Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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1104 Section XIV • Gynecology

◆ The rectovaginal fascia is sutured to the center of the perineal body (Figures 99-19

and 99-20).

◆ The transverse perineal and bulbocavernosus (also called bulbospongiosus) muscles join the

anal sphincter and rectovaginal septum at the perineal body.

◆ If these muscles are not inextricably bound together, they may be joined end-to-end. If

there is excessive perineal laxity, the perineal muscles may also be overlapped, but such

overlap may require extensive lateral dissection of the transverse perineal muscles toward

the ischial tuberosities (Figure 99-21).

CHAPTER 99 • Repair of Rectovaginal Fistulae 1105

FIGURE 99 –19

Incise for transverse

perineal muscle

FIGURE 99 –20

FIGURE 99 –21

1106 Section XIV • Gynecology

◆ A 00 or 000 rapid absorbable suture is used to close the vaginal mucosa and perineal skin

(Figures 99-22 through 99-24).

STEP 4: POSTOPERATIVE CARE

◆ The most common short-term complication is urinary retention, so a urinary catheter may

be necessary until the normal micturition reﬂ ex recovers.

◆ Postoperative management consists of careful perineal hygiene and stool softeners.

◆ Excessive antibiotic use in the absence of infection may lead to diarrhea and impaired

wound healing of the rectal mucosal suture line, in addition to the increased risk of infec-

tion with resistant organisms.

◆ Although perineal skin breakdown is common, it does not seem to affect the ultimate

success of the repair.

STEP 5: PEARLS AND PITFALLS

◆ Long-term functional outcome of overlapping anal sphincteroplasty may be disappointing,

with anal continence rates as low as 50%.

◆ Patients should be counseled that restoration of anatomy does not guarantee restoration of

function.

CHAPTER 99 • Repair of Rectovaginal Fistulae 1107

Rectovaginal fascia

FIGURE 99 –22

FIGURE 99 –24

Subcuticular suture

Continuous suture

FIGURE 99 –23

1108 Section XIV • Gynecology

SELECTED REFERENCES

1. Martius H: Die Gynäkologischen Operationen. Leipzig, Georg Thieme, 1949.

2. Hankins GDV, Hauth JC, Gilstrap LC, et al: Early repair of episiotomy dehiscence. Obstet Gynecol

1990;75:48-51.

3. Mengert WF, Fish SA: Anterior rectal wall advancement. Technique for repair of complete perineal

laceration and rectovaginal ﬁ stula. Obstet Gynecol 1955;3:262-267.

4. Noble GH: A new operation for complete laceration of the perineum designed for the purpose of

eliminating danger of infection from the rectum. Trans Am Gynecol Soc 1902;27:357-363.

5. Sultan AH, Kahn MA: Perineal and primary anal sphincter repairs. In Cardozo L, Staskin D (eds):

Textbook of Female Urology and Urogynecology. London, Isis Medical Media, 2001, pp 628-642.

1110

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the location of the lymph nodes in relation to the chest

wall musculature, fascial boundaries, lymphatic drainage pathways, vascular supply

supporting structures, and innervation of surrounding tissues is essential for appropriate

surgical management.

◆ Figure 100-1 demonstrates the breast gland and its rich intraparenchymal lymph channels

coursing toward the deeper major nodal reservoirs.

◆ Figure 100-2 illustrates the supporting structure of the chest wall musculature, the major

blood vessels, and the location of the lymph nodes.

◆ The lymph nodes lateral to the pectoralis minor muscle constitute level I nodes; those im-

mediately beneath the muscle, the level II nodes; and those medial to it, level III nodes. The

interpectoral nodes (Rotter’s nodes) are located between the pectoralis major and minor

muscles and are part of level III nodes. Internal mammary nodes are located medially along

internal mammary vessels beneath the sternum. Unnamed intramammary lymph nodes can

be present in all quadrants of the breast.

◆ The boundaries of the axilla are deﬁ ned by the pectoral minor muscle medially, the latissi-

mus dorsi muscle laterally, the axillary vein superiorly, and the subscapularis and teres

major muscles posteriorly.

◆ Axillary lymph node dissection removes the lymph nodes lateral to the pectoralis minor

muscle (level I nodes) and posterior to the pectoralis minor muscle (level II nodes). In

some cases, the lymph nodes medial to the pectoralis (level III nodes) and the interpectoral

nodes (Rotter’s nodes) are also removed.

◆ Other types of lymph node procedures or treatments include the following:

◆ Sentinel node biopsy

◆ Lymph node sampling

◆ Excision of a palpable lymph node

◆ Axillary irradiation

CHAPTER

100

Axillary Node Dissection

Baiba J. Grube

CHAPTER 100 • Axillary Node Dissection 1111

Line of incision

Level II nodes

Level III nodes

Level I nodes

Internal mammary gland

FIGURE 100–1

Median nerve

Axillary artery and

vein

Latissimus dorsi muscle

Serratus anterior muscle

Pectoralis major muscle

Deltoid muscle

Pectoralis minor muscle

FIGURE 100–2

1112 Section XV • Miscellaneous Procedures

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Selection of a surgical option for local control of breast cancer is a complex decision based

on the tumor features, the body habitus, and individual choice. Interdisciplinary discussion

with radiation oncologists, medical oncologists, and plastic surgeons, in addition to the

oncologic surgeon, provides a comprehensive understanding of the options available to the

patient.

◆ Lumpectomy with axillary lymph node dissection may be an alternative procedure to a

modiﬁ ed radical mastectomy for many women, especially in the current era of mammo-

graphic screening and identiﬁ cation of early stage disease and with the use of induction

chemotherapy to reduce the size of the primary tumor.

◆ Discussion of the planned procedure with the anesthesiologist is critical.

◆ Long-acting paralytic agents should be avoided when an axillary dissection is planned to

detect intact motor nerve function.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The patient is placed in the supine position, close to the edge of the operating table for ease

of exposure of the axilla, with the arm extended on a padded arm board with or without a

wedge. The arm may be prepped out separately and covered in a sterile stockinette to allow

free rotation of the arm medially to relax the pectoralis major and minor muscles.

◆ Many incisions have been used for axillary dissection. The transverse incision approxi-

mately 1 cm below the hair-bearing area extending from the latissimus dorsi to the pectora-

lis major medially results in the most cosmetically attractive incision. Other incisions may

be perpendicular to the axilla or S-shaped incisions.

◆ A marking pen is used to draw the planned incision. The skin is incised and extended

through the dermis into the subcutaneous adipose tissue to expose the investing fascia of

the axilla (Figure 100-3). The thickness of the ﬂ aps will vary according to body mass

index. In heavyset individuals, the ﬂ aps will be thick and may cave into the axilla, making

dissection difﬁ cult. Adequate exposure is essential to avoid injury to important structures.

CHAPTER 100 • Axillary Node Dissection 1113

Pectoralis major muscle

retracted

Pectoralis minor muscle

Axillary fat and

lymph nodes

FIGURE 100–3

1114 Section XV • Miscellaneous Procedures

2. DISSECTION

◆ Dissection is initiated by elevating the skin ﬂ aps with skin hooks or Freeman face lift

retractors with electrocautery.

◆ As the ﬂ aps are elevated, the assistant holds upward tension on the skin ﬂ aps while the

surgeon uses countertraction on the axillary fat pad.

◆ The skin ﬂ aps are raised circumferentially and retracted with medium Richardson retractors

to expose the axillary fat and lymph nodes (see Figure 100-3).

◆ Dissection is initiated along the pectoralis major muscle medially from superior to inferior.

Care must be exercised to avoid injury to the medial anterior thoracic nerve (medial pecto-

ral nerve), which may penetrate both pectoral muscles and emerge medially or may course

along the lateral aspect of the pectoralis minor. Injury to this nerve may lead to atrophy of

part of the pectoralis major muscle.

◆ The fascia along the pectoralis major is incised and retracted medially with a small or

medium Richardson retractor, exposing the underlying pectoralis minor. The clavipectoral

fascia along the pectoralis minor is then incised and the retractor is replaced, exposing the

level II nodes posterior to the pectoralis minor. The arm may now be rotated medially to

take tension off the pectoral muscles and expose the axillary contents. Care must be taken

to avoid traction of the extremity and the brachial plexus in the anesthetized patient.

◆ The inferior reﬂ ection of the axillary fascia is identiﬁ ed, and dissection is continued from

medial to lateral on the serratus anterior muscle to the latissimus dorsi muscle laterally.

◆ Dissection is continued along the lateral aspect of the latissimus dorsi muscle to the level of

its tendinous insertion (Figure 100-4). This marks the location of the overlying axillary

vein. Dissection along the ventral aspect of the latissimus dorsi should be avoided until the

thoracodorsal nerve, artery, and vein are identiﬁ ed, visualized, and maintained in view

during dissection.

◆ Dissection from the tendinous insertion of the latissimus dorsi proceeds medially, inferior to

the axillary vein.

◆ The superior extent of the axillary dissection should begin approximately 5 mm below the

axillary vein to preserve the lymphatics of the arm and reduce the likelihood of upper

extremity lymphedema (see Figure 100-4). This tissue is rich in lymphatics and blood

vessels, which should be ligated with ﬁ ne silk ties or Weck Hemoclips.