DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Malignant melanoma.
2. Left axillary lymphadenopathy.
POSTOPERATIVE DIAGNOSES:
1. Malignant melanoma.
2. Left axillary lymphadenopathy.
OPERATION PERFORMED: Left radical axillary dissection.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Laryngeal mask airway.
ESTIMATED BLOOD LOSS: Less than 50 mL.
DRAINS: A 10 mm Jackson-Pratt drain.
SPECIMEN: Left axillary contents.
COMPLICATIONS: None.
FINDINGS: Multiple matted lymph nodes in the inferior aspect of the axilla along the latissimus dorsi muscle.
INDICATIONS: The patient is a (XX)-year-old male who underwent a wide local excision of a Clark level IV malignant melanoma of the left scapular region with associated sentinel lymph node biopsy, which was negative at that time for axillary metastasis. He presents with a 2-week history of a swollen lump in his left axilla, which on fine needle aspiration revealed poorly differentiated carcinoma. The patient will now undergo a left radical axillary dissection to remove all the involved nodes in the left axilla, as well as all the lymph nodes well up into the apex of the axilla for therapeutic treatment.
DESCRIPTION OF OPERATION: After adequate preparation, the patient was taken to the operating room where an LMA was inserted. He was then positioned in the standard fashion for left axillary dissection. The area was shaved, prepped and draped in the standard fashion. The arm was draped within the field.
A transverse incision extending up along the pectoralis muscle and down posteriorly along the latissimus dorsi was made, incising through skin and subcutaneous tissue. The flap was developed over the pectoralis major muscle. The edge of the pectoralis major muscle was identified and it was used to dissect up to the axillary vein. Dissection then occurred just slightly cephalad to the axillary vein pulling down as much of the axillary contents as possible. The entire dissection was carried up to the undersurface of the pectoralis minor right at the very apex. Lymph-bearing tissue was peeled down from just above the axillary vein inferiorly. The branches of the axillary vein were divided either with silk ligatures or clips. The entire axillary contents were peeled off the vein and posterior to the vein down to the thoracodorsal vessels and nerve, which were clearly identified and preserved throughout the entire procedure, as well as the long thoracic nerve.
Dissection continued in a caudal manner pulling the axillary contents with the specimen. The highest axillary nodes were removed separately and sent to pathology. Further dissection continued. The largest mass of lymph nodes were matted along the posterior edge of the latissimus dorsi and inferiorly. They appeared to have some skin involvement; therefore, an ellipse of skin was taken with the specimen in order to not cut into tumor. There was some traction on the long thoracic nerve at its most inferior aspect, being pulled by tumor fibrosis, but not involved by tumor. The long thoracic nerve was dissected free from the entire axillary contents and was preserved as well. All the palpable lymph nodes were removed. The entire specimen was ultimately removed. Inspection of the axilla revealed the thoracodorsal nerve and the long thoracic nerve, both of which were functioning with compression. There was no other lymph-bearing tissue left in the axilla.
The area was then irrigated with sterile water. A 10 mm Jackson-Pratt drain was placed in the axilla and brought out through a separate stab incision. The incision was then closed with 2-0 nylon in a vertical mattress interrupted fashion. A pressure dressing was then applied and the patient was then awoken from anesthesia and transported to the recovery room in satisfactory and stable condition. The patient will be on 23-hour observation.
