Keywords

Preoperative Preparation

  • The morning of the surgery, radioactive colloid (technetium-99m-tagged sulfur colloid) is injected into the breast in a sterile fashion. The sites of injection are deep to biopsy or tumor site, superficial in dermal site over biopsy site or tumor, or superficial around the nipple-areolar complex.

  • May obtain preoperative lymphoscintigraphy for locating the sentinel lymph node.

  • Once the patient is in the OR suite and after general anesthesia, 5 ml of lymphazurin or methylene blue are injected peri-tumorally (Fig. 7.1). Avoid injecting directly into the tumor site as the tumor may block lymphatic channels.

  • The entire breast is massaged in circular motion for a minimum of 5 minutes to ensure flow through lymphatic channels.

Fig. 7.1
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Injection of methylene blue and/or tracer

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Preference Card

  • Drapes: minor laparotomy sheet, ¾ sheets × 3

  • Sutures: 3-0 Vicryl, 4-0 Monocryl

  • Medications: 1% and 0.5% Marcaine in a 50/50 mixture, lymphazurin blue or methylene blue

  • Equipment: mastectomy set, #15 blade scalpel, electrocautery (set 40/40) and pad, liga clip, minor lap drape, Yankauer suction and suction tubing, 0.25 inch Steri-Strips, surgical glue, surgical bra, Neoprobe and cover, Kerlix

Patient Positioning/Operating Room Setup (See Fig. 5.1)

  • Patient is supine with the arm abducted 90°.

  • All pressure points are padded, pillow under knees.

  • Surgeon stands ipsilateral to dissection site – below arm.

  • Surgical assistant stands ipsilateral to dissection site – above arm.

Nodal Points

Incision

  • The Neoprobe is used to detect area of highest count in the axillary nodal basin (using increasing scales of detection as needed) (Fig. 7.2a, panel 4).

  • Use the probe with varying angles in axilla away from nipple-areolar complex to maximize localization.

  • Once “hottest” site is determined, the site is marked with pen, and a 15 blade scalpel is used to make an incision in transverse fashion (approximately 2 cm incision) (Fig. 7.2a, panel 5).

Fig. 7.2
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(a, b) Lymph node biopsy

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The Extent of the Sentinel Lymph Node Biopsy

  • Dissection continues with sharp or electrocautery down to clavipectoral fascia.

  • The gamma probe is used to re-evaluate location of strongest signal as well was direct visualization of blue lymphatics to detect “hot” nodes (Fig. 7.2a, panel 6).

  • Remove the “hottest” node and record the count (Fig. 7.2b, panel 7).

  • The “10 percent rule” is utilized; remove all sentinel lymph nodes with counts greater than 10% of the most radioactive node.

  • Resect all blue, enlarged, firm, or abnormal lymph nodes (Fig. 7.2b, panel 8).

  • Perform a final scan in axilla with gamma probe (Fig. 7.2b, panel 9).

  • Send all specimens to pathology for permanent evaluation.

Irrigation, Hemostasis, and Closure

  • The cavity is then irrigated and proper hemostasis is obtained with electrocautery cautery and direct pressure.

  • Approximate the deep dermal layer with simple inverted interrupted stitches using 3-0 Vicryl.

  • The dermis is then closed with a 4-0 Monocryl running subcuticular stitch.

  • 0.25 inch Steri-Strips are placed along the length of incision (parallel).

  • Kerlix fluff placed and surgical bra applied to patient.

Pearls and Pitfalls

Common complications include surgical site infection, seroma, and hematoma. Caution must be made with injection of isosulfan blue or methylene blue. The use of isosulfan blue may be associated with severe anaphylactic reaction. Methylene blue injected interdermally may cause skin necrosis and injected intraparenchymally may cause induration and erythema. Pearls include reviewing preoperative imaging.