Axillary Lymphadenectomy

The term ‘axilla’ refers to the arm pit or underarm part of the body. Deep to the skin, there are numerous lymph nodes within the fatty tissue of the axilla. A lymph node is a bean-shaped organ that is part of the body’s immune system. There are up to 50 lymph nodes in the axilla. Many kinds of cancers can spread through the body via the lymph nodes.

Axillary dissection is done under general anaesthetic. Following positioning on the operating table, an incision is made in the axilla. The lymph nodes are then removed. A number of key structures are identified and preserved. These include the thoracodorsal nerve which supplies the latissimus dorsi muscle, the long thoracic nerve which supplies serratus anterior muscle and the axillary vein which drains much of the blood from the arm.

It usually takes 60-90 minutes. At the end of the operation a soft silicone drain is placed in the wound bed and brought out through the skin. It is designed to stay in place for 4-6 weeks until the wound drainage diminishes to the point that the body can deal with the fluid itself.

Prior to your operation you may need to attend a Preadmissions Clinic. Your fitness for surgery will be assessed, tests may be ordered and referrals to other specialists arranged if required.

You cannot eat for 6 hours prior to your operation. You may sip water for up to 2 hours prior to your operation. Fasting decreases the risk of vomiting and aspiration during induction of anaesthesia. Aspiration can cause pneumonia and a prolonged stay in hospital.

Axillary dissection is done under general anaesthesia. You will be asleep during the whole procedure. The anaesthetist will discuss the anaesthetic with you prior to your operation. They will see you in the pre-operative area and accompany you to the operating theatre.

Following general anaesthesia, you are positioned on the operating table, the incision site is marked, and local anaesthetic is injected to decrease post-operative discomfort. A skin incision approximately 5cm in length is made at the lower border of the hair-bearing skin. The lymph nodes are then removed completely with preservation of the other important anatomical structures in the area. A silicone drain placed to drain away any excess fluid that may collect in the space left behind.

Following the operation, you will wake up in the recovery area. You will feel a little disoriented and may feel a little nauseous. The staff in recovery are equipped to help you. Immediate post-operative pain is usually minimal. Once you are awake and oriented, you will be taken to a ward bed. After a few hours, and once the nurses are satisfied that it is safe, you can get out of bed.

There are no dietary restrictions or special dietary supplements that are required after axillary lymph node dissection. You may eat whatever you choose. Oral analgesia including paracetamol is usually all that is required for pain relief. Occasionally stronger pain medications are required. You may bathe and shower. The wound is waterproof and can get wet.

You should avoid strenuous physical activity for two weeks after your operation. It increases the risk of post-operative bleeding which could result in a trip back to the operating theatre. Once this period has passed and you feel that you have recovered, you may return to your normal physical activities. It is important to move your arm and shoulder gently in order to preserve mobility.

Post-operative swelling around the wound is normal and usually resolves within a month or so. No specific wound management is needed in the first two weeks while the dressings are on. After this, gentle scar massage is advisable for 10 minutes two or three time a day for 6 months. You may use whatever moisturising lotion you like (e.g. sorbolene, bio-oil etc.) but creams with Vitamin E should be avoided for the first post-operative month. Alternatively, you can keep the scar covered with a silicon strip for 12 hours a day for 6 months. These strips are available from the chemist but are quite costly.

Initially the scar will be pink. Over 6-12 months, the scar will fade until it becomes pale.

Bleeding
This occurs in <5% patients and is usually self-limiting. Occasionally a return to theatre is required for evacuation of blood clot from the wound.

Wound Infection
These can complicate any type of surgery and can usually be treated with a short course of oral antibiotics. Uncommonly, IV antibiotics or further surgery is required.

Seroma
This is a lump that is created by a collection of lymphatic fluid that has leaked out of disrupted lymphatic channels following the axillary lymph node dissection. They usually resolve spontaneously. They should be aspirated if they become uncomfortable. Occasionally they can get infected and then a return to the operating theatre may be required to evacuate the infected fluid.

Numbness or Tingling
This may occur if nerve supplying sensation to the skin are disrupted during the operation. It is usually temporary but is occasionally permanent.

Weakness
Damage to motor nerves in the axilla can occur, particularly if the tumour is stuck to them. Damage to the long thoracic nerve causes winging of the scapula and difficulty protracting the arm. Damage to the thoracodorsal nerve leads to weakness in the trapezius muscle so that abducting and shrugging the shoulder can be difficult. These complications are uncommon but are more likely to occur if the tumour is stuck to the nerves.

Lymphoedema
Lymphoedema is swelling that is caused by accumulation of lymphatic fluid within the tissues. It is a common complication of axillary dissection that arises due to disruption of the lymphatic vessels. The area affected may swell to a variable degree. Mild cases are barely noticeable. Severe cases can severely impair limb function and the overlying skin may become thickened or hard. In addition, the affected area is at risk of infection. The chance of this occurring following an axillary dissection is around 20%.

A follow-up appointment should be arranged in rooms 2 weeks after your operation for a discussion regarding pathology. At this appointment, your wounds will be assessed, and any further investigations and management arranged.

There is no specific law covering surgery and driving. It is not advisable to drive immediately after surgery. In general, in order to return to driving, you must:

1. Have a valid drivers’ licence
   
2. Be able to control your vehicle during an emergency
   
3. Be able to testify in court as to your capacity to drive

Your car insurer may not cover you following an accident if:

1. You have had recent surgery (‘recent’ is not clearly defined)
   
2. You are taking pain or sedative medications that may impair your concentration or judgement

Aim to return to driving when:

1. You are pain free
   
2. You have full range of motion
   
3. You are not taking strong pain medications or sedatives
   
4. Your reaction time is not compromised

If you are in doubt, do not drive. Call your insurer for advice.

  - Driving Safety and Medicines PDF
NSW Government fact sheet

If you have any questions, please do not hesitate to contact us.

Ph: 02 8307 0977
Fax: 02 8088 7420
Email: info@drgideonsandler.com