Axillary Clearance

Axillary Clearance

The axillary (arm pit) lymph nodes provide the main lymphatic drainage of the breast. To understand what this means, you need to understand what lymphatic fluid is. The heart pumps blood to the rest of the body (including the breast) through arteries. Most of the fluid in the blood returns to the heart through veins.

A small amount of fluid stays in the tissues (including the breast) and returns to the heart through narrow clear channels called lymphatics. This lymphatic fluid goes through a series of lymph nodes to be screened for infection.

If breast cancer cells reach the lymphatics, they can be trapped by the axillary lymph nodes. Lymphatic fluid reaches a group of one to four lymph nodes first before reaching the rest of the axillary nodes. These are called the sentinel lymph nodes.

If your lymph nodes are normal on ultrasound, you will have a sentinel node biopsy NOT an axillary clearance. If you have abnormal lymph nodes on examination or on ultrasound, a biopsy is performed to confirm the presence of breast cancer cells. If this is confirmed or if you have had a sentinel node biopsy showing cancer cells in the nodes, you may proceed to an axillary clearance.

An axillary clearance is removing the lymph nodes in the arm pit. I often get asked how many nodes will be removed. The answer is that the number of lymph nodes we have varies from one person to the other.

We do not count the lymph nodes as we perform an axillary clearance nor do we see or feel every lymph node. What we do is remove all the fatty tissue that contains the lymph nodes within particular boundaries. The boundaries are the axillary vein above, the angular vein below, the thoracodorsal nerve laterally (towards the arm) and the inside of edge of the pectoralis minor muscle medially (towards the midline).

The operation is either done through a mastectomy incision or a separate axillary incision at the bottom of the hair-bearing tissue of the arm pit. The fatty tissue containing the lymph nodes is removed as described above. Local anaesthetic is injected. A drain tube is placed and the wound closed with dissolving sutures. The drain is made of silicon and is attached to a vacuum suction bag. It stays in for 1-2 weeks depending on the amount drained each day.

What are the risks of surgery?

Surgical procedural risks can be divided into anaesthetic and surgical risks. Anaesthetic risks are usually discussed with the patient by the anaesthetic team.

Surgical risks specific to axillary clearance include:

The risk of significant bleeding from an axillary clearance is small.

The risk of infection from an axillary clearance is small and is further reduced by giving prophylactic antibiotics at the start of the procedure.

The commonest complication of an axillary clearance is a collection of inflammatory fluid called a “seroma”. This occurs up to 80% of the time and may need to be drained multiple times. Drainage is a simple procedure that is painless and is carried out in the office without the need for any anaesthetic.

There are a number of nerves that course through the area of dissection and need to be preserved. Three of these nerves supply muscles and if damaged may cause weakness of these muscles resulting in weakness of arm movement or so-called “winging” of the scapula. Thankfully, damage to these nerves is rare as dissection is done very carefully to preserve these nerves.

Another nerve is a sensory nerve called the intercosto-brachial nerve which supplies sensation to the inside of the arm. This travels through the tissues removed and is usually divided resulting in permanent numbness in this small area over the inside of the arm. Although this is permanent, it does reduce slightly with time and is well tolerated.

Perhaps the most troublesome complication of an axillary clearance is arm lymphoedema. This results from interruption of the lymphatic drainage of the arm as the arm is also drained by the axillary nodes some of which may be removed during the axillary clearance.

This can be prevented by avoiding taking excessive amount of fatty tissue outside of the above-mentioned boundaries.

The risk of severe lymphoedema is around 8% and is increased in overweight patients and in those receiving radiotherapy to the breast or chest wall.

After axillary surgery, it is important to mobilize the shoulder gently to avoid getting a stiff shoulder. You may be seen by the physiotherapist prior to discharge for some advice on gentle shoulder exercises.

Before surgery

Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.

You will be contacted by the hospital the day before your procedure to let you know what time to come in.

This is usually 1-2 hours before your surgery unless you are required to have a radiological procedure such as the placement of a guidewire for your breast surgery.

After surgery

Pain is usually mild after an axillary clearance.

You should take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).

Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.

Stronger pain killers such as opioid anaelgesics (Endone, Codeine) may help in the first couple of days but should be taken sparingly as they can cause constipation

The wound is dressed with Dermabond glue which is waterproof. The glue feels hard which is normal. It sheds off over the 2-3 weeks.

The axillary drain stays in for 1-2 weeks. It is usually kept in for the first week. During the second week, if the drainage is <20mls/day for two consecutive days, the drain is removed. Otherwise, the drain is removed at 2 weeks. The drain output is usually monitored by the Hospital In The Home (HITH) nursing service but can also be done through our rooms with our breast care nurse if your private fund does not pay for this service.

If the drain is removed too early, there is an increased risk of seroma formation.

Patients are usually admitted to hospital overnight and can go home the next day.

You will be followed up within 1-2 weeks of your surgery to review the wound, the drain output and discuss your pathology results.

Your follow up appointment will be booked by the ward clerk prior to your discharge.