Abstract P2-12-03: Endofascial axillary lymphadenectomy – Towards a drainless protocol

Abstract

Background: The pathogenesis of seroma formation following axillary dissection continues to be poorly understood, although it seems that the greater the surgical disruption of the axilla, the higher the incidence of seroma and lymphoedema. We have previously described the laminated, three-dimensional structure of the clavipectoral fascia (CPF) that is evident during axillary ultrasonography and dissection . We propose that reconstituting the CPF reduces dead space, partially restores pressure gradients and facilitates collateralization to improve lymphatic flow, thereby reducing the incidence of seromas. Herewith, is a description of our technique for reconstitution of the CPF and our experience thus far. Method: Technique: Following mastectomy or breast conservation surgery, the lateral border of pectoralis major is defined. Here, the medial, anterior laminae of the CPF are identified but not incised. Once the anterior extent of the CPF is displayed, a longitudinal incision is made through the midpoint of the CPF to access the axillary contents. If there is a substantial axillary tail, then the CPF is incised along the perimeter of the tail to include intra-mammary lymph nodes. A loose areolar tissue plane is encountered; the edges of the CPF are grasped and elevated and this areolar tissue plane developed by blunt and sharp dissection. Medially, this loose areolar tissue plane leads directly to a posterior gutter, and the long thoracic nerve on serratus anterior is identified and preserved. Superiorly, a deeper lamina of the CPF along the inferior border of the axillary vein has to be incised to find the thoracodorsal nerve. Identification of the intercostobrachial nerves is standard, as is the lateral dissection. Identification of the long thoracic nerve and thoracodorsal bundle results in definition of a vertical sheet, ‘the interneural tissue’. This can be grasped between the thumb and index finger and is excised en bloc. This tissue contains fat, lymph nodes and lymphatic vessels and is lined by thin fascial layers that we consider related to the CPF3. At this stage, the anterior laminae of the CPF and axilla are carefully palpated for any residual nodes. After haemostasis, the CPF is reconstituted with a running, absorbable ‘lymphostatic’ suture. No drain is placed in the axilla. Results: Between 2012 – 2015, 64 patients have undergone axillary dissection with reconstitution of the CPF in our unit.. The average age was 54 years (range 29-87 years). An average of 12 nodes were procured (range 2-26 nodes). Only 5 women (8%) required seroma aspiration. Conclusion: We have dispensed with axillary drains in those who have had reconstitution of the CPF and only a minority of our patients required axillary seroma aspiration. We believe this technique should be given consideration to decrease the use of drains following axillary dissection. Citation Format: Meredith IC, Popadich A, Mouat CH, Barrett K, King B. Endofascial axillary lymphadenectomy – Towards a drainless protocol. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-03.

A Prospective Study of the Efficacy of Endofascial Axillary Dissection to Reduce Axillary Seroma Formation

“…Thus, it is the multiple refections and the condensation of the multilaminated clavipectoral fascia which cover and compartmentalize the axilla. The main difference between the reports published by King and Meredith 6 and our study is that while they did not use drains following an endofascial dissection, we routinely placed drains. While we had a comparison group of routine axillary dissection in our study, they did not report any such comparison.…”

“…This was demonstrated in the study by King and Meredith who did not use drains postoperatively after the endofascial method and had acceptable rates of seroma aspiration. 6 The early drain removal after an endofascial axillary dissection translates into clinical benefits in terms of improved patient convenience, improved local hygiene, reduced postoperative visits for drain care, psychological benefit, and possibly, early initiation of adjuvant therapy. It might also lead to lower drain and seroma-related issues such as pain, infection, and wound complications.…”

“…This was demonstrated in the study by King and Meredith who did not use drains postoperatively after the endofascial method and had acceptable rates of seroma aspiration. 6…”

“…4 A novel method to reduce axillary seroma is the endofascial axillary dissection which was described by King and Meredith, at The Breast Centre Bowen Hospital, Wellington, New Zealand. 5 6 The aim of our study was to compare the endofascial axillary dissection with the standard method of axillary dissection regarding axillary drain output, nodal harvest, seroma incidence, days taken for drain removal, and complication rates after breast conservation surgery.…”