AXILLARY LYMPH NODE DISSECTION (ALND)
Axillary node dissection is a surgical procedure performed to remove lymph nodes from the axillary (armpit) region of the body. This procedure is commonly carried out during breast cancer surgery, as the axillary lymph nodes are one of the first places breast cancer cells are likely to spread. The goal of axillary node dissection is to assess the extent of cancer spread and determine the appropriate course of treatment.
There are two types of axillary node dissections:
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Sentinel lymph node biopsy (SLNB): In this procedure, the surgeon removes only the sentinel lymph node(s), which are the first lymph node(s) that cancer cells would potentially spread to from the primary tumor. A dye or radioactive substance is injected into the area around the tumor, which helps identify the sentinel node(s). If the sentinel node(s) test negative for cancer cells, it's less likely that the cancer has spread to other lymph nodes.
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Axillary lymph node dissection (ALND): This procedure involves removing a larger number of lymph nodes (usually 10-40) from the axilla. ALND is typically performed when cancer cells are found in the sentinel lymph node(s) or when there is clinical suspicion of lymph node involvement.
Axillary lymph node dissection (ALND) has been largely replaced by the minimally invasive technique of sentinel lymph node biopsy (SLNB) for breast cancer staging.
The lymph nodes with the highest radioactive signals are removed.
Women with positive SLNB may require subsequent ALND and further treatment.
Following the surgery, the removed lymph nodes are examined by a pathologist to determine the extent of the cancer spread. This information, along with other factors such as tumor size and grade helps guide the decision on further treatments, such as chemotherapy, radiation, or hormone therapy.
Anesthetic Implications for ALND
Anesthesia type: General anesthesia or local anesthesia + IV sedation
Airway: Endotracheal tube or LMA
Preoperative:
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Patients are frequently very anxious due to the possibility of breast malignancy
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Avoid BP cuff or IV in the ipsilateral arm
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Monitor and prevent brachial plexus injuries caused by overstretching the arm
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Breast cancer is the most common cancer among women
Intraoperative:
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May need to avoid muscle relaxants
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Duration for SLNB: 10-30 minutes
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Duration of ALND: 1.5 hours
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Position: Supine, one arm extended, one arm tucked
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EBL: Minimal
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Isosulfan blue dye may cause an artifactual drop in O2 saturation
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Isosulfan dye reaction: Itching, localized swelling, blue hives, hypotension
Postoperative:
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Pain management
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Monitoring for complications
Complications:
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Allergic dye or radioisotope reaction
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Discoloration of urine and stool
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Blue staining of the skin
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Anaphylaxis
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Nerve injury: Long thoracic nerve, thoracodorsal nerve, and intercostobrachial nerve
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Lymphedema
Sources:
Elisha, S. (2010). Case Studies in Nurse Anesthesia.
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Sherwin, A., & Buggy, D. J. Anaesthesia for breast surgery. Mater Misericordiae University Hospital and University College Dublin. Retrieved from https://www.bjaed.org/article/S2058-5349(18)30101-X/pdf
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.