Wide Local Excision of an Intermediate-Thickness Back Melanoma with a Sentinel Lymph Node Biopsy of Left Axillary Lymph Nodes

CHAPTER 1

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 excisionfor an intermediate melanoma,along with the sentinel lymph node biopsy.So the patient today has a intermediate-thickness melanomaon the early side, closer to 1 mm.Today we are gonna do the sentinel lymph node biopsyfor prognostic information to find outif there is any evidence of any spreadof the melanoma to his lymph nodes.This is indicated because it is greaterthan 0.8 mm in thickness.He doesn't have any other worrisome featuresin his melanoma, no ulceration, no mitoses.The guidelines suggest that a 1- to 2-cm marginis adequate in this case, and so we'll doa 1 cm margin today for him.Preoperatively, the patient went to nuclear medicinewhere he was injected with a technetium-labeled dyearound the site of the melanoma.This allows me to identify the first lymph nodesthat 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 imagingallowed us to identify that the lymph nodeswere 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 identifythe sentinel lymph nodes.Then you'll see us do the wide local excision first.In this case, we're doing that to prevent shine-throughwhen we then move to the left axilla to lookfor the sentinel lymph nodes.After we remove the melanoma itself,then we'll reposition the patient and we'll performthe sentinel lymph node biopsy within the left axilla.

CHAPTER 2

So isosulfan blue will act as our additional tracerin addition to the radioactive tracer,the technetium-labeled that he got in nuclear medicine,and this needs to be an intradermal injectionin order to be taken up correctly by the lymphatics.Just clean off the skin.And this will stain, so you just wanna be carefulthat 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 mappingwas 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 nodeas 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 mappedto the left axilla, you know, the nuclear medicineis really helpful for melanomas on the torsobecause the drainage pattern is such that it can goto bilateral axilla or bilateral groins,or sometimes even the neck.So having the imaging in nuclear medicine ahead of timereally 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 resectingthe 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 localizethe 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 prepis we're gonna use a non-sterile probe just to confirmthat we don't have any in-transit nodesthat 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 isan intermediate-thickness melanoma.Do you remember the depth?Yeah, this one I saw online was,it had a mitotic activity of 1.1This 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 featureswe 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 withmore 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 databetween 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 itwhen we look at the lymph node, and then we markall the way around.All right, 1-cm margin, and our,the margin of excision is reallyto prevent local recurrence.That's the endpoint in all the studies that looksat what margin you should use,and so that's why we take this additional margin.Okay, so then we wanna think abouthow 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 incisionwith the additional thought process being thatif 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 havea positive margin or a recurrence of this scarand we had to come back, this would bea 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 intradermalinjection, just outside of our line of resection.Okay, great. Thank you.Let's do a little more down here.Thank you. Thank you.

CHAPTER 3

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 pathologistcan 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 bluetaken up by a lymphatic, yeah there,which is a great sign, again.Okay, good.Knife down for a sec, and then we're justgonna clean up our edges here.Help us with hemostasis.Okay, good.Okay, wonderful.

CHAPTER 4

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 downonto the correct plane in which to resect the melanomafor the oncologic excision is just above the fascia.So unlike a sarcoma, where we would take the fasciafor 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 withan Allis is, again, this is not partof 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 holda little tension that way?Perfect,and my goal here is really to get a -full thickness of the underlying tissue all the way downto 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.

CHAPTER 5

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 uswhere 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 wasany problem with tension, then at this pointI 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.

CHAPTER 6

So I use 2-0 Vicryl, just to closethe 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 Vicryldeep dermals and run a Monocryl.This is really, this layer is justto 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 anythingthat you think about differently in the lower extremitywhere you're more susceptible to infections or?Yeah, so I think the thing you think about moreis 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'sgonna be important, or at the bottom of the foot,which is a weight bearing area.Exactly.Then you have to think abouthow you're gonna close that,and often we'll collaborate with plastics.Right.Or if it's just an areawhere you need some skin grafting.I know you do a lot of in-office procedures,but for you, what's your thresholdfor bringing it into the OR?A lot of it is just, can the patienttolerate 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 graftor a flap for closure, that would be a reasonto come to the operating room.If someone is on a blood thinner and I'm concernedthat there may be more than the usual amount of blood lossor just a really big resection, something like that,it's, I might elect to offer themto 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 morein the middle and then we'll run it.For this, we're gonna take the half-inch Steri'scut in thirds, and then we'll do Tegaderm and topper.Just do one more down there and maybe one thereand then run it.And this patient's very active,so I think just making sure we're closing this in layersunder low tension to make sure he doesn't haveany wound issues, and then also to make surehe 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 itright in the corner and it helps you avoida 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 cornerand it was, the dog ear was more.It just makes it hardto line it up nicely. Exactly, yeah.So, but then you cancome 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 askthe patients to take it easy.Someone who's very active may need to, you know,avoid intense activity for a week or two afterwardsjust 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 gonnaturn supine now.

CHAPTER 7

All right, so now I'm just gonna confirmthe 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.

CHAPTER 8

All right, we'll take a marker.So I like to use the probe to findthe 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 directionyou'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 incisionyou're making now in the future if you need it, yep.

Some local.Okay, all right.

CHAPTER 9

So hold tension for me.Perfect.Good.

CHAPTER 10

All right.Right here?Let's start in the middle.Okay, good.We're just gonna go down through the subcutaneous tissuesuntil 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 tissuesand 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 fasciaand to know that I'm in the axilla, what I'm looking foris 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 nowwe'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 probeto help orient me to where I'm going.Yeah, I see some blue.I know. That does look blue.So probably I'm gonnahave 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 Allisor with a silk stitch, and then when I'm confidentthat I have the node, I will do a figure of eight to give mea 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 secand show you too, make sure you can see.Hold that there.So here you can see I've got my stitchthrough the lymph node, and then I see the pedicleof the node here with blue in the lymphaticsand as well as the little vessels.So now our job is to dissect out the nodeand then to clip at the pedicle to make sure thatwe 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 dois use my probe to make sure I really understandwhere 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 capsulewe 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 effectiveagainst preventing lymphatic leak and seromathan cautery alone.So now to me, it looks like we have the nodepretty 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 thenthe 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.

CHAPTER 11

So now what we're gonna do iswe're gonna take counts on this node,which we saw was both blue and hot, and that'll give usa sense for how much...How many counts we would need to findall the sentinel nodes, which will beany 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 countover about 300 or so accounts as a sentinel node,'cause that's 10%, but we're also looking for anythingthat 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.

CHAPTER 12

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 beanright here under my fingers.Yeah, I feel it, yeah.So we'll try and pull that upand 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 ifI can deliver it a little bit so thatwe're not really digging in a hole.So this is a case where probablyI'm going to open up the fascia againjust 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 justdeliver 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 dissectdown 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 surprisinggiven 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 stickmy probe back in there and make sure there's nothing obviousbefore 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 axillarysentinel 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 dividefrom 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.

CHAPTER 13

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 thatif 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 ofjust, 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 reasonto make it hard for yourself, yep,because here really the goal is just to bury the knotand 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 settingin 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 biopsyis 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 curvein 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 pullthe 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.

CHAPTER 14

Today you saw we did a wide local excision ofan intermediate-thickness back melanoma as well asthe sentinel lymph node biopsy of left axillary lymph nodes.We are able to identify several sentinellymph nodes for this patient.The patient did great.Hopefully he won't have any melanoma in his lymph nodes.