Table of Contents
- Case Overview
- Special Equipment
- Statement of Consent
Wide local excision (WLE) with sentinel lymph node biopsy (SLNB) remains the cornerstone for treatment of patients with intermediate-thickness and thick melanoma lesions with clinically negative nodes. This procedure involves resection of the melanoma with circumferential margins including all the subcutaneous tissue to the level of the deep fascia. WLE is accompanied by lymphatic mapping in order to localize, resect, and analyze the sentinel node(s) for the presence of lymph node metastases. In this paper with accompanying animation and video, a 40-year-old otherwise healthy patient presents with a new melanoma on his back diagnosed via biopsy. The surgical management of intermediate-thickness melanoma and rationale for treatment are reviewed. We also highlight recent advances in postoperative treatment of those with clinically occult regional disease.
Melanoma; sentinel lymph node biopsy; lymphangiography; surgical oncology.
Invasive cutaneous melanoma is estimated to be the sixth most common cancer in the United States, accounting for approximately 84,000 new cases and 8,200 deaths in 2018.1 Early identification of suspicious skin lesions is critical. For patients with lesions less than 1 mm in thickness and no nodal involvement, 5-year survival is excellent. In the setting of localized disease with a primary greater than 1 mm in thickness, 5-year survival depends on Breslow depth, ulceration, and mitotic rate but can approach 90%. Prognosis varies widely among patients with locoregional disease (stage III) and primarily depends on tumor burden in draining lymph nodes and resectability of the primary lesion.2 Finally, survival was historically poor in patients with distant metastatic sites such as the lung, brain, or bone (stage IV), but recent advances in targeted therapy and immune checkpoint blockade have reshaped the treatment landscape.3–5
Wide local excision (WLE) with sentinel lymph node biopsy (SLNB) remains the cornerstone for treatment of melanoma lesions with Breslow thickness greater than 0.8 mm and clinically negative nodes (stage I/II disease). The WLE procedure involves excision of the lesion with 1–2-cm margins and resection of the subcutaneous tissues to the level of the deep fascia. The goal of the SLNB is to accurately stage and assess the draining nodal basin in patients with no clinical evidence of regional disease. This procedure involves intradermal injection of blue dye or radioisotope in the skin surrounding the primary lesion in order to localize, resect, and analyze the draining node(s) for the presence of subclinical metastases.
The probability of a positive SLN is related to the tumor (T) stage of the primary lesion and associated adverse factors.6 The 8th edition of the American Joint Committee on Cancer (AJCC) T staging classification is predominantly based on Breslow thickness and the presence or absence of ulceration. However, a number of additional prognostic factors have been identified and are commonly reported in pathology reports such as tumor cell mitotic rate.7–10 For lesions with a Breslow depth less than 0.8 mm without adverse features (T1a), the probability of positive SLNB is less than 5%. For lesions with a Breslow thickness less than 0.8 mm with ulceration or 0.8–1 mm with or without ulceration (T1b), the probability is 5–10%. Finally, for lesions with a Breslow depth greater than 1 mm (T2a or greater), the probability is greater 10% and will vary based on additional adverse features. These probabilities can be used to determine the risks and benefits of the SLNB when assessing the utility of this prognostic procedure for an individual patient. The rationale for this practice is based on important data from the Multicenter Selective Lymphadenectomy Trials (MSLT)-I and II.13-15, 24
Earlier data from the MSLT-I trial demonstrated the prognostic significance of the sentinel node.13, 141717 For patients with intermediate-thickness or thick melanoma lesions (> 1.2 mm), the disease-specific survival rate at 10 years was significantly worse in patients with lymph node disease compared with those who had a negative SLNB (62 versus 85%, hazard ratio [HR] 3.09, 95% CI 2.12-4.49). At that time, if a positive SLN was identified, completion lymph node dissection (CLND) was then performed. The MSLT-II trial was then designed to assess the disease-specific survival benefit of CLND procedure in patients with a positive SLN.24 Approximately 2000 patients who had a WLE of intermediate-thickness or thick melanoma lesions with a positive SLNB were randomized to CLND or close observation with nodal basin ultrasounds. While there was improvement in regional control in patients undergoing CLND, there was no improvement in melanoma-specific survival between the two groups at three years (86 vs 86%, adjusted HR 1.08, 95% CI 0.88-1.34). The DeCOG-SLT trial demonstrated similar findings with no difference in distant metastasis-free survival or overall survival at five years.25, 263030 As a result, patients without clinically evidence locoregional disease now rarely undergo CLND. The SLNB is instead used as a staging procedure, which helps to determine the adjuvant surveillance and treatment plans for patients with melanomas of Breslow depth 0.8 mm or greater. Importantly, MSLT-I and -II largely reflect an era in melanoma surgery prior to the discovery of effective systemic therapies for metastatic melanoma, providing even further rationale to (1) limit morbid surgeries such as the CLND, which has no proven impact on melanoma-specific survival, and (2) encourage the use of the SLNB, which can best stratify a patient's stage and the predicted benefit of adjuvant systemic therapies.
This a 40-year-old, otherwise healthy individual who presented with a changing pigmented lesion on his left upper back. This was biopsied by his dermatologist and demonstrated melanoma with 1.4-mm Breslow depth. He was referred to a surgical oncologist for further management. Review of pathology report showed no ulceration and 2 mitoses. No other worrisome features.
Examination of the patient demonstrates a well-healing biopsy site with no evidence of gross residual melanoma. There is no evidence of either satellite lesions (cutaneous nodules that are < 2 cm in distance from primary tumor and draining lymph node basin) or in-transit metastases (cutaneous nodules > 2 cm between primary tumor and draining lymph node basin). These physical findings would reflect disease in the draining lymphatic channels and are considered locoregional disease.
A thorough lymph node examination, including palpation of cervical, supraclavicular, axillary, and inguinal nodes, reveals no palpable lymphadenopathy. Approximately 10% of melanoma patients will present with regional disease (lymphatic spread of tumor to nearest nodal basin), and 5% can present with distant metastases (hematogenous spread to distant organs).11 Any clinically suspicious nodes should be biopsied prior to surgical resection. The presence of clinically-evident, biopsy-proven lymph node spread of melanoma signifies clinical stage III disease. In these cases SLNB is unnecessary as the utility of SLNB is in identifying clinically-occult lymph node metastases.
For this patient, no additional work up or preoperative treatment is necessary. In the absence of physical exam findings suggestive of locoregional disease or neurological symptoms that may reflect distant metastases, routine labs or cross sectional imaging are not recommended by the National Comprehensive Cancer Network (NCCN).12
Based on the T stage, the probability of a positive lymph node biopsy is greater than 10% for this patient. The therapeutic value of the SLNB remains controversial. However, SLNB certainly provides prognostic information that guides adjuvant treatment options and surveillance. If the sentinel node is negative, patients are typically followed with physical examination including total body skin exam and nodal basin evaluation. No additional labs or imaging are necessary to screen for asymptomatic reoccurrence. If the sentinel node is positive, treatment varies based on individual patient risk factors and the underlying tumor biology.
Localization of sentinel nodes can be performed with intraoperative dermal injection of a vital blue dye (isosulfan blue (up to 1 ml) or methylene blue (up to 1 ml of 1% solution)) and/or preoperative lymphangiography with a radiotracer. In the latter procedure, a technetium-99m sulfur radiocolloid (0.25 mCi–0.5 mCi) is injected intradermally into the primary lesion, typically on the day of surgery. Static and dynamic images are obtained that highlight the draining lymph node basin. When both blue dye and radiotracer are used for localization, the success rate of identifying the SLN is greater than 95%.13, 16 When the sentinel node is not identified, it can be secondary to poor technique (i.e. inadequate injection of tracer), prior surgery that disrupted the lymphatic drainage channels, or complete infiltration of the draining lymphatic vessels with metastatic disease.17 In this procedure, the combination of techniques will be described.
There are limited alternative options for excision of the primary lesion for this patient that would have similar oncologic outcomes. Standard Mohs micrographic surgery is not recommended for invasive melanomas and remains controversial even for in situ disease or in cosmetically sensitive areas.18 The definitive diagnosis of melanoma depends on the use of immunohistochemistry so surgical procedures that rely on the use of frozen section evaluation may not be sufficient. In cosmetically sensitive cases staged procedures, sometimes referred to as “slow Mohs”, may be considered as these allow tissue fixation and IHC evaluation. With regards to standard surgical resection, several large randomized studies have assessed the margins required for local control.19-22 Current recommendations are for 1-cm margins for lesions < 1 mm in Breslow depth, 1–2-cm margins for those 1–2 mm in depth, and 2 cm for those > 2 mm.12
There are certain populations that may not benefit from SLNB. For patients with T1a disease and less than 5% chance of positive sentinel node, SLNB is typically deferred. Furthermore, for patients with T1b disease and a 5–10% chance of a positive sentinel node with additional low risk factors such as older age or low mitotic rate,7, 23 the decision regarding whether to perform SLNB requires an individualized discussion with the patient. A personalized risk and benefits discussion is also appropriate for patients with decreased 10-year survival due other medical conditions, as well as those unable to or unwilling to undergo adjuvant therapy and surveillance.
This case outlines the surgical management of a patient with intermediate-thickness melanoma.
Preoperatively, same-day dynamic lymphoscintigraphy is obtained which demonstrates mapping of the draining nodal basin to the left axilla. Formal lymphoscintigraphy is most useful in the case of a truncal injection as the lymphatic drainage pattern can be less stereotyped than for the extremities. For example the skin of the mid back could drain to a single or multiple nodal basins in the bilateral axillae or groins. The skin of the upper back could drain to the neck or the axillae.
Following induction of general anesthesia, the patient is positioned for optimal resection of the primary lesion and the SLNB. It is important to discuss these plans with the anesthesiologist, as it may affect the airway management. Here, the patient is initially positioned in the right lateral decubitus position. The patient is prepped and draped in the normal sterile fashion.
Vital blue dye (isofulfan blue) is injected intradermally around the primary lesion, creating a wheal. It is important that the dye is injected intradermally, and not subcutaneously, in order to be taken up by the lymphatic vessels.
The site of the primary melanoma is outlined with a skin marker. It is important to include all areas of color irregularity and any possible satellite lesions. Then, 1–2 cm margins are outlined around the border of the lesion. These margins are sufficient for oncologic resection as discussed in the earlier section. In order to facilitate closure of the resection in a tension-free, linear fashion, an elliptical shape can be used. Skin flaps may also be used. If it appears that the final tissue defect cannot be closed primarily due to tumor size or anatomic constraints, then a rotational flap or skin graft is considered.28
Local anesthetic, typically lidocaine with 1% epinephrine, is injected along the elliptical outline. Using a combination of sharp dissection and electrocautery, the skin and subcutaneous tissues are divided down the deep fascia. For appropriate oncologic resection, it is critical to divide the tissue at a 90-degree angle to avoid skiving toward the tumor and to remove all tissue above the fascia.
The specimen is removed and oriented appropriately for pathologic analysis. Any method of marking can be appropriate as long as it allows orientation of the specimen in the event that a positive margin would need further surgical treatment.
Hemostasis is achieved and the space is closed in multiple layers. The specific method can vary per surgeon preference. Here, the deep space is closed with a series of interrupted deep dermal sutures using Vicryl to release the tension at the fascial layer. The skin is closed with a running subcuticular stich using Monocryl. The closed wound is then covered with skin glue or Steri-Strips per surgeon preference, followed by a sterile dressing with Tegaderm.
The drapes are removed, and the patient is repositioned supine with the left arm out at a 90-degree angle. Using the gamma probe, mapping of the draining lymph node basin is confirmed to track to the left axilla. While this technique has a high success rate, the false negative rate (or inability to identify the sentinel node) historically has been noted at approximately 5%.16, 19 In the modern era of radiographic surveillance and effective salvage systemic therapies a CLND is not indicated in the case of a lymphatic mapping failure. Surveillance nodal ultrasound and physical exam would be a more appropriate alternative, with further treatment as indicated if a recurrence were to occur.
The left axilla is prepped and draped in a sterile fashion. The incision is marked along the inferior aspect of the hairline for cosmetic purposes, and local anesthetic is injected. Using a combination of sharp dissection and electrocautery, the skin and subcutaneous tissues are incised down to the axillary fascia. The gamma probe is then used to aid further dissection and identify the sentinel nodes. Once a node is identified, it can be removed by placing a silk stitch through the node to serve as an anchor and then using electrocautery to perform a circumferential dissection. Care must be taken during dissection near the lymphovascular pedicle in order to maintain hemostasis.
Once the node is removed, the gamma probe is used to quantify the final count ex vivo. The procedure continues until all the sentinel nodes with gamma counts greater than 10% of highest nodal count are removed. It is also important to remove nodes that otherwise appear suspicious based on the presence of blue dye, abnormal size, or obvious nodal metastases.
Once the sentinel nodes have been identified and removed, the axillary incision is closed in multiple layers. This can be dictated by surgeon preference. It is typical to close the axillary fascia with interrupted Vicryl stiches, followed by the subcutaneous space and skin as described above. The wound is closed with skin glue or Steri-Strips, and then with a dry sterile dressing and Tegaderm. The patient is extubated and taken to the postoperative recovery area.
Operating time can vary widely, but can often be 1–3 hours from incision to closure depending on the location of the primary lesion, need for repositioning, and the number of nodal basins that must be explored. Blood loss is typically minimal. Cosmesis can be excellent. Typically, patients are discharged that same day with minimal range of motion restrictions.30 Pain is usually managed without opioids although axillary surgery may require some additional pain control in the first few postoperative days.
The morbidity of sentinel node dissection is significantly lower compared to CLND.24, 31, 34 Complications are mostly limited to infection, seromas/hematomas, wound dehiscence, and sensory nerve injuries. The rate of lymphedema depends on the extent of the dissection and the number of nodes that must be removed, in addition to patient factors. Rates of lymphedema after SLNB can vary between 0.5–5%, compared to up to 30% for CLND.24, 33, 35
This patient underwent complete resection of his 1.4-mm melanoma with no evidence of residual melanoma at the primary site and no evidence of lymph node metastases in any of the lymph nodes sampled on final pathologic evaluation. His wounds healed well without complication and he returned to work. Final AJCC 8th edition melanoma stage is determined to be Stage IB. Routine dermatologic follow-up is recommended every 3–6 months for 5 years, and the signs/symptoms of melanoma recurrence that should prompt urgent evaluation were reviewed.
Current guidelines support the use of adjuvant therapy in stage IIB or greater melanoma. Thus patients with melanoma metastases identified in the SLN specimens or with high risk primary features (T3b or greater) are usually completely staged with cross-sectional imaging and brain MRI. A medical oncologist with expertise in melanoma will then discuss adjuvant treatment and surveillance options with the patient, and a multidisciplinary treatment team including a dermatologist, surgical oncologist, and medical oncologist will be established.36-41
- Vital blue dye (isosulfan blue or methylene blue)
- Nuclear medicine facilities for lymphoscintigraphy
- Intraoperative gamma probe
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
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Cite this article
Sierra-Davidson K, Nnamani Silva ON, Cohen S. Wide local excision of an intermediate-thickness back melanoma with a sentinel lymph node biopsy of left axillary lymph nodes. J Med Insight. 2023;2023(337). doi:10.24296/jomi/337.
Table of Contents
- 1. Introduction
- 2. Surgical Approach
- 3. Incision
- 4. Dissection
- 5. Orientation of the Specimen and Hemostasis
- 6. Closure
- 7. Confirm Mapping to the Left Axilla
- 8. Approach to Sentinel Lymph Node Biopsy
- 9. Incision
- 10. Dissection
- 11. Take Count on the Node
- 12. Exploration for More Sentinel Lymph Nodes
- 13. Closure
- 14. Post-op Remarks
- Intradermal Injection of Isosulfan Blue
- Confirm No In-Transit Nodes with Probe
- Inject Local Anesthetic
- Release Edges
- Find the Plane
- Complete the Excision
- Inject Local Anesthetic
- Dissect Down to Axillary Fascia
- Use Probe for Orientation
- Lift Node with Silk Stitch
- Dissect out the Node
- Dissection of Second SLN
- Dissection of Next Node Cluster: SLN 3 and 4 with Non-Sentinel Nodes
- Confirm No More Hot Nodes
I am Sonia Cohen. I'm a surgical oncologist here at Mass General. I specialize in sarcoma and melanoma. Today we're gonna be doing a wide local excision for an intermediate melanoma, along with the sentinel lymph node biopsy. So the patient today has a intermediate-thickness melanoma on the early side, closer to 1 mm. Today we are gonna do the sentinel lymph node biopsy for prognostic information to find out if there is any evidence of any spread of the melanoma to his lymph nodes. This is indicated because it is greater than 0.8 mm in thickness. He doesn't have any other worrisome features in his melanoma, no ulceration, no mitoses. The guidelines suggest that a 1- to 2-cm margin is adequate in this case, and so we'll do a 1 cm margin today for him. Preoperatively, the patient went to nuclear medicine where he was injected with a technetium-labeled dye around the site of the melanoma. This allows me to identify the first lymph nodes that drain that skin called the sentinel lymph nodes. With a melanoma on the back, as in this case, the drainage pattern could actually be to either axilla, to either groin, or even to the neck. In this case, the preoperative labeling and imaging allowed us to identify that the lymph nodes were in the left axilla. So what you'll see today, the first step is, I'll actually inject another dye, isosulfan blue, around the melanoma biopsy site. This is another marker that allows me to identify the sentinel lymph nodes. Then you'll see us do the wide local excision first. In this case, we're doing that to prevent shine-through when we then move to the left axilla to look for the sentinel lymph nodes. After we remove the melanoma itself, then we'll reposition the patient and we'll perform the sentinel lymph node biopsy within the left axilla.
So isosulfan blue will act as our additional tracer in addition to the radioactive tracer, the technetium-labeled that he got in nuclear medicine, and this needs to be an intradermal injection in order to be taken up correctly by the lymphatics. Just clean off the skin. And this will stain, so you just wanna be careful that you don't get it everywhere when you're injecting, and so the key to the injection, like I said, is the intradermal injection, and you wanna do it in four quadrants. So really just get it in the dermis and inject, and what you wanna see is the wheal and the blue there, and then just be careful when you're pulling out. And he mapped well in, with the nuclear medicine imaging and injection. This is sometimes helpful if the nuclear medicine mapping was not definitive, or also during the procedure, if we see any blue lymphatics or blue nodes, you know, we will treat those as a sentinel node as well and take them. All right, so after the injection, if you don't mind, do you have gloves on? Giving some massage while I clean this up, just to try and get the lymphatics to take it up. And in this case, because he mapped to the left axilla, you know, the nuclear medicine is really helpful for melanomas on the torso because the drainage pattern is such that it can go to bilateral axilla or bilateral groins, or sometimes even the neck. So having the imaging in nuclear medicine ahead of time really helps us identify where we're looking. In this case, because he mapped to the left axilla, if we try and do the procedure without resecting the primary that's been injected with the dye, we'll get a lot of shine-through. That will make it difficult, so we're gonna start with the melanoma excision, remove it, and then that will allow us to really localize the node within the axilla after.
In cases where we don't have to worry about shine-through, then we would start with the sentinel node, and then the last thing we're gonna do before we prep is we're gonna use a non-sterile probe just to confirm that we don't have any in-transit nodes that are lighting up. So this is obviously the primary site that was injected, the tracer injection that we're picking up, and I just wanna make sure that there's no, you can leave that, yeah, thank you, that there are no surprises. Okay, great.
Okay, so this melanoma is an intermediate-thickness melanoma. Do you remember the depth? Yeah, this one I saw online was, it had a mitotic activity of 1.1 This is 1.4. So the depth of the tumor is 1.4 mm. 1.4 mm, correct. Yep, good, and then the other high risk features we look for are whether it's ulcerated. This one was not, and then the mitotic rate, which was two for him. Yeah, exactly, so for intermediate-thickness tumors, our margins of excision? For this one, 'cause it's greater than one, we usually do the 1-2 cm. Yep, perfect, and in this case, because it's on the back and we have quite a bit of... Oh yeah. You know, we can certainly get away with more than one and perhaps even two, but I think with the low risk features, most people would say that one is acceptable. Okay. But again, there's no good data between one and two, okay. Okay. So usually I mark out exactly where I see the lesion. We've given it in time to get into the lymphatics. So hopefully we'll be able to see it when we look at the lymph node, and then we mark all the way around. All right, 1-cm margin, and our, the margin of excision is really to prevent local recurrence. That's the endpoint in all the studies that looks at what margin you should use, and so that's why we take this additional margin. Okay, so then we wanna think about how this would best close. In this case, if it were more in the midline on the back, then we would think about doing a longitudinal incision with the additional thought process being that if we need to do any additional resection, then we're gonna want room to extend our resection. In this case, I think clearly he's got, it'll close much more nicely if we do a tangential incision. And then in addition to that, if we, let's say you did have a positive margin or a recurrence of this scar and we had to come back, this would be a much easier way to extend. Okay. One, two, three. Let's see, and then... Okay, so that'll be our excision, and that should close nicely for us with little tension. Okay, great. We'll take the local, please.
So again, we're gonna try for an intradermal injection, just outside of our line of resection. Okay, great. Thank you. Let's do a little more down here. Thank you. Thank you.
All right, so then I'll just have you hold tension while we're... And I'll take the 10 blade, please. Here you go. Okay, thanks. You guys all set for incision? Okay. I wouldn't put, don't put your hand, yeah. If you're gonna... Oh yeah, that's right. So use your sponge rather than... Like that, it's okay? Yeah, perfect, good. Just gonna turn my body here. Thank you. Come back and do this side of the excision. I'm actually gonna switch places with you. Yeah. Thank you. And then just roll your fingers a little. Perfect. And I usually like to do the resection sharply, especially through the dermis so that the pathologist can get a good look at the margins. And then we'll go through further. Good. Okay, good. Yep, you can stay there. And then you can see there's some blue taken up by a lymphatic, yeah there, which is a great sign, again. Okay, good. Knife down for a sec, and then we're just gonna clean up our edges here. Help us with hemostasis. Okay, good. Okay, wonderful.
Okay, so our next step is now to release the edges, and then we're gonna find our appropriate plane. The skin on the back is quite thick. So we wanna make sure we get through it and then down onto the correct plane in which to resect the melanoma for the oncologic excision is just above the fascia. So unlike a sarcoma, where we would take the fascia for an oncologic excision, it's not necessary for melanoma. Do some more hemostasis there. Adjust our light. All right. Good, all right. Let's work on the other corner. Is this okay, or you want a fresh blade? No, that's perfect, thank you. You're welcome. Okay, good.
All right, so I will take an Allis, please. So then at this point, one advantage to holding with an Allis is, again, this is not part of our oncologic resection. This is just cosmetic in order to close, and if we get a good grip on that, it allows us both to orient it. We know we're on the lateral part of the resection, and we won't lose that orientation, and then it also gives us a nice grip. Thank you. You're welcome. All right, so can you kind of hold a little tension that way? Perfect, and my goal here is really to get a - full thickness of the underlying tissue all the way down to fascia without skiving in or out. And the tissues on the back are quite thick. There we go. Okay, so you see that fascial layer there, overlying the muscle? So that's the plane that we wanna be in, okay?
So now if you could kind of hold a little tension like that. Just go ahead and do what I'm doing. Up here. Yep, perfect. Thank you. Okay. Okay, so that's our specimen.
And we're just gonna orient our specimen. So if you could put a long stitch here, that's long lateral, and then you're gonna put a short stitch here. That's short superior, okay, and that way the pathologist can tell us where our margins are positive if we have positive margins. So what would you like to call it? So this is left back melanoma. Long stitch lateral, short stitch superior. All right. You want it for permanent? Yes, please, thank you. For permanent. Okay, so once I have adequate hemostasis, I'll take some irrigation, and then if there was any problem with tension, then at this point I would raise flaps, but I think in this case, we're gonna be able to close this without tension, so we won't need to do that. I will take a 2-0 Vicryl, please, and I'll give you these sponges back. Thank you. And I'll take a clean one if you have. Is now a good time for Dylan? Yeah, absolutely, thank you. Take that. Thank you. Adson with teeth.
So I use 2-0 Vicryl, just to close the deeper Scarpa's layer. Huh, this Adson is... Not working? Yeah. Can I borrow these? There's always one good pair and one bad pair. Yeah, weird. A really bad pair. Thank you. Thank you. All right. I'll grab some scissors. Thank you. So we'll close this in layers. We'll use 2-0 Vicryl in Scarpa's, and then 3-0 Vicryl deep dermals and run a Monocryl. This is really, this layer is just to take tension off the incision. Trade you for a 3-0. Thank you very much. You're welcome. Does your operative planning depend on location? I know the common principles apply, but is there anything that you think about differently in the lower extremity where you're more susceptible to infections or? Yeah, so I think the thing you think about more is like if you need a skin graft or a flap for closure. For instance, a patient who has a melanoma on the hand, where the functional consequence of the resection's gonna be important, or at the bottom of the foot, which is a weight bearing area. Exactly. Then you have to think about how you're gonna close that, and often we'll collaborate with plastics. Right. Or if it's just an area where you need some skin grafting. I know you do a lot of in-office procedures, but for you, what's your threshold for bringing it into the OR? A lot of it is just, can the patient tolerate it under local anesthesia? Some people just are too anxious. Anyone who needs general anesthesia for like, the sentinel lymph node biopsy, we'll do in the operating room. Other things are, if I do need to do a skin graft or a flap for closure, that would be a reason to come to the operating room. If someone is on a blood thinner and I'm concerned that there may be more than the usual amount of blood loss or just a really big resection, something like that, it's, I might elect to offer them to do it in the operating room. But any - just a straightforward, wide local excision can certainly be done in the clinic. Do we have another 3-0 Vicryl, or is this it? All right, I'll trade you. All right, I think we'll do one more in the middle and then we'll run it. For this, we're gonna take the half-inch Steri's cut in thirds, and then we'll do Tegaderm and topper. Just do one more down there and maybe one there and then run it. And this patient's very active, so I think just making sure we're closing this in layers under low tension to make sure he doesn't have any wound issues, and then also to make sure he has a cosmetically acceptable scar. So we'll take the Monocryl next. So I just put my knot like, outside of the corner. Okay, yeah. Because it's hard to get it right in the corner and it helps you avoid a dog ear. A dog ear. Yeah, yesterday, yeah that's a good point. What were you gonna say, yesterday? Yeah, yesterday I was starting at the corner and it was, the dog ear was more. It just makes it hard to line it up nicely. Exactly, yeah. So, but then you can come out of the corner, right? Right. Right. And what do you tell your patients after the procedure? What things should we, (Sonia giggling). You're so good. Yeah, so you know, there's not much tension here. So we were able to close it with dissolvable sutures. If we were worried about tension on the wound, then we would add some retention sutures to help with that. Postoperatively, I usually just ask the patients to take it easy. Someone who's very active may need to, you know, avoid intense activity for a week or two afterwards just to make sure that things heal nicely for them. We'll leave this bandage on for 48 hours, ask him to keep it dry until it comes off, and that's it. Okay. I'll take a wet and a dry, please. Next time, will you cut them all the same length? The same length, yeah, 'cause see, look what happens. It looks crazy. That's it for this. Yeah, and then don't pull, just - perfect. Okay, we'll take the other one. Sponge, hang on one sec. Let me just dry it off here so it sticks. Good. Okay, perfect. All right, great. So we're done with that part. We're gonna turn supine now.
All right, so now I'm just gonna confirm the mapping to the left axilla and not to any other basin. So that's good signal there. Check, nothing here, nothing there. No signal there. Okay, so mapping confirmed to the left axilla.
All right, we'll take a marker. So I like to use the probe to find the point of maximal signal just to make sure that, while we do have a lot of room to move our incision around, it's nice to know sort of the general direction you're going before you make your incision, and then the other points, I think, you know, we're gonna be heading generally this direction. The other point is for the patient, for cosmesis, you do wanna keep your incision behind the pec here. That looks nicer, and then you wanna think about, if this patient did need a lymphadenectomy in the future, how you would orient your incision, and typically it would be something like that. So you just wanna be able to use the incision you're making now in the future if you need it, yep.
Some local. Okay, all right.
So hold tension for me. Perfect. Good.
All right. Right here? Let's start in the middle. Okay, good. We're just gonna go down through the subcutaneous tissues until we get to the axillary fascia. Good. Excuse me. Oh, no problem. Pull up, up is okay. Perfect. Okay. Good. Okay. We'll take a Weitlaner, please. So this helps us spread the subcutaneous tissues and figure out where the fascia is. I think that's probably still Scarpa's there. We have a couple more layers to go. We'll trade for DeBakey's, please. So just pick up opposite me here. Good, And so really when I'm looking for the axillary fascia and to know that I'm in the axilla, what I'm looking for is a change in the quality of the fat. Okay. So pick up right there, like a little nicer bite. Yeah, good, perfect. Okay, so this is the axillary fascia here. so get a good bite in there, like right in there. Yeah, there you go. Good. Perfect. Okay. Gonna reposition my Weitlaner, And you can see here, you can feel there's - we're really splitting this fascia layer here, and then when we get into the fatty tissue there, it's gonna look a little different 'cause now we're gonna be in the axilla. So you see that fat bulging out. It looks different than your subcutaneous fat. All right, good, So just grab opposite me here a little. Don't pull on that 'cause that's a vessel. Yeah. Yeah, okay go ahead. Right here? You can go back there, just be gentle. Okay. Yep. Good.
Okay, so now that we're basically in axilla, the next thing I'm gonna do is I'm gonna use my probe to help orient me to where I'm going. Yeah, I see some blue. I know. That does look blue. So probably I'm gonna have you do some lady fingers now. Okay. I'll take the two Riches. Yep, perfect. Thank you. Yeah, you can give that back. Hang on, let me position you there. Nice, okay. Can you hold one there, one there? Yeah. Okay, great. So you can see here some blue tracer there, and I feel a lymph node there. So that's certainly the direction we're going. Okay. All right, so then I'm gonna use my probe now. So I see blue leading up. Okay, so right here I'm seeing a bluish dye here, and then I can feel that there is a lymph node, and then when I take my probe, it's hot, localizing to that region. So that is gonna be a sentinel lymph node. So now we're gonna dissect that out and remove it.
All right, let me reposition you. Okay, yeah, that's perfect. Okay, I'll take a, just a silk, please. Okay, so usually once I've identified the node, I'll lift it up either within an Allis or with a silk stitch, and then when I'm confident that I have the node, I will do a figure of eight to give me a good grip without tearing through the node. All right, next I'll take a Schnidt, please.
So now here I can see, because - I'm gonna move this for a sec and show you too, make sure you can see. Hold that there. So here you can see I've got my stitch through the lymph node, and then I see the pedicle of the node here with blue in the lymphatics and as well as the little vessels. So now our job is to dissect out the node and then to clip at the pedicle to make sure that we don't get any bleeding or seroma or anything like that. So I'm just gonna dissect the... All right, I'll take a clip, please. Thank you very much. Okay. and here, like we talked about, I clip away and then... All right, so now that I've got that free, what I like to do is use my probe to make sure I really understand where the node is. So I'm just going after the node I want. So I'm gonna continue to do - just separating these guys around. Here, I'm just loosening that sort of, the capsule we talked about that holds the fat together. It's like a fibro-fatty capsule, just loosening that so we can really get what we want. I'll take a clip, please. And then anything that looks like little lymphatics, I'm gonna clip because the clips are much more effective against preventing lymphatic leak and seroma than cautery alone. So now to me, it looks like we have the node pretty well isolated up here, and I'm just gonna check and make sure, 'cause sometimes the sentinel nodes are in chains, and what you don't wanna do is take one and then the rest of the chain retracts, and you lose your... Right. Okay, so I think we're pretty good there. All right, I'll take clips, please. Thank you. Okay, another clip. Thank you. All right, so now we have our node. My Bovie is getting trapped. Thank you. I'm just gonna - okay, so now you can relax on that. Okay.
So now what we're gonna do is we're gonna take counts on this node, which we saw was both blue and hot, and that'll give us a sense for how much... How many counts we would need to find all the sentinel nodes, which will be any node that's up to 10%. Yes? Axillary sentinel node? So this is gonna be left axillary sentinel lymph node. And I'll tell you when to count. Okay. 3210. 3210. Okay, so now we know that unless there's a hotter node, if this is the hottest node, any node that has a count over about 300 or so accounts as a sentinel node, 'cause that's 10%, but we're also looking for anything that we feel that's abnormal or anything that's blue. Okay. Those would all be things we'd wanna wanna take. Thank you very much.
All right, so now we'll look around. Do we wanna leave the... Doesn't matter. Whatever you want. All right, let's see if we can find that one. Luckily, the first one was easy. Okay, so you hold that there and this, and so when I give it to you to retract, just hold it exactly where I give it to you, yeah. Because I think it's gonna be up in this corner. I feel a node. Yeah, so it might be this one that I'm feeling right here. Take a feel, like there's a jelly bean right here under my fingers. Yeah, I feel it, yeah. So we'll try and pull that up and see if that's the hot node that we're feeling. Can I have an Allis, please? I like to bring the axillary fat out, so sometimes I'll use the Allis just to see if I can deliver it a little bit so that we're not really digging in a hole. So this is a case where probably I'm going to open up the fascia again just so we can pull over - Bovie, please. So, you are gonna, like hold them like that. Yeah, perfect. Good, perfect. And I'm just gonna kind of release that fibrofatty tissue. We see a little blue there, so let's see if we can. And this will allow me to just deliver the fat out a little more. Okay. So now I see a node there, but you know, it doesn't look abnormal or blue. I will check it just to make sure. Okay, so I think our node is further in there. All right, Schnidt, please. Thank you. Now I'm just gonna kind of dissect down into the axilla bluntly. Can I have a clip, please? Thank you. And another clip. Thanks. Okay, thanks. All right. Allis, thank you. Okay. Still not seeing anything blue. I think we got lucky with that first one. Bovie, please. So I'm just gonna - this kind of sheer tissue here, I'm just gonna open a little. Schnidt. Thank you. Allis. All right, let's see. Not seeing anything blue. All right, so... Okay. All right, I think, let's try the Deaver. Let's see if we can get a little deeper in there. Hold that there. Can I try the bigger one? Thank you. Yeah, just... All right, don't let go, just hold it where I'm giving, yeah. Mmhmm, got it? Yep, got it. Okay, good, can I have a clip? And then a DeBakey? Thank you. I'm just gonna get this little vessel and split. Another clip? Thank you. Okay, and he is not paralyzed anymore, right? Thank you. Schnidt? Perfect. No, I think, but do you know if he has twitches? I'll check. Thank you. I appreciate that. All right. We're still not doing a good job here. No, we'll just, we'll try again. It's not up there. It's like all the way up there. He has twitches. Perfect, thank you so much. Sure. Okay, there it is. It's right there. Right there. Okay, can I have an Allis? Hold that for a sec. Thank you. Oh man. Okay. Okay, we're in the right space. Okay, oh yes, I got it. Oh my god, Allis. This is like, right under his axillary vein. All right, there we go. Stitch. Is this long enough or or do you want a full length? I'll take what you have. I have a full length, too. Oh, okay. We're like essentially in his back, okay. Cut, please. Thank you. Which I guess is not surprising given that the melanoma was on his back. All right. We're all the way up near the axillary vein, which we're compressing a little so we can loosen now, and then this node here is certainly hot, but not particularly blue. All right, clip. Thank you. Okay, Bovie. Another clip. Thank you. Clip. Thank you. Clip, and here I'm using a lot of clips just because, you know, once all this retracts, I won't be able to get to it if there is an issue. Another clip. Clip. Thank you. Okay, and then don't move, 'cause I'm just gonna stick my probe back in there and make sure there's nothing obvious before we count this. All right, so I'm gonna put this in here. All right, and go ahead and pull your guys out. Perfect, thank you. All right, let's count this one. We'll take a count, please. Ready? Yep. Left axillary sentinel lymph node biopsy, 1709. Or sentinel lymph node, 1709. Thank you. Yep. All right. Let's see. I'm gonna let go of this. We'll take this... Number two okay, Sonia? It doesn't matter. I mean, just the, if it has a number. All right, I think we have one more there. All right, so I think. Okay, will you hold that up? Do you think that's blue? Maybe, yeah. Not really - like this thing? Yeah, you see that like little ball? Yeah, mmhmm. Can I have that stitch? Yeah. Yeah, let's put a - let's pull it out and see if... Here you go. Thank you. Like this guy? Yeah, I agree. Could be it. Yeah. Okay. This guy, right? Yeah. We'll find out. Okay. It has like a little bluish tone. Yeah, maybe. All right, cut please. Thank you. If you're right, you win the prize. Yeah, I agree. And then if I go beyond it. All right, great.
All right. It was hidden. It was hidden in the fat, and they're always like, sometimes they're actually harder to find when they're big. Oh yeah? Because you're thinking about... I don't know why. I don't know. Yeah, all right, we'll see if it's blue once we have it out. but I see what you mean, that little... See that like little tone. Yeah, as long as it's not melanoma, we're good. Clip, please. Another clip. Another clip. Clip. Thank you. Clip. All right. Hopefully we got it all. Let me check before I let it go away. Okay, great. All right, so I'm gonna put that in there. You can take those out. Let's start counting all these guys. I mean, look how small this one is, tiny. So how individually are you..? All of them are gonna go individual. Okay. Count, please. All right, so this is left axillary sentinel lymph node, 630. So then this one, you need. We're going to need a couple more specimen jars. I think this is non-sentinel lymph node. I'm not even sure there's a node in there, so we'll just put it here, and then can I have Metz, please? Thank you. All right. And then we are gonna separate these guys. So remember we saw the one that was blue? Yeah. It was super blue. I think, oh, there he is. There he is. Yeah. That guy? Okay. So this one, I'm gonna just divide from the other one, all right. So then this one is gonna be... We'll take another count, please. Ready? Yep. Okay, 915. Yep. All right, and this is non-sentinel. And then these can all go together.
All right, I think we got everything. Great, all right. So now we will just do some irrigation.
That's where the axilla is. It's just deep. Yeah, so everything looks nice. All right, so let's close. We'll take a 3-0 Vicryl, please, and now we'll close the axillary fascia. I'll have you just hold these. Perfect, thank you. DeBakey. Thank you. Okay. Don't pull so hard, like yeah, exactly. Because I'm just really just taking this - this layer of fascia that's on it, and then we'll do another layer like in Scarpa's, or the deep dermis, at least. The reason we close the axillary fascia is that if he does get a seroma postoperatively, it helps prevent it from him having any leakage, and then also hopefully would help prevent infection, and so that's why I'm running it with a Vicryl, just to try and get a watertight closure, and then I'll do the deep dermal, and then you can run the skin. Okay. And then, you know, here it's, we can do like a little bit of Scarpa's and a little bit of just, oh, this is the bad one, sorry. Oh, sorry. Thank you. Okay, great. Just do a couple deep dermals. I got one, two, three, four, five, six. One, two, three, four, five, six, seven, eight, nine, 10, 11. Okay. Okay. All right. All right, I'll take that local. Thank you. 630. Here's this needle back. Thank you. And then we'll take the Monocryl next. Let's give the rest of it. All right, great. Go further away from the corner. Like there's really, yeah, there's no reason to make it hard for yourself, yep, because here really the goal is just to bury the knot and have it be a good, strong knot, and you wanna pull it through before you - all right. I think that should be enough, and now is when you can try and get it close to the corner. Yeah, exactly, but go behind your knot, right? That's what buries it, but don't cut it. Yeah, so really just avoid the knot. Come out and just make sure you're not in epidermis. It doesn't have to be perfect, right. It's just good. There you go. Now do your nice plastics. So things we worry about in the postoperative setting in terms of wound issues with the wide local excision, you know, infection, cellulitis, hematoma obviously. Here, especially in the axilla, we worry about seroma. The rate of lymphedema for sentinel lymph node biopsy is much lower than that for a lymphadenectomy. Oh yeah. Especially in someone who's young, active - exactly. But if patients do get lymphedema, we can refer them to PT and that's often very helpful. Oh, okay, good. Try and go in more perpendicular. Yep, good. Because that allows you to follow the curve in the needle and get a better bite, yep. Now this is probably where I would do my deep. Yep, do my hitch and then, yep, or no, just deep, right? Because you want the knot to go deep, and if you just pull the bottom one, then you won't, you won't bunch it up as much. Yeah, there you go, good. Because when you pull this one, it bunches. Yeah, but this one you're actually, yep. Yep, good, now bury - go behind the knot again and pull it out.
Today you saw we did a wide local excision of an intermediate-thickness back melanoma as well as the sentinel lymph node biopsy of left axillary lymph nodes. We are able to identify several sentinel lymph nodes for this patient. The patient did great. Hopefully he won't have any melanoma in his lymph nodes.