palpable lymphnode is marked centrally A lazy-S incision is drawn reaching the near-center of the
Step 2: Incision
Incision through skin and subdermal tissue
Step 3: Using retractors
When reaching the axillary fat, self-holding retractors may be helpfull to view of the axillary content.
Step 4: Hemostasis using bipolar diathermia
Small bleeding vessels are closed using bipolar diathermia. The lymphnode is dissected very close to the capsule using the bipolar diathermia, thereby ensuring no harm to nerves or larger vessels.
Step 5: Dissecting using metzenbaum scissors
The Lymphnode is removed using a combination of metzenbaum scissors and bipolar diathermia. Keep the dissection close to the capsule of the lymphnode. Use retractors to obtain a better view. Use forceps to handle the lymphnode, holding in the capsule, without damaging it.
Step 6: Lymphnode removed
The lymphnode is succesfully removed. The capsule is intact, this ensures no lymphoma cells or cancer cells left behind in the operative field.
Step 7: Assessment of lymphnode
The lymphnode measures 4x3x3 cm in size. The capsule is intact. Some minor fatty tissue is left in the capsule.
Step 8: Hemostasis
Gently and thoroughly hemostasis is always important
Step 9: Incision closed
The wound is closed using self-degradable inverted sutures in the axillary fascia and dermis. I often use vicryl 4-0 The skin is closed used running self-degradable sutures with burrowed stiches.
Post-Operative Plan
The patient had the skin further closed/secured using micropore plaster. Compression was applied to the axilla using gauze and mefix plaster. The patient was discharged later the same day. No active sports to be performed for 2 weeks.
- Always perform lazy-s incisions when removing lymphnodes in the axilla or groin
- Be aware of the dangerzones with nerves (thoracodorsal nerve and thoracicus longus nerve) and bloodvessels.
