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Segment 1: Introduction
The axillary lymph nodes are categorized as level I, level II and level III nodes.
In the axillary lymph node dissection procedure, only level I and II nodes are removed.
These nodes lie lateral and deep to the pectoralis minor muscle...
...and are enveloped within fatty tissue, known as the axillary fat pad. The fat pad will be removed along with the axillary lymph nodes.
The fat pad also contains the axillary vein, the thoracodorsal bundle, the long thoracic nerve, and medial pectoral nerves.
Underarm dimple
Axillary hairline
To begin the procedure, locate the anterior axillary fold, the underarm dimple, and the axillary hairline.
Axillary vein
Underarm dimple
Clavipectoral fascia
Cutting open the fascia reveals the axillary fat, which appears smoother and less lobular than subdermal fat.
Axillary vein
The next step is to locate the axillary vein, which lies at the superior border of the surgical field.
Axillary vein
Axillary artery Brachial plexus
Do not dissect regions superior to this vein, as this will risk damage to the axillary artery and brachial plexus.
To locate the vein, dissect the superior border carefully with a hemostat.
Superficial branches
Superficial branches of the vein may be visible; do not tie off these branches until the thoracodorsal bundle is identified.
Clean off the fat from the vein using rough dissection.
Throacodorsal bundle
Throacodorsal nerve
The bundle inserts into the latissimus dorsi muscle, about four fingers width from the axillary vein.
To locate the bundle, venture deep into the axillary fat pad.
Identify the vein, artery and nerve to confirm the bundles identity.
Once located, perform rough dissection to clean off the medial side of the bundle.
Dissect the skin off the fat pad; this skin flap should not be too thin.
Tendinous portion
The tendinous portion of the muscle indicates that the axillary vein is nearby.
Locate the lateral side of the thoracodorsal bundle, and clean off the fat. The bundle is now isolated from the fat pad.
Pointer vessel
The thoracodorsal vein sometimes contains a branch that leads towards the chest wall.
Pointer vessel
...which lies superficial of the serratus anterior muscle. Note that the thoracodorsal bundle and the long thoracic nerve lie on the same plane.
To locate the nerve, pull the fat pad in a lateral direction, and return to the tunnel opening.
...and palpate the chest wall to locate the long thoracic nerve.
The nerve should feel like a guitar string on the chest wall.
Insert a finger to spread the tissue above the nerve. This isolates the nerve without displacing it.
Corner vessels
Dissect the fat pad off the inferior border once all vessels are secured.
At this point, the fat pad is only connected to the pectoralis minor muscle.
Next, raise the arm to provide better access to the pectoralis minor muscle.
Insert a finger into the tunnel entrance, placing it above the long thoracic nerve. This protects the nerve from the following dissection steps.
Dissect the fat off the lateral border of the pectoralis minor muscle...
...then raise the muscle, revealing the fat underneath. The level II axillary nodes lie within this fat.
Dissect medially...
The fat pad is now separated from the pectoralis minor muscle.
Fatty tissue remaining between the thoracodorsal nerve and long thoracic nerve should also be removed.