Breast, Endocrine

Surgery: Complications, Risks and Consequences
Brendon J. Coventry Editor
Breast,
Endocrine and
Surgical
Oncology
Surgery: Complications, Risks and Consequences
Series Editor
Brendon J. Coventry
For further volumes:

http://www.springer.com/series/11761
Brendon J. Coventry
Editor
Breast, Endocrine
and Surgical Oncology
Editor
Brendon J. Coventry, BMBS, PhD,
FRACS, FACS, FRSM
Discipline of Surgery
Breast, Endocrine and Surgical
Oncology Unit
Royal Adelaide Hospital
University of Adelaide
Adelaide, SA
Australia
ISBN 978-1-4471-5420-4 ISBN 978-1-4471-5421-1 (eBook)

DOI 10.1007/978-1-4471-5421-1
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2013957871
© Springer-Verlag London 2014

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This book is dedicated to my wonderful wife
Christine and children Charles, Cameron,
Alexander and Eloise who make me so
proud, having supported me through this
mammoth project; my patients, past, present
and future; my numerous mentors, teachers,
colleagues, friends and students, who know
who they are; my parents Beryl and
Lawrence; and my parents-in-law Barbara
and George, all of whom have taught me and
encouraged me to achieve
“Without love and understanding we have
but nothing”
Brendon J. Coventry
Foreword I
This comprehensive treatise is remarkable for its breadth and scope and its author-
ship by global experts. Indeed, knowledge of its content is essential if we are to
achieve optimal and safe outcomes for our patients. The content embodies the
details of our surgical discipline and how to incorporate facts and evidence into our
surgical judgment as well as recommendations to our patients.
While acknowledging that the technical aspects of surgery are its distinguishing
framework of our profession, the art and judgment of surgery requires an in depth
knowledge of biology, anatomy, pathophysiology, clinical science, surgical out-
comes and complications that distinguishes the theme of this book. This knowledge
is essential to assure us that we are we doing the right operation, at the right time,
and in the right patient. In turn, that knowledge is essential to take into account how
surgical treatment interfaces with the correct sequence and combination with other
treatment modalities. It is also essential to assess the extent of scientific evidence
from clinical trials and surgical expertise that is the underpinning of our final treat-
ment recommendation to our patient.
Each time I sit across from a patient to make a recommendation for a surgical
treatment, I am basing my recommendation on a “benefit/risk ratio” that integrates
scientific evidence, and my intuition gained through experience. That is, do the
potential benefits outweigh the potential risks and complications as applied to an
individual patient setting? The elements of that benefit/ risk ratio that are taken into
account include: the natural history of the disease, the stage/extent of disease, sci-
entific and empirical evidence of treatment outcomes, quality of life issues (as per-
ceived by the patient), co-morbidity that might influence surgical outcome, risks
and complications inherent to the operation (errors of commission) and the risk(s)
of not proceeding with an operation (errors of omission).
Thus, if we truly want to improve our surgical outcomes, then we must under-
stand and be able to either avoid, or execute sound management of, any complica-
tions that occur (regardless of whether they are due to co-morbidity or iatrogenic
causes), to get our patent safely through the operation and its post-operative course.
These subjects are nicely incorporated into the content of this book.
vii
viii Foreword I
I highly recommend this book as a practical yet comprehensive treatise for the
practicing surgeon and the surgical trainee. It is well organized, written with
great clarity and nicely referenced when circumstances require further
information.
Charles M. Balch, MD, FACS

Professor of Surgery
University of Texas, Southwestern Medical Center,
Dallas, TX, USA
Formerly, Professor of Surgery, Johns Hopkins Hospital,
Baltimore, MD, USA
Formerly, Executive Vice President and CEO,
American Society of Clinical Oncology (ASCO)
Past-President, Society of Surgical Oncology (USA)
Foreword II
Throughout my clinical academic career I have aspired to improve the quality and
safety of my surgical and clinical practice. It is very clear, while reading this impres-
sive collection and synthesis of high-impact clinical evidence and international
expert consensus, that in this new textbook, Brendon Coventry has the ambition to
innovate and advance the quality and safety of surgical discipline.
In these modern times, where we find an abundance of information that is avail-
able through the internet, and of often doubtful authenticity, it is vital that we retain
a professional responsibility for the collection, analysis and dissemination of evi-
denced-based and accurate knowledge and guidance to benefit both clinicians and
our patients.
This practical and broad-scoped compendium, which contains over 250 proce-
dures and their related complications and associated risks, will undoubtedly become
a benchmark to raise the safety and quality of surgical practice for all that read it. It
also manages to succeed in providing a portal for all surgeons, at any stage of their
careers, to reflect on the authors’ own combined experiences and the collective
insights of a strong and influential network of peers.
This text emphasizes the need to understand and appreciate our patients and the
intimate relationship that their physiology, co-morbidities and underlying diagnosis
can have upon their unique surgical risk with special regard to complications and
adverse events.
I recognize that universally across clinical practice and our profession, the evi-
dence base and guidance to justify our decision-making is growing, but there is also
a widening gap between what we know and what we do. The variation that we see
in the quality of practice throughout the world should not be tolerated.
This text makes an assertive contribution to promote quality by outlining the
prerequisite foundational knowledge of surgery, science and anatomy and their
complex interactions with clinical outcome that is needed for all in the field of
surgery.
ix
x Foreword II
I thoroughly recommend this expertly constructed collection. Its breadth and

quality is a testament to its authors and editor.
Lord Ara Darzi, PC, KBE, FRCS, FRS

Paul Hamlyn Chair of Surgery
Imperial College London, London, UK
Formerly Undersecretary of State for Health,
Her Majesty’s Government, UK
Conditions of Use and Disclaimer
Information is provided for improved medical education and potential improvement

in clinical practice only. The information is based on composite material from
research studies and professional personal opinion and does not guarantee accuracy
for any specific clinical situation or procedure. There is also no express or implied
guarantee to accuracy or that surgical complications will be prevented, minimized,
or reduced in any way. The advice is intended for use by individuals with suitable
professional qualifications and education in medical practice and the ability to
apply the knowledge in a suitable manner for a specific condition or disease, and in
an appropriate clinical context. The data is complex by nature and open to some
interpretation. The purpose is to assist medical practitioners to improve awareness
of possible complications, risks or consequences associated with surgical proce-
dures for the benefit of those practitioners in the improved care of their patients. The
application of the information contained herein for a specific patient or problem
must be performed with care to ensure that the situation and advice is appropriate
and correct for that patient and situation. The material is expressly not for medico-
legal purposes.
The information contained in Surgery: Complications, Risks and Consequences
is provided for the purpose of improving consent processes in healthcare and in no
way guarantees prevention, early detection, risk reduction, economic benefit or
improved practice of surgical treatment of any disease or condition.
The information provided in Surgery: Complications, Risks and Consequences is
of a general nature and is not a substitute for independent medical advice or research
in the management of particular diseases or patient situations by health care profes-
sionals. It should not be taken as replacing or overriding medical advice.
The Publisher or Copyright holder does not accept any liability for any injury,
loss, delay or damage incurred arising from use, misuse, interpretation, omissions
or reliance on the information provided in Surgery: Complications, Risks and
Consequences directly or indirectly.
xi
xii Conditions of Use and Disclaimer
Currency and Accuracy of Information
The user should always check that any information acted upon is up-to-date and
accurate. Information is provided in good faith and is subject to change and alter-
ation without notice. Every effort is made with Surgery: Complications, Risks and
Consequences to provide current information, but no warranty, guarantee or legal
responsibility is given that information provided or referred to has not changed
without the knowledge of the publisher, editor or authors. Always check the quality
of information provided or referred to for accuracy for the situation where it is
intended to be used, or applied. We do, however, attempt to provide useful and valid
information. Because of the broad nature of the information provided incomplete-
ness or omissions of specific or general complications may have occured and users
must take this into account when using the text. No responsibility is taken for
delayed, missed or inaccurate diagnosis of any illness, disease or health state at any
time.
External Web Site Links or References
The decisions about the accuracy, currency, reliability and correctness of informa-
tion made by individuals using the Surgery: Complications, Risks and Consequences
information or from external Internet links remain the individuals own concern and
responsibility. Such external links or reference materials or other information should
not be taken as an endorsement, agreement or recommendation of any third party
products, services, material, information, views or content offered by these sites or
publications. Users should check the sources and validity of information obtained
for themselves prior to use.
Privacy and Confidentiality
We maintain confidentiality and privacy of personal information but do not guaran-

tee any confidentiality or privacy.
Errors or Suggested Changes
If you or any colleagues note any errors or wish to suggest changes please notify us
directly as they would be gratefully received.
How to Use This Book
This book provides a resource for better understanding of surgical procedures and
potential complications in general terms. The application of this material will
depend on the individual patient and clinical context. It is not intended to be abso-
lutely comprehensive for all situations or for all patients, but act as a ‘guide’ for
understanding and prediction of complications, to assist in risk management and
improvement of patient outcomes.
The design of the book is aimed at:
• Reducing Risk and better Managing Risks associated with surgery
• Providing information about ‘general complications’ associated with surgery
• Providing information about ‘specific complications’ associated with surgery
• Providing comprehensive information in one location, to assist surgeons in their
explanation to the patient during the consent process
For each specific surgical procedure the text provides:
• Description and some background of the surgical procedure
• Anatomical points and possible variations
• Estimated Frequencies
• Perspective
• Major Complications
From this, a better understanding of the risks, complications and consequences
associated with surgical procedures can hopefully be gained by the clinician for
explanation of relevant and appropriate aspects to the patient.
The Estimated frequency lists are not mean’t to be totally comprehensive or to
contain all of the information that needs to be explained in obtaining informed con-
sent from the patient for a surgical procedure. Indeed, most of the information is for
the surgeon or reader only, not designed for the patient, however, parts should be
selected by the surgeon at their discretion for appropriate explanation to the indi-
vidual patient in the consent process.
xiii
xiv How to Use This Book
Many patients would not understand or would be confused by the number of

potential complications that may be associated with a specific surgical procedure, so
some degree of selective discussion of the risks, complications and consequences
would be necessary and advisable, as would usually occur in clinical practice. This
judgement should necessarily be left to the surgeon, surgeon-in-training or other
practitioner.
Preface
Over the last decade or so we have witnessed a rapid change in the consumer
demand for information by patients preparing for a surgical procedure. This is
fuelled by multiple factors including the ‘internet revolution’, altered public con-
sumer attitudes, professional patient advocacy, freedom of information laws, insur-
ance issues, risk management, and medicolegal claims made through the legal
system throughout the western world, so that the need has arisen for a higher, fairer
and clearer standard of ‘informed consent’.
One of the my main difficulties encountered as a young intern, and later as a
surgical resident, registrar and consultant surgeon, was obtaining information for
use for the pre-operative consenting of patients, and for managing patients on the
ward after surgical operations. I watched others struggle with the same problem too.
The literature contained many useful facts and clinical studies, but it was unwieldy
and very time-consuming to access, and the information that was obtained seemed
specific to well-defined studies of highly specific groups of patients. These patient
studies, while useful, often did not address my particular patient under treatment in
the clinic, operating theatre or ward. Often the studies came from centres with vast
experience of a particular condition treated with one type of surgical procedure,
constituting a series or trial.
What I wanted to know was:
• The main complications associated with a surgical procedure;
• Information that could be provided during the consent process, and
• How to reduce the relative risks of a complication, where possible
This information was difficult to find in one place!
As a young surgeon, on a very long flight from Adelaide to London, with much
time to think and fuelled by some very pleasant champagne, I started making some
notes about how I might tackle this problem. My first draft was idle scribble, as I
listed the ways surgical complications could be classified. After finding over 10 dif-
ferent classification systems for listing complications, the task became much larger
and more complex. I then realized why someone had not taken on this job before!
xv
xvi Preface
After a brief in-flight sleep and another glass, the task became far less daunting
and suddenly much clearer – the champagne was very good, and there was little else
to do in any case!
It was then that I decided to speak with as many of my respected colleagues as I
could from around the globe, to get their opinions and advice. The perspectives that
emerged were remarkable, as many of them had faced the same dilemmas in their
own practices and hospitals, also without a satisfactory solution.
What developed was a composite documentation of information (i) from the
published literature and (ii) from the opinions of many experienced surgical practi-
tioners in the field – to provide a text to supply information on Complications,
Risks and Consequences of Surgery for surgical and other clinical practitioners to
use at the bedside and in the clinic.
This work represents the culmination of more than 10 years work with the sup-
port and help of colleagues from around the world, for the benefit of their students,
junior surgical colleagues, peers, and patients. To them, I owe much gratitude for
their cooperation, advice, intellect, experience, wise counsel, friendship and help,
for their time, and for their continued encouragement in this rather long-term and
complex project. I have already used the text material myself with good effect and
it has helped me enormously in my surgical practice.
The text aims to provide health professionals with useful information, which can
be selectively used to better inform patients of the potential surgical complications,
risks and consequences. I sincerely hope it fulfils this role.
Adelaide, SA, Australia Brendon J. Coventry, BMBS, PhD,

FRACS, FACS, FRSM
Acknowledgements
I wish to thank:
The many learned friends and experienced colleagues who have contributed in
innumerable ways along the way in the writing of this text.
Professor Sir Peter Morris, formerly Professor of Surgery at Oxford University,
and also Past-President of the College of Surgeons of England, for allowing me to
base my initial work at the Nuffield Department of Surgery (NDS) and John
Radcliffe Hospital in the University of Oxford, for the UK sector of the studies. He
and his colleagues have provided encouragement and valuable discussion time over
the course of the project.
The (late) Professor John Farndon, Professor of Surgery at the University of
Bristol, Bristol Royal Infirmary, UK; and Professor Robert Mansel, Professor of
Surgery at the University of Wales, Cardiff, UK for discussions and valued advice.
Professor Charles Balch, then Professor of Surgery at the Johns Hopkins
University, Baltimore, Maryland, USA, and Professor Clifford Ko, from UCLA and
American College of Surgeons NSQIP Program, USA, for helpful discussions.
Professor Armando Guiliano, formerly of the John Wayne Cancer Institute,
Santa Monica, California, USA for his contributions and valuable discussions.
Professor Jonathan Meakins, then Professor of Surgery at McGill University,
Quebec, Canada, who provided helpful discussions and encouragement, during our
respective sabbatical periods, which coincided in Oxford; and later as Professor of
Surgery at Oxford University.
Over the last decade, numerous clinicians have discussed and generously con-
tributed their experience to the validation of the range and relative frequency of
complications associated with the wide spectrum of surgical procedures. These cli-
nicians include:
Los Angeles, USA: Professor Carmack Holmes, Cardiothoracic Surgeon, Los
Angeles (UCLA); Professor Donald Morton, Melanoma Surgeon, Los Angeles;
Dr R Essner, Melanoma Surgeon, Los Angeles.
xvii
xviii Acknowledgements
New York, USA: Professor Murray Brennan; Dr David Jacques; Prof L Blumgart; Dr
Dan Coit; Dr Mary Sue Brady (Surgeons, Department of Surgery, Memorial
Sloan-Kettering Cancer Centre, New York);
Oxford, UK: Dr Linda Hands, Vascular Surgeon; Dr Jack Collin, Vascular Surgeon;
Professor Peter Friend, Transplant and Vascular Surgeon; Dr Nick Maynard,
Upper Gastrointestinal Surgeon; Dr Mike Greenall, Breast Surgeon; Dr Jane
Clark, Breast Surgeon; Professor Derek Gray, Vascular/Pancreatic Surgeon;
Dr Julian Britton, Hepato-Biliary Surgeon; Dr Greg Sadler, Endocrine Surgeon;
Dr Christopher Cunningham, Colorectal Surgeon; Professor Neil Mortensen,
Colorectal Surgeon; Dr Bruce George, Colorectal Surgeon; Dr Chris Glynn,
Anaesthetist (National Health Service (NHS), Oxford, UK).
Bristol, UK: Professor Derek Alderson.
Adelaide, Australia: Professor Guy Ludbrook, Anesthetist; Dr Elizabeth Tam,
Anesthetist.
A number of senior medical students at the University of Adelaide, including
Hwee Sim Tan, Adelaine S Lam, Ramon Pathi, Mohd Azizan Ghzali, William Cheng,
Sue Min Ooi, Teena Silakong, and Balaji Rajacopalin, who assisted during their stu-
dent projects in the preliminary feasibility studies and research, and their participa-
tion is much appreciated. Thanks also to numerous sixth year students, residents and
surgeons at Hospitals in Adelaide who participated in questionnaires and surveys.
The support of the University of Adelaide, especially the Department of Surgery,
and Royal Adelaide Hospital has been invaluable in allowing the sabbatical time to
engineer the collaborations necessary for this project to progress. I thank Professors
Glyn Jamieson and Guy Maddern for their support in this regard.
I especially thank the Royal Australasian College of Surgeons for part-support
through the Marjorie Hooper Fellowship.
I thank my clinical colleagues on the Breast, Endocrine and Surgical Oncology
Unit at the Royal Adelaide Hospital, especially Grantley Gill, James Kollias and
Melissa Bochner, for caring for my patients and assuming greater clinical load when
I have been away.
Professor Bill Runciman, Australian Patient Safety Foundation, for all of his
advice and support; Professors Cliff Hughes and Bruce Barraclough, from the Royal
Australasian College of Surgeons, the Clinical Excellence Commission, New South
Wales, and the Australian Commission (Council) on Safety and Quality in Healthcare.
Thanks too to Kai Holt, Anne-Marie Bennett and Carrie Cooper who assisted
and helped to organise my work. I also acknowledge my collaborator Martin
Ashdown for being so patient during distractions from our scientific research work.
Also to Graeme Cogdell, Imagart Design Ltd, Adelaide, for his expertise and help-
ful discussions.
I particularly thank Melissa Morton and her global team at Springer-Verlag for
their work in preparing the manuscript for publication.
Importantly, I truly appreciate and thank my wife Christine, my four children and
our parents/ wider family for their support in every way towards seeing this project
through to its completion, and in believing so much in me, and in my work.
Adelaide, SA, Australia Brendon J. Coventry, BMBS, PhD,

FRACS, FACS, FRSM
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Brendon J. Coventry
2 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Richard Rainsbury, Brendon J. Coventry, Armando Giuliano,
Robert Mansel, Jim Katsaros, Richard Rahdon, Venkat Ramakrishnan,
Krishna Clough, Nora Hansen, and Helen Mabry
3 Thyroid and Parathyroid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Armando Giuliano, Samuel Wells Jr., Thomas Reeve,
Hisham Abdullah, and Brendon J. Coventry
4 Adrenal Gland Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Sarah Thompson, David Walsh, and Brendon J. Coventry
5 Lymphatic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
John Thompson, Armando Giuliano, Guy Rees, Douglas Tyler,
Brendon J. Coventry, Nora Hansen, and Helen Mabry
6 Splenic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Brendon J. Coventry and David Watson
7 Specialized Cancer Procedures and Surgery. . . . . . . . . . . . . . . . . . . . . 201
John Thompson, Brendon J. Coventry, Douglas Tyler,
and Hidde M. Kroon
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
xix
Contributors
Hisham Abdullah, MD Putrajaya Hospital, Putrajaya, Malaysia

Krishna Clough, MD Department of General and Breast Surgery,
Institut Curie, Paris, France
Brendon J. Coventry, BMBS, PhD, FRACS, FACS, FRSM Discipline of
Surgery, Breast, Endocrine and Surgical Oncology Unit, Royal Adelaide Hospital,
University of Adelaide, Adelaide, Australia
Armando Giuliano, MD, FACS, FRCSEd Department of Surgery,
Cedars-Sinai Medical Center, Los Angeles, CA, USA
Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center,
Los Angeles, CA, USA
Saul and Joyce Brandman Breast Center – A Project of Women’s Guild, Cedars-
Sinai Medical Center, Los Angeles, CA, USA
Nora Hansen, MD Departments of Surgical Oncology and General Surgery,
Northwestern Memorial Hospital, Chicago, IL, USA
James Katsaros, MBBS, FRACS James Katsaros Clinic,
North Adelaide, Australia
Hidde M. Kroon, MD, PhD Sydney Melanoma Unit, Sydney Cancer Center,
Royal Prince Alfred Hospital, Sydney, NSW, Australia
Helen Mabry, MD Center for Breast Care, The University of Toledo
Medical Center, Toledo, OH, USA
Robert Mansel, MD Institute of Cancer and Genetics,
Cardiff University School of Medicine, Cardiff, Wales
Richard Rahdon, MBBS, Bmed Sci, FRACS Body Recon Plastic Surgery,
Geelong, VIC, Australia
xxi
xxii Contributors
Richard Rainsbury, MBBS, BSc, MS, FRCS BMI Sarum Road Hospital,
Winchester, United Kingdom
Venkat Ramakrishnan, MS, FRACS, FRCS St. Andrews Centre for Plastic
Surgery and Burns, Chelmsford, Essex, United Kingdom
Guy Rees, MBBS, FRCS, FRACS Discipline of Surgery, Otolaryngology,
Head and Neck Surgery, The Queen Elizabeth Hospital, Royal Adelaide Hospital,
and Lyell McEwin Hospital, The University of Adelaide, Adelaide, Australia
Thomas Reeve, MBBS Endocrine Surgical Unit, University of Sydney,
Sydney, NSW, Australia
John Thompson, MD Department of Surgery, Royal Prince Alfred Hospital,
Melanoma Institute, The University of Sydney, Sydney, Australia
Sarah Thompson, MD, PhD, FRACS Oesophagogastric and Upper GI Unit,
Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital,
Adelaide, Australia
Douglas Tyler, MD Division of Surgical Oncology, Department of Surgery,
Duke University Medical Center, Durham, NC, USA
David Walsh, MBBS, FRACS Discipline of Surgery, The Queen Elizabeth
Hospital, The University of Adelaide, Adelaide, Australia
David Watson, MBBS, MD, FRACS Department of Surgery,
Flinders Medical Centre, Adelaide, Australia
Samuel Wells Jr., MD Medical Oncology Branch and Affiliates,
National Cancer Institute at the National Institutes of Health, Bethesda, MD, USA
Chapter 1
Introduction
Brendon J. Coventry
This volume deals with complications, risks, and consequences related to a range of
procedures under the broad headings of breast surgery including reconstructive
breast surgery, thyroid and parathyroid surgery, adrenal surgery, lymphatic surgery,
in particular nodal resection from biopsy to radical lymphadenectomy, splenectomy,
and more specialized surgical oncology procedures including isolated limb infusion
and perfusion and retroperitoneal dissections, for resection of lymph nodes,
sarcomas, lymphomas, and testicular cancers.
Important Note
It should be emphasized that the risks and frequencies that are given here
represent derived figures. These figures are the best estimates of relative fre-
quencies across most institutions, not merely the highest-performing ones,
and as such are often representative of a number of studies, which include
different patients with differing comorbidities and different surgeons. In addi-
tion, the risks of complications in lower- or higher-risk patients may lie out-
side these estimated ranges, and individual clinical judgement is required as
to the expected risks communicated to the patient, staff, or for other purposes.
The range of risks is also derived from experience and the literature; while
risks outside this range may exist, certain risks may be reduced or absent due
to variations of procedures or surgical approaches. It is recognized that differ-
ent patients, practitioners, institutions, regions, and countries may vary in
their requirements and recommendations.
B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM

Discipline of Surgery, Breast, Endocrine and Surgical Oncology Unit,
Royal Adelaide Hospital, University of Adelaide,
L5 Eleanor Harrald Building, North Terrace,
5000 Adelaide, SA, Australia
e-mail: brendon.coventry@adelaide.edu.au
B.J. Coventry (ed.), Breast, Endocrine and Surgical Oncology, 1

Surgery: Complications, Risks and Consequences,
DOI 10.1007/978-1-4471-5421-1_1, © Springer-Verlag London 2014
2 B.J. Coventry
Individual clinical judgement should always be exercised, of course, when

applying the general information contained in these documents to individual
patients in a clinical setting.
The authors would like to thank and acknowledge the following experienced
clinicians who discussed the chapters and acted as advisors: John Farndon (late),
Bristol, England, UK; Michael Greenall, Oxford, England, UK; Jane Clarke,
Oxford, England, UK; Gregory Sadler, Oxford, UK; Peter Malycha, Adelaide,
Australia; Charles M Balch, Texas, USA; Rick Essner, Los Angeles, USA; Murray
Brennan, New York, USA; Christopher O’Brien, Sydney, Australia; and Donald L
Morton, Los Angeles, USA.
Chapter 2
Breast Surgery
Richard Rainsbury, Brendon J. Coventry, Armando Giuliano, Robert Mansel,

Jim Katsaros, Richard Rahdon, Venkat Ramakrishnan, Krishna Clough,
Nora Hansen, and Helen Mabry
Armando Giuliano MD, FACS, FRCSEd

Department of Surgery, Surgical Oncology, Los Angeles, CA, USA
Samuel Oschin Comprehensive Cancer Institute, Surgical Oncology, Los Angeles, CA, USA
Saul and Joyce Brandman Breast Center – A Project of Women’s Guild,
Los Angeles, CA, USA
R. Rainsbury, MBBS, BSc, MS, FRCS
BMI Sarum Road Hospital, Winchester, UK
B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM (*)
Royal Adelaide Hospital, University of Adelaide, L5 Eleanor Harrald Building,
North Terrace, 5000 Adelaide, SA, Australia
R. Mansel, MD
Institute of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, Wales
J. Katsaros, MBBS, FRACS
James Katsaros Clinic, North Adelaide, Australia
R. Rahdon, MBBS, Bmed Sci, FRACS
Body Recon Plastic Surgery, Geelong, VIC, Australia
V. Ramakrishnan, MS, FRACS, FRCS
St. Andrews Centre for Plastic Surgery and Burns, Chelmsford, Essex, United Kingdom
K. Clough, MD
Department of General and Breast Surgery, Institut Curie, Paris, France
N. Hansen, MD
Departments of Surgical Oncology and General Surgery, Northwestern Memorial Hospital,
Chicago, IL, USA
H. Mabry, MD
Center for Breast Care, The University of Toledo Medical Center, Toledo, OH, USA

4 R. Rainsbury et al.
General Perspective and Overview
The relative risks and complications increase proportionately according to the

type of surgery, site of a breast lesion, extent of procedure performed, tech-
nique, the complexity of the problem, and the breast and lesion size. Extensive
or complex surgery usually carries higher risks of bleeding and infection than
smaller procedures, in general terms. Similarly, risk is relatively higher for
recurrent and complex breast problems, for associated axillary lymph node
dissections and especially for those closer to neural structures (e.g., brachial
plexus, axillary, long thoracic, or thoracodorsal). Axillary lymph node dissec-
tion procedures are typically associated with a higher frequency and greater
range of complications compared to procedures involving the breast alone.
This is principally related to the surgical accessibility, risk of tissue/nerve
injury, seroma formation, and interruption of lymphatic channels and outflow
from the upper limb and chest.
Reconstructive procedures carry a further range of potential complications also
related to the donor site for autogenous tissue (e.g., back or abdomen) or the use of
foreign material as an implant (e.g., breast prosthesis or abdominal mesh). This, in
broad terms, increases the extent of tissue injury and risk of infection, bleeding, and
nerve injury. The type and extent of any reconstructive procedure is associated with
complications related to “technical and anatomic” issues.
In general, for many breast operations, the complications are similar in type
and frequency. Knowledge of the anatomy and the variations commonly seen
are helpful in minimizing nerve and vessel injury. Surgeons argue the benefits
of one approach over the other, but there is somewhat little tangible data to
demonstrate differences in terms of the observed or reported complications.
Other surgeons will argue that the use of drains adds to the complication rates,
but this needs to be balanced with the extent and risks of bleeding and lymphatic
leakage.
Possible reduction in the risk of misunderstandings over complications or conse-
quences from breast surgery might be achieved by:
• Good explanation of the risks, aims, benefits, and limitations of the procedure(s)
• Useful planning considering the anatomy, approach, alternatives, and method
• Avoiding likely associated vessels and nerves
• Adequate clinical follow-up
Multisystem failure, systemic sepsis, and death are rare after breast surgery,
even with extensive reconstruction, but are reported and remain a risk.
Positioning on the operating table has been associated with increased
risk of deep venous thrombosis and nerve palsies, especially in prolonged
procedures.
The use of specialized units with standardized preoperative assessment,
multidisciplinary input, and high-quality postoperative care is essential to
the success of complex breast surgery overall and can significantly reduce risk of
complications or aid early detection, prompt intervention, and cost.
2 Breast Surgery 5
With these factors and facts in mind, the information given in this chapter must
be appropriately and discernibly interpreted and used.
Important Note
represent derived figures. These figures are best estimates of relative frequen-
cies across most institutions, not merely the highest-performing ones, and as
such are often representative of a number of studies, which include differ-
ent patients with differing comorbidities and different surgeons. In addition,
the risks of complications in lower- or higher-risk patients may lie outside
these estimated ranges, and individual clinical judgment is required as to the
expected risks communicated to the patient, staff, or for other purposes. The
range of risks is also derived from experience and the literature; while risks
outside this range may exist, certain risks may be reduced or absent due to
variations of procedures or surgical approaches. It is recognized that different
patients, practitioners, institutions, regions, and countries may vary in their
requirements and recommendations.
For diagnostic fine- or core-needle biopsy complications, see volume 1 or lymph

node surgery (Chap. 5), or for other procedures, see the relevant chapter.
Female Breast Surgery
Excisional Breast Biopsy (Lumpectomy)
Description
Excisional biopsy may be performed with general anesthesia or under local anes-
thesia with or without IV sedation. Excisional breast biopsy is removal of an abnor-
mality in the breast typically for diagnosis. The aim of the surgery is to determine
the nature of the mass and to rule out carcinoma. The lump may be small or large;
however, the nature and breast size are important factors in determining risk of
complications. A non-palpable mass will usually require a form of localization (see
next case). Preoperative workup includes mammogram (especially in women aged
>30–40 years as tumor may be obscured by the density of younger breast tissue) and
ultrasound (for assessing solid, cystic, or malignant characteristics). A diagnostic
fine- or core-needle biopsy is usually performed prior to excisional biopsy, under
MMG or U/S guidance if required. Incisional biopsy for diagnosis may be included
under this risk profile; however, excisional biopsy aims to remove the entire lesion,
often with a “cuff” of normal tissue. The incision chosen may be peri-areolar,
horizontal, or even radial according to the location and desired cosmesis. Dissection
usually aims to excise a margin of normal tissue around the lesion, often includ-
ing pectoral fascia. Electrocautery, and deep, absorbable suture closure, is used
for hemostasis, often avoiding wound drains. Marking sutures are usually used to
orientate the specimen to define pathological margins.
Anatomical Points
The anatomical base of the breast extends from the inferior clavicle to the infra-
mammary fold and from the lateral sternum into the axilla. Occasionally, islands
of breast tissue exist in the axilla, isolated from the axillary tail. The nipple-areolar
complex and main breast mass may vary considerably between individuals, with
age and posture. A breast mass can be located anywhere within the breast. The size
and nature of the mass and breast essentially determines the placement and type of
incision, surgical result, and cosmesis. The possibility of mastectomy or further sur-
gery is often a consideration in preoperative placement of incision. Care should be
taken to avoid downward repositioning of the nipple with large excisions of lower
pole breast tissue. This deformity may be avoided by mobilizing nearby normal
breast tissue into the area of the defect.
Perspective
See Table 2.1. Hematoma is an uncommon, but significant, complication. Rarely,

operative drainage is required. The risk of infection after an excisional breast biopsy
is minimal and preoperative antibiotics are rarely used. Poor cosmesis, dimpling,
scarring, and skin necrosis can occur after excisional biopsy. Removing as little
tissue as possible (especially subcutaneous fat, where possible) improves cosmetic
outcome. Often after surgery the patient perceives that the mass is still present. This
is related to healing scar or seroma formation. This postoperative mass may be pal-
pable for up to 6 months postoperatively while the scar is remodeling. There is often
some temporary paresthesia over the incision. Many patients describe it as burning
or shooting pain. Acute postoperative pain is usually managed well with oral pain
medication and resolves after a couple of days. Chronic pain is rare.
Major Complications
The major risk of excisional biopsy is development of a large postoperative hematoma.

This complication can be avoided by meticulous control of bleeding during surgery.
Most hematomas can be managed nonoperatively. Large hematomas require surgical
evacuation and, if left untreated, may become infected or spontaneously drain. Draining
of infected hematomas can lead to open wounds that persist for months.
2 Breast Surgery 7
Table 2.1 Excisional breast biopsy (lumpectomy) estimated frequency of complications, risks,
and consequences
Complications, risks, and consequences Estimated frequency
Most significant/serious complications
Infection 1–5 %
Bleeding 1–5 %
Bruising 50–80 %
Hematoma formation
Small 5–20 %
Large (reoperative evacuation) <0.1 %
Incomplete excision of lesion (procedure dependenta 1–5 %
Necessity for further surgerya 5–20 %
(Re-excision/completion mastectomy/axillary clearance)
Rare significant/serious problems
Fat necrosis 0.1–1 %
Failed biopsy of lesiona 0.1–1 %
Less serious complications
Pain/tenderness
Acute (<4 weeks) 5–20 %
Chronic (>12 weeks) <0.1 %
Paresthesia (sensory nerve injury) 0.1–1 %
Skin flap problems 0.1–1 %
Wound Scarring
Skin scarring (poor cosmesis, dimpling/deformation of the skin) 1–5 %
Deep scar formation (residual breast lump) 5–20 %
Drain tube(s)a 1–5 %
Note: The pathology of the lesion and breast size will largely determine the likelihood of complete
clearance and necessity for further procedures or treatment
a
Depends on the underlying pathology, surgical technique preferences, and location in the breast
Failure to diagnose due to inadequately sampling a palpable lesion, biopsying

the wrong area, or incomplete excision are uncommon with an excisional biopsy,
but may necessitate further surgery. Preoperative verification of the position of the
mass in the awake patient is wise, as some lesions are best felt in one position. It is
important to be sure that the mass can be identified and marked once the patient is
supine and anesthetized. If there is any question preoperatively regarding the pal-
pability or location of the lesion, an image-guided procedure should be performed
prior to surgery to ensure removal of the suspicious lesion (see below). Dense
fibrous breast tissue can obscure the mass. In most situations the mass should be
removed entirely.
If skin flaps are raised to remove a superficial mass, care should be taken not
to make the flaps too thin, causing reduced blood supply to the skin, resulting in
necrosis, tissue loss, or skin dimpling. If skin necrosis occurs, the necrotic skin
must be excised if the area is extensive or it may be treated with local wound care
if it is small.
Consent and Risk Reduction

Main Points to Explain
• GA risk
• Wound infection
• Bleeding/hematoma
• Abscess formation
• Cosmetic deformity
• Further surgery
Localization Biopsy of Mammographically Detected Lesions

(Hookwire or Carbon-Track Localization)
Description
General anesthesia is usually used, but local anesthesia and IV sedation may be
used. A mammographic or ultrasound image-guided localization and excisional
breast biopsy is indicated for a non-palpable mammographically detected lesions,
architectural distortion, or suspicious microcalcifications. The localization can be
achieved by a hookwire or using a carbon track, both being placed using a needle
and MMG or U/S, to locate and mark the lesion (Fig. 2.1).
Fine-needle or core-needle biopsy should be obtained prior to operation, if pos-
sible, to permit better operative planning and margin consideration. Often a cancer
operation rather than a diagnostic procedure can be performed, perhaps sparing the
patient two operations. Rarely, two wires or carbon markings are used to define
large lesions.
Fig. 2.1 Scar following

carbon black marking and
carbon-localised breast
biopsy showing residual
sequestered carbon at the
scar several years later
2 Breast Surgery 9
The incision chosen may be peri-areolar, curvilinear, horizontal, or even radial

according to the lesion location, marker, and desired cosmesis. Dissection usually
aims to excise a margin of normal tissue around the lesion and hookwire/carbon
marker, often including pectoral fascia. Radioactive seed implantation under mam-
mographic control has also been used. Electrocautery and deep, absorbable suture
closure is used for hemostasis, often avoiding wound drains. Marking sutures
are usually used to orientate the specimen to define pathological margins. Once
the specimen is removed, a specimen radiograph is performed to compare to the
original film and determine completeness of excision and radiological margins.
Anatomical Points
taken to avoid downward repositioning of the nipple with large excisions of lower
pole breast tissue. This deformity may be avoided by mobilizing nearby normal
breast tissue into the area of the defect.
Perspective
See Table 2.2. Complications overall are not very common. Development of a large
postoperative hematoma is a significant complication (Figs. 2.2 and 2.3). Infection
and prolonged drainage can be significant and may result in cosmetic problems.
Failure to diagnose the abnormality can also occur. Cosmetic defects are rarely
troublesome. However, all may require further surgery and this can be significant,
resulting in further hospitalization.
Often, after surgery a mass may be palpable due to scarring and seroma forma-
tion and may persist for up to 6 months postoperatively while the scar is remodel-
ing. There is often some temporary paresthesia over the incision. Many patients
describe it as burning or shooting pain. Acute postoperative pain is usually man-
aged well with oral pain medication and resolves after a couple of days. Chronic
pain is rare.
Major Complications
The major risks are development of a large postoperative hematoma or infection.

These complications are rare and can be avoided with careful hemostasis. Large
Table 2.2 Localization biopsy of mammographically detected lesion—hookwire or carbon,

estimated frequency of complications, risks, and consequences
Infection 1–5 %
Bleeding 1–5 %
Bruising 50–80 %
Hematoma formation
Small 5–20 %
Displacement of hookwire/carbon mistrackinga 1–5 %
Incomplete excision of lesion (procedure dependenta) 1–5 %
Failed biopsy of lesiona 1–5 %
(Re-excision/completion mastectomy/axillary clearance)
Pain/tenderness
Paresthesia (sensory nerve injury; breast, nipple) 0.1–1 %
Skin flap problems 0.1–1 %
Wound scarring
Skin scarringa 1–5 %
(poor cosmesis, dimpling/deformation of the skin)
clearance and necessity for further procedures or treatment. Technical issues may determine accu-
racy of localization and biopsy
a
hematomas may require surgical evacuation, otherwise infection and spontaneous

drainage may occur. Draining of infected hematomas can lead to open wounds that
last for months. Dense fibrous breast tissue can make localization and excision dif-
ficult. Occasionally, the localization hookwire or carbon mark is inaccurate or dis-
placed, leading to failed biopsy. Failure to diagnose due to inadequately sampling a
non-palpable lesion, biopsying the wrong area, or incomplete excision, is not very
common with a localization biopsy, but may necessitate another localizing proce-
dure and further surgery. Removal of the lesion may be confirmed using a specimen
MMG or U/S.
If skin flaps are raised to remove a superficial mass, care should be taken not to
make the flaps too thin, causing reduced blood supply to the skin, resulting in necro-
sis, tissue loss, or skin dimpling. Extensive skin necrosis may require dressings and/
or excision and skin flap repair.
2 Breast Surgery 11
Fig. 2.2 Breast hematoma after partial mastectomy and sentinel node biopsy
Fig. 2.3 Breast hematoma

after core biopsy of left breast

• GA risk
• Wound infection
• Further surgery
Subcutaneous Mastectomy (Complete Mastectomy)
Description
used. Subcutaneous mastectomy is removal of breast tissue only, usually used for
in situ carcinoma, where axillary dissection is not required, or for mastectomy for
benign conditions (e.g., prophylactic mastectomy, reconstruction, severe breast
pain, equalization after contralateral mastectomy). Some may regard it as a lesser
type of mastectomy, but it should include >99 % of breast tissue. Mammography is
done to exclude or define pathology. An inframammary peri-areolar incision is often
used and can be extended laterally. The nipple-areolar complex may be preserved
without devascularizing the nipple, especially if later reconstruction is desired.
Cosmesis is achieved by tapering the edges and/or liposuction. Reconstruction is
sometimes performed, either immediate or delayed. Hemostasis and suction drain-
age can reduce hematoma formation. Absorbable interrupted sutures and a running
subcuticular skin suture are often used for closure.
Anatomical Points
The breast tissue is excised including the full anatomic extent of the breast, superiorly
extending to below the clavicle, medially to the sternal edge, laterally into the axilla,
and inferiorly to the inframammary fold. The breast and the chest wall shape vary con-
siderably between individuals and with age, dictating the extent of surgery required.
Perspective
See Table 2.3. Postoperative hematoma is best avoidable by careful hemostasis.

Infection is rare. Seroma formation may occur and it can be aspirated if it is large
2 Breast Surgery 13
Table 2.3 Subcutaneous mastectomy estimated frequency of complications, risks, and

consequences
Infection 1–5 %
Bleeding/hematoma formation
Small 5–20 %
Large (reoperative evacuation) 0.1–1 %
Bruising >80 %
Aspiration (postoperative)a 1–5 %
Incomplete excision of lesion (procedure dependentb) 1–5 %
Failed biopsy of lesionb 1–5 %
Nerve injury (shorter term <12 weeks)a 50–80 %
Nerve injury (longer term)a
Arm/chest wall paresthesia (intercostobrachial nerve injury) 1–5 %
Necessity for further surgeryb 20–50 %
(Re-excision/completion mastectomy/axillary clearanceb)
Possibility of further treatment (surgery, radiotherapy, chemotherapy, 5–20 %
endocrine therapy)b
Asymmetry >80 %
Volume loss (size disparity)b >80 %
Skin flap necrosisb 0.1–1 %
Dehiscence 0.1–1 %
Edema of chest [+/− arm/hand]b 0.1–1 %
Nipple necrosisb 0.1–1 %
Pneumothorax <0.1 %
Pain/tenderness
Phantom breast painb 5–20 %
Lymphocele lymphatic leak 5–20 %
Seroma formation 5–20 %
Fat necrosis 5–20 %
Arm/breast/chest swellinga 1–5 %
Blood transfusion 0.1–1 %
Wound scarringb
Skin scarring (poor cosmesis; dimpling/deformation) 1–5 %
Deep scar formation (residual breast/chest wall lump) 0.1–1 %
Drain tube(s)b 20–50 %
a
Complications of axillary surgery must be included if this is performed synchronously with breast
surgery
b
or left to resolve if small. Recurrent seromas can be unpredictable, tedious, and last
for >1 month. The scars may be unequal in position or size when the patient has
recovered fully from surgery. There may be excess skin that is unsatisfying to the
patient. Both of these conditions may require another operation. Acute postopera-
tive pain is common and is easily managed with oral analgesics. Chronic pain is
rare. Some patients may temporarily experience heightened sensation of the nipple,
if retained, but this usually resolves. Numbness or paresthesias of the nipple are also
possible. If immediate reconstruction is done, these complications need discussion
and consideration (see various forms of reconstruction). The axilla complications
are not present as axillary surgery is not typically included. Infection is uncommon.
Major Complications
A large hematoma may require evacuation and control of the bleeding with further
surgery. If a large hematoma is not drained, it may drain spontaneously or rarely
dissipate. Large hematomas also increase risk of infection. Although sometimes
unpredictable, poor cosmesis because of unequal scar position/size, excessive skin,
dimpling, excess scarring, or persistence of a subareolar mass, then additional oper-
ations may be indicated to improve the outcome. However, most women do not
complain of deformity. Chronic pain or paresthesia are not common, but can be
significant problems.

• GA risk
• Wound infection
• Skin necrosis
• Further surgery
Partial Mastectomy (Segmental Breast Resection;

Segmentectomy)
Description
General anesthesia is usually used, but local anesthesia may be used +/− IV seda-
tion. Partial mastectomy (PM) or lumpectomy is indicated for breast conservation
2 Breast Surgery 15
for excision of invasive breast usually cancer or ductal carcinoma in situ (DCIS).
The aim is to remove the carcinoma with surrounding normal tissue to achieve
margins of 1–2 cm. Preoperative mammogram and ultrasound (and occasionally
MRI) are used to determine the nature and extent of the lesion and identify other
lesions in either breast.
PM may follow an excisional, incomplete, or localization biopsy. A specimen
MMG or U/S is often used to assess margins and may be used to guide resection
of more tissue intraoperatively. Separate samples may be used to assess the biopsy
margins. Marker sutures or clips are used to orientate the specimen for the patholo-
gist. Marker clips may be used for guiding the radiation therapy.
The incision chosen may be peri-areolar, curvilinear, horizontal, or even
radial according to the location and desired cosmesis. Dissection usually aims to
excise a wide margin of normal tissue around the lesion, often including pectoral
fascia. Mobilization of remaining breast tissue may be necessary to reapproxi-
mate the breast parenchyma, especially in the medial and lower breast, to reduce
shape deformity. Electrocautery and deep, absorbable suture closure is used for
hemostasis, often avoiding wound drains, with a subcuticular skin suture. A sep-
arate axillary incision is often used for axillary lymph node surgery (described
separately).
Anatomical Points
taken to avoid downward repositioning of the nipple with large excisions, notably
the lower breast tissue. This deformity may be avoided by mobilizing nearby nor-
mal breast tissue into the area of the defect. Cancer specimens involving the nipple
by direct extension require removal of the nipple as part of the segmental resection.
Invasive cancer may invade any of the structures surrounding the breast includ-
ing the skin, the pectoralis muscle, the ribs, and the chest wall. Usually very large
cancers that invade one of these structures will be initially treated with neoadjuvant
chemotherapy prior to operation.
Perspective
See Table 2.4. The most significant, but infrequent, complications are develop-
ment of a large hematoma, infection, abscess formation, incomplete excision
with close or involved margins, and the requirement for further surgery due to
Table 2.4 Partial mastectomy (segmental breast resection; segmentectomy) estimated frequency
of complications, risks, and consequences
Infection 1–5 %
Small 5–20 %
Bruising >80 %
Lymphocele lymphatic leak 5–20 %
Seroma formation 5–20 %
Wound scarring
Skin scarringa (poor cosmesis; dimpling/deformation of the skin) 1–5 %
Incomplete excision of lesion (procedure dependenta) 1–5 %
Failed biopsy of lesiona 1–5 %
(Re-excision/completion mastectomy/axillary clearancea)
Asymmetry >80 %
Volume loss (size disparity)a >80 %
Nipple necrosisa 0.1–1 %
Pneumothorax <0.1 %
Pain/tenderness
Arm/breast/chest swellingb 1–5 %
Skin flap problemsa 0.1–1 %
a
b
Complications of axillary surgery must be included if this is performed synchronously with breast
surgery
these. Favorable cosmetic outcome and optimal margins can be competing goals.
Surgical judgment is important to maximize both goals. Poor cosmesis, dimpling,
skin necrosis, and hypertrophic scarring are usually less severe, but more frequent
complications. There may be some temporary paresthesia surrounding the inci-
sion. Patients often describe it as burning or shooting pain. Acute postoperative
pain is usually controlled with oral pain medication. Chronic pain is rare. The risk
of infection after a partial mastectomy is minimal and prophylactic antibiotics are
rarely indicated.
2 Breast Surgery 17
Major Complications/Consequences
A major consequence of conservative breast surgery is incomplete carcinoma exci-

sion, often necessitating further surgery. Occasionally, a 3rd resection or a total mas-
tectomy may be advisable, if excision is still incomplete. The cosmetic outcome may
be reduced after more than one re-excision such that mastectomy becomes a more
appealing alternative. Mastectomy may be followed by immediate reconstruction.
Hematoma formation can be avoided by meticulous control of bleeding dur-
ing surgery. Most hematomas can be managed nonoperatively. Large hematomas
require surgical evacuation. Infection and abscess formation may complicate
large hematomas if left untreated and can spontaneously drain. Draining of infected
hematomas can lead to open wounds that last for months. Recurrent large seromas
or lymphatic sinuses are rare, but also significant complications.
If skin flaps are raised to remove a superficial mass, care should be taken not
to make the flaps too thin, causing reduced blood supply to the skin, resulting in
skin necrosis, tissue loss, or skin dimpling. Extensive skin necrosis may require
dressings and/or excision and skin flap repair.

• GA risk
• Wound infection
• Further surgery
Modified Radical Mastectomy (Usually Including

Axillary Clearance)
Description
General anesthesia is required. The main indication is breast cancer that is not
amenable to breast conservation due to size, location, contraindication to radia-
tion therapy, local ulceration/extension, the presence of multiple cancers in different
quadrants of one breast, or patient preference. Some patients prefer mastectomy
with or without delayed reconstruction. The advantages to mastectomy include a
lower incidence of local recurrence and a new breast cancer, avoidance of radiation
therapy for selected patients, and possibly better cosmetic result with immediate
reconstruction especially for patients with large tumors, small breasts, or tumors
Fig. 2.4 Patent blue dye marking and radioisotope lymphatic mapping for breast cancer, showing
tumour site in right breast (circle) and lymph node sites (right axilla and internal mammary)
in the lower breast. Axillary lymph node surgery, either sentinel node biopsy or
definitive level I/II axillary dissection, is usually included at the same operation as
the mastectomy (Fig. 2.4). The arm is typically “free draped” to the elbow allowing
good access to the axilla. A transverse or oblique elliptical incision is usually used,
including the nipple-areolar complex, any involved skin, and any recent biopsy inci-
sions. Subcutaneous saline, vasoconstrictive agent, and/or local anesthetic is used
by some surgeons for defining the subcutaneous plane for dissection and hemosta-
sis. Superior and inferior skin flaps are raised to expose the breast for resection.
The borders of the dissection are the lateral edge of the sternum, the clavicle supe-
riorly, the latissimus dorsi laterally, and the rectus sheath inferiorly. Then the breast
is dissected off the pectoralis muscle (the pectoral fascia is preferably left intact if
immediate reconstruction with implants or expanders is anticipated) with care taken
to control perforating vessels. The lateral attachments of the breast are left intact until
the axillary dissection is completed. The breast is retracted laterally and the lateral
border of the pectoralis major is identified. Axillary dissection (see separately) is infe-
rior to the axillary vessels. Suction drains are used to drain the chest wall and axilla by
most surgeons, but some do not. The skin flaps are trimmed, if necessary, to achieve
a flat chest wall and a straight scar. An absorbable interrupted deep dermal suture is
usually used followed by a monofilament absorbable subcuticular skin suture.
Anatomical Points
The anatomical base of the breast extends from the inferior clavicle to the
inframammary fold and from the lateral sternum into the axilla. Occasionally, islands
2 Breast Surgery 19
taken to avoid downward repositioning of the nipple with large excisions, notably
the lower breast tissue. This deformity may be avoided by mobilizing nearby nor-
mal breast tissue into the area of the defect. Cancer specimens involving the nipple
by direct extension require removal of the nipple as part of the segmental resection.
Invasive cancer may invade any of the structures surrounding the breast includ-
ing the skin, the pectoralis muscle, the ribs, and the chest wall. Usually very large
cancers that invade one of these structures will be initially treated with neoadjuvant
chemotherapy prior to operation. Occasionally a duplicated axillary vein is present.
Variations in the vascular structures of the axilla are uncommon, but care should
be taken to identify the important neurovascular structures during axillary surgery.
There are reports of aberrant slips of muscle that span the axilla. They may be low-
lying deltoid fibers or, more commonly, a slip of latissimus extending anterior to
the axillary vein.
Perspective
See Table 2.5. Despite the extent of surgery, major complications are usually not
severe or frequent and are mostly related to the axillary surgery. The most significant
complications are hemorrhage, development of a large hematoma, infection, abscess
formation, and the requirement for further surgery due to these. Hemorrhage after
mastectomy is usually caused by perforating vessels that retract into the pectoralis
muscle and then bleed when the patient coughs or moves postoperatively. Seroma
is fairly common and usually occurs after the drains are removed. If the seroma is
small, it can be allowed to resolve on its own. If it is larger, it may be aspirated or a
drain may be replaced. Drains are often removed when their output is <50 ml/day.
Lymphedema of the arm is a complication of axillary clearance that occurs in
3–80 % of patients who undergo axillary dissection. Severe lymphedema is rare,
but often unpredictable. Intercostobrachial nerve injury is common and results in
sensory changes to the upper inner arm and axilla. Patients complain of numbness
and tingling as well as changes in sweating. The affected area usually decreases
in size over time, but never fully resolves. Pain may occasionally be very severe,
especially during recovery.
Injury to the thoracodorsal nerve leads to paralysis of the latissimus dorsi muscle.
The motor deficits include slight weakness in arm adduction and internal rotation of
the shoulder. It is not a very disabling injury, and most patients adapt to it well with-
out changes in lifestyle. Injury to the long thoracic nerve leads to paralysis of the
serratus anterior muscle. This results in winging of the scapula and shoulder pain.
Wound infection is not very common, but it may occur and should be treated
promptly with antibiotics. Skin flap necrosis can occur and is usually caused by
making the flaps too thin, trauma to the skin edges, or the stretching of expanders
Table 2.5 Modified radical mastectomy (including axillary clearance) estimated frequency
of complications, risks, and consequences (female)
Complications, risks, and consequences
(including axillary lymph node surgery) Estimated frequency
Paresthesia of chest wall, inner arm (intercostal due interruption) 50–80 %
Infection 1–5 %
Seroma formation/large lymphocelea 1–5 %
Need for Aspiration (postoperative)a 1–5 %
Nerve Injury (shorter term <12 weeks)a 50–80 %
Injury to nerve to lat. dorsi/nerve to serratus anterior 0.1–1 %
Lateral cutaneous nerve of arm or forearm 0.1–1 %
Brachial plexus injury <0.1 %
Edema (swelling) of arm/handa
Minor 20–50 %
Severe 1–5 %
Skin flap necrosis 1–5 %
Small 0.1–1 %
Axillary vein injury/thrombosis 0.1–1 %
Axillary artery injury (+/− spasm) 0.1–1 %
Neuropraxia/dysesthesia—permanent paina 0.1–1 %
Edema of chest [+/− arm/hand]b 0.1–1 %
Wound dehiscence 0.1–1 %
Lymphatic fluid leak/sinusa <0.1 %
Rib osteomyelitisb <0.1 %
Pneumothoraxb <0.1 %
Incomplete excision of lesion (procedure dependant)b 0.1–1 %
Mortality (operative)b <0.1 %
Pain/tenderness
Excess axillary skinb 50–80 %
Bruising >80 %
Shoulder problems 5–20 %
Possibility of further treatment (surgery, radiotherapy, 50–80 %
chemotherapy, endocrine therapy)b
Arm stiffness 1–5 %
Axillary fibrous band/cord adhesionsa 1–5 %
2 Breast Surgery 21
Table 2.5 (continued)

(including axillary lymph node surgery) Estimated frequency
Small lymphocelea 20–50 %
Wound scarringb
Skin scarring (poor cosmesis, dimpling/deformation) 1–5 %
Wound drain tube(s)b 50–80 %
a
Complications of axillary surgery are included since this is almost always performed as part of
modified radical mastectomy
b
in patients undergoing immediate reconstruction. Pneumothorax is a very rare, but

serious, complication. It must be recognized promptly. It can happen during injec-
tion of the tumescent solution or during dissection in a frail, thin patient. Incomplete
carcinoma excision and further surgery are extremely rare.
Poor cosmesis, dimpling, skin necrosis, and hypertrophic scarring are usually
less severe, but more frequent complications. There may be some temporary par-
esthesia surrounding the incision. Patients often describe it as burning or shoot-
ing pain. Acute postoperative pain is usually controlled with oral pain medication.
Chronic pain is rare. The risk of infection after a partial mastectomy is minimal and
prophylactic antibiotics are rarely indicated. Mastectomy may be followed by the
immediate reconstruction and associated complications of this.
The major complications of modified radical mastectomy include hemorrhage, arm

lymphedema, thrombosis, or injury to axillary vein, damage to the brachial plexus,
and injury of the long thoracic nerve. Hemorrhage may be intra- or postoperative.
The latter is recognized by swelling or discoloration of the skin flaps, large volumes
of blood in the drains, or changes in the patient’s vital signs. Hemorrhage requires
a return to the operating room with evacuation of the hematoma and control of
the bleeding vessel. Transfusion is rare, and there are usually no long-term conse-
quences of postoperative hemorrhage. Large hematomas require surgical evacu-
ation. Infection and abscess formation may complicate large hematomas if left
untreated and can spontaneously drain. Draining of infected hematomas can lead to
open wounds that last for months. Recurrent large seromas or lymphatic sinuses
are rare, but also significant complications. Extensive skin flap necrosis from isch-
emia as a result of very thin flaps may require dressings and/or excision and rotation
skin flap repair. Arm lymphedema can be temporary or permanent varying widely
in the literature from 3 % to 80 %. The incidence, as well as the severity, usually
increases with the number of lymph nodes removed. Other risk factors for lymph-
edema include older age, obesity, postoperative infection, and axillary radiation. If
lymphedema is recognized early and treated promptly, the development of chronic,
severe lymphedema may be prevented. Early treatment involves good skin care,
nighttime elevation, fitted compression garments, avoiding procedures on the arm,
and manual lymph evacuation.
Axillary vein thrombosis may occur at the time of surgery or postoperatively.
It may contribute to arm swelling and discomfort. Acute thrombectomy may be
useful. Axillary vein or artery injury should be repaired using standard vascu-
lar surgery techniques. Proximal and distal control of the injured vessel must be
obtained. Vein narrowing of >50 % should be relieved with a vein patch. The bra-
chial plexus injury may result from stretch and positional retraction overhead for
a prolonged period or from high dissection above the axillary vein. Microsurgical
nerve repair may be required. Stretch and strain injuries usually resolve with time
and physical therapy. Long-term brachial plexus injuries are rare, but devastating.
Injury to the long thoracic nerve to serratus anterior muscle results in a winged
scapula and shoulder pain. Physical therapy can improve the condition somewhat.
Pneumothorax is very rare, but potentially fatal.
Angiosarcoma of the upper extremity, known as Stewart-Treves syndrome and
usually associated with postoperative radiation, is very rare, but may develop many
years after modified radical mastectomy. It is fatal if not recognized and treated early.

• GA risk
• Wound infection
• Further surgery
Duct and Nipple Surgery (Microdochectomy and Central Duct

Excision [Hadfields Procedure])
Description
General anesthesia is often used, but local anesthesia with IV sedation is some-
times preferred. The aims are to diagnose or exclude malignancy or control
2 Breast Surgery 23
discharge. Microdochectomy is used for a discharging duct that can be identi-

fied, cannulated, and excised. If available, ductoscopy can be used to visualize the
lumen of the duct. The aim is to remove a localized duct system, leaving the oth-
ers intact, to obtain a pathological diagnosis. Central duct excision is indicated
for patients with unilateral bloody nipple discharge, particularly from multiple
ducts, or when identification of the discharging duct or cannulation is not feasible.
Most bilateral and non-bloody nipple discharges are caused by pregnancy, lacta-
tion, pituitary tumors, or most commonly benign ectasia/fibrocystic changes. The
majority of bloody nipple discharge represents either a papilloma or duct ectasia.
Most are benign, but malignancy must be ruled out for bloody or copious unilateral
discharge. Radial or peri-areolar incisions can be used for microdochectomy or
central duct excisions. Preoperative mammogram and ultrasound should be per-
formed to detect abnormalities that may require separate consideration. The lesion
in question is usually within 1–3 cm of the nipple, in the infundibular subareolar
part of the duct. Hemostasis is achieved with electrocautery. The incision should
then be closed using absorbable deep dermal interrupted sutures and a subcuticular
skin suture.
Anatomical Points
The ductal system of the breast has complex arborization. Some 10–12 individual
ducts open onto the nipple. Occasionally, a duct may open at the side or base of the
nipple or even within the areola. The ducts do not travel only in a radial direction,
but often branch and overlap adjacent ducts. If possible, it is important to properly
identify the duct in question and ensure that it is excised. A ductoscope or a lacrimal
probe can often help identify the abnormal discharging duct at the time of surgery.
The nipple may be inverted and require eversion, increasing the difficulty of can-
nulation or resection.
Perspective
See Table 2.6. Complications are not usually severe or frequent, however, some
can occur. Most cases of bloody nipple discharge are caused by benign intraductal
papillomas. Carcinoma is the cause of bloody nipple discharge in approximately
5–10 % of cases. Accurate identification of the discharging duct is important for
microdochectomy. The discharging duct should be checked, noted, and marked pre-
operatively by the operating surgeon. Occasionally the duct may not produce any
blood on the day of the operation. Blind resection should not be attempted, rather
the operation should be delayed until the blood can be expressed. Central duct exci-
sion is also a possible alternative to microdochectomy in this situation. Adverse
scarring is not a common problem because the incision is often made at the edge of
the nipple-areolar complex.
Postoperative pain is usually easily controlled with oral analgesics. Chronic pain
is a rare complication. Some patients develop nipple pain and sensitivity that can
Table 2.6 Microdochectomy or central subareolar duct excision (Hadfields procedure) estimated
frequency of complications, risks, and consequences
Infection 1–5 %
Small 5–20 %
Inability to cannulate/locate the discharging ducta 1–5 %
Wound scarringa
Skin scarring (poor cosmesis, dimpling/deformation of the skin) 1–5 %
Deep scar formation (palpable breast lump) 5–20 %
Failed/incomplete excision of lesion (procedure dependenta) 1–5 %
(Re-excision/completion mastectomy/axillary clearancea)
Paresthesia (sensory nerve injury, breast, nipple) 0.1–1 %
Skin flap problems (nipple necrosis/areolar)a 0.1–1 %
Nipple pain 0.1–1 %
Nipple retraction/flatteninga 0.1–1 %
Sexual problems 0.1–1 %
Mammary fistula 0.1–1 %
Discharging sinus/persistent dischargea 0.1–1 %
Inability to breastfeed from the operated breasta, b
Microdochectomy 0.1–1 %
Central duct excision 100 %
Pain/tenderness
Chronic (>12 weeks) 0.1–1 %
Bruising 50–80 %
Note: The pathology of the lesion will largely determine the likelihood of complete clearance and
necessity for further procedures or treatment. Technical issues may determine accuracy of localiza-
tion and biopsy
a
b
Breastfeeding from the unaffected breast if normal prior to surgery will usually remain normal
last for several months. Loss of nipple sensation can occur as a consequence of this
operation. The sensory nerves to the nipple may be transected or stretched. The
nipple may retract postoperatively in some cases. Nipple retraction may be avoided
by placing a purse-string suture posterior to the nipple to reconstruct normal projec-
tion. Even with only a full-thickness flap and no tissue posterior to the nipple, devas-
cularization is rare, but it can result in nipple necrosis (Fig. 2.5). The patient may
need reconstructive surgery to recreate a nipple. If the majority of ducts are removed
in the central duct excision, breastfeeding may be impeded; however, this is rare if
only one or two ducts are removed. Hematoma formation can usually be avoided
with meticulous hemostasis. Rarely will a hematoma require operative drainage.
2 Breast Surgery 25
Fig. 2.5 Partial nipple

necrosis after breast implant
insertion
Most resolve without further intervention. Prophylactic antibiotics are sometimes

used. Infection may infrequently occur, but abscess formation is very rare.
Major Complications
Although relatively rare, serious complications can occur and patients should be
advised of these. These include nipple necrosis which may be partial or complete,
particularly with central duct excision where devascularization of the nipple-areolar
complex results, sometimes compounded by infection. Reconstructive surgery may
be required. Failure to diagnose and remove the underlying abnormality can occur,
as can subsequent close follow-up. Persistent nipple discharge may result or
recurrent discharge may occur. A repeat ductogram and/or further surgery may be
required. Loss of ability to breastfeed from the operated breast is uncommon with
microdochectomy, but usual with central duct excision. Loss of nipple sensation
and chronic breast pain are potential important long-term major consequences.
Adverse cosmetic results, including nipple retraction and nipple-areolar distor-
tion, may be considered major sequelae by some patients.

• GA risk
• Wound infection
• Nipple necrosis
• Further surgery
Breast Abscess Drainage
Description
General or local anesthetic +/− IV sedation is used. The aim is to drain the pus
from the breast abscess cavity. Most small abscesses can be managed with percu-
taneous aspiration and antibiotics. If symptoms have been present for weeks, the
patient is systemically ill, the abscess is very large, or drainage is incomplete, the
patient is probably best served by formal incision, and drainage. When the patient
is systemically unwell or considerable surrounding cellulitis is present, IV antibi-
otics may be required. If lactating, the breast should be regularly expressed of milk
with a breast pump. The patient can usually still breastfeed using the contralateral
breast.
An incision is made directly over the abscess and drained of pus, irrigated and
a small drain placed, or left open, and the cavity packed if the abscess is large.
Healing often takes 1–2 months and cosmetic deformity is not uncommon.
Anatomical Points
Breast abscesses can occur in any area of the breast. If the abscess occurs at the
circumareolar edge, this condition may represent a periductal fistula especially if
the patient is a smoker. The fistula must be unroofed and curetted to allow heal-
ing. Occasionally, infected sebaceous (epidermoid) cysts or areolar gland (of
Montgomery) cysts may be large and present as abscesses.
Perspective
See Table 2.7. The complications of breast abscess drainage include a chronic
healing wound, recurrent abscess, milk fistula, periductal fistula, systemic
infection, disfiguring scar, and breast deformity. If the wound is closed
over a drain or the skin closes too quickly in an open cavity, it is possible that
the abscess may recur. If it does repeat, incision and drainage are required. If
the abscess is large, the skin may need to be left open. Systemic infection is
rare, except in the immunocompromised host. Appropriate antibiotics should
be selected to cover the most common organisms. Staphylococcus aureus and
streptococcal species are the most common organisms. Non-puerperal abscesses
are most likely to contain anaerobes. Antibiotics of choice include flucloxacil-
lin, cepahalosporins, clindamycin, or vancomycin. Vancomycin is the preferred
antibiotic for penicillin-allergic pregnant women. Milk fistula may occur in a
lactating patient. As long as the patient continues to breastfeed, the fistula may
be slow to heal.
2 Breast Surgery 27
Table 2.7 Breast abscess drainage estimated frequency of complications, risks, and consequences
Persistent infection 20–50 %
Systemic infection 1–5 %
Recurrent abscess/failed drainagea 5–20 %
Bruising 5–20 %
Small 5–20 %
Necessity for further surgerya
(Re-excision/completion mastectomy/axillary clearancea) 20–50 %
Tumor underlying (all ages)a 1–5 %
Inability to breastfeed
Temporarily 50–80 %
Permanently 0.1–1 %
Nipple pain 0.1–1 %
Nipple or areolar necrosis 0.1–1 %
Nipple deformity/retraction/flatteninga 0.1–1 %
Sexual problems 0.1–1 %
Mammary fistula 0.1–1 %
Discharging sinus persistent dischargea 0.1–1 %
Pain/tenderness
Wound scarringa
Skin scarring (poor cosmesis; dimpling/deformation of the skin) 50–80 %
Note: The pathology of the lesion will largely determine the likelihood of complete clearance/
drainage and necessity for further procedures or treatment
a
Major Complications
Systemic infection is the most serious complication of breast abscess. Fortunately,

it is very rare. When the abscess is evacuated, the pus should be sent for culture and
sensitivity. Antibiotic therapy should be tailored to treat the offending organism.
Scarring and skin dimpling with cosmetic deformity are common complications
that can be minimized by keeping the skin incisions as small as possible and closing
the skin when possible.

• GA risk
• Wound infection
• Chronic discharge
• Abscess Reformation
• Breastfeeding problems
• Further surgery
Nipple Biopsy (Paget’s or Other Disease)
Description
Nipple biopsy is usually performed under local anesthesia, but sedation or general
anesthesia is occasionally used. The aim of the nipple biopsy is to exclude carci-
noma. Paget’s disease is in situ carcinoma of the nipple characterized by erythema,
scaling, or ulceration of the nipple, which is often associated with an underlying
breast carcinoma (95 %). The usual differential diagnosis is eczema. The diagno-
sis is often delayed due to trial of eczema treatments. A full-thickness incisional
or punch biopsy is used. A preoperative mammogram and ultrasound are used to
investigate underlying breast parenchymal pathology. There is division of opinion
over the origin of Paget’s clear cells varying from a direct extension of an underly-
ing in situ or invasive carcinoma to a physically separate focus of in situ carcinoma
arising in the nipple isolated from any underlying carcinoma. It may represent wide
ductal system “field” change. In the majority of cases, the carcinoma, if present, is
located within a few centimeters of the nipple-areolar complex. It can be difficult to
identify the location of the carcinoma and it may be only an in situ carcinoma. An
alternative approach is to take a small amount of underlying breast tissue at the time
of nipple biopsy. If the workup does not demonstrate any radiographic abnormality
and the nipple biopsy demonstrates Paget’s disease, then an MRI can be obtained to
further evaluate the breast parenchyma. If no other lesion can be identified, then the
patient has the option of proceeding with a central lumpectomy in order to attempt
to capture the carcinoma or the patient may want to proceed with a mastectomy
with or without immediate reconstruction. An underlying breast carcinoma may not
be present, so some surgeons adopt an expectant management plan, with regular
imaging, often using several modalities.
2 Breast Surgery 29
Table 2.8 Nipple biopsy (Paget’s disease) estimated frequency of complications, risks, and
consequences
Dimpling/deformation of the nipple skin 5–20 %
Infection 1–5 %
Bruising 5–20 %
Missed/incomplete excision of lesion (procedure dependent)a 1–5 %
Necessity for further surgery (pathology dependant, re-excision/ 1–5 %
completion mastectomy/axillary clearance)a
Paresthesia (sensory nerve injury) 1–5 %
Skin ischemia/necrosisa 1–5 %
Bleeding/hematoma formation 0.1–1 %
Pain/tenderness
Wound scarring 5–20 %
Note: The pathology of the lesion and ability to identify the discharging duct will largely determine
the likelihood of complete clearance and necessity for further procedures or treatment. Technical
issues may determine accuracy of biopsy
a
Anatomical Points
Nipple shape can vary considerably dictating the ease and cosmetic results. Some
10–12 individual ducts open onto the nipple. Occasionally, a duct may open at the
side or base of the nipple or even within the areola. The nipple may be inverted and
require eversion, increasing the difficulty of biopsy. Anatomic studies have identi-
fied branches of the lateral cutaneous branch of the fourth intercostal nerve entering
the peri-areolar area most consistently at the lower lateral position (4 o’clock on left
and the 8 o’clock on right breast). Care should be taken to avoid incisions in those
areas, if possible.
Perspective
See Table 2.8. First described in 1874 by Sir James Paget as a “disease of the mam-
mary areola preceding cancer in the mammary gland,” we now understand the Paget
cells to be cancerous cells, even if they are in situ. If a significant part of the nipple
is removed, nipple deformity may result. Rarely, if lactation or discharge occurs,
ductal leakage can occur from ducts misdirected in the postoperative scar tissue. It
is often difficult to make a diagnosis of Paget’s disease and adequate tissue must be
obtained. Full-thickness biopsy is required. Biopsy of the underlying breast tissue

as well as the suspicious nipple skin is often helpful. If a diagnosis is not secured,
but Paget’s is still suspected, the patient should be followed closely and re-biopsied
if required.
Major Complications
The major complications of nipple biopsy are nipple deformity and infection. The
nature of Paget’s disease makes failure to diagnose not uncommon.
Open nipple biopsy is indicated to rule out Paget’s disease. Paget’s disease, if
identified, represents a form of nipple involvement by pagetoid cells and an effort
should be made to identify whether an underlying breast carcinoma is present and
the location. Hematoma formation, infection, and paresthesia of the nipple are
uncommon with the nipple biopsy.

• GA risk
• Wound infection
• Further surgery
Male Breast Surgery
Mastectomy (Modified Radical Mastectomy)
Description
General anesthesia is usually used; occasionally local anesthesia and IV seda-

tion can be used. Male breast cancer accounts for <0.1 % of all cancers in males
and 1 % of all breast cancers. Risk factors include testicular disease, gynecomas-
tia, increasing age, Jewish ancestry, family history, Klinefelter’s syndrome, and
BRCA-2 genetic mutation. About 4–16 % of all men with breast cancer have the
BRCA-2 mutation. Cancer in the male breast usually presents as a painless sub-
areolar mass, often with skin involvement, nipple retraction, and/or axillary node
involvement. Mammography and U/S can be helpful in distinguishing cancer from
2 Breast Surgery 31
gynecomastia. Once a diagnosis of cancer has been made, most men undergo modi-
fied radical mastectomy. Sentinel node biopsy may be considered in selected clini-
cally node negative men. An elliptical around the nipple-areolar complex and tumor
mass, with in-continuity axillary dissection, is usually performed (described sepa-
rately). Inferior and superior flaps are raised; neurovascular structures including
the axillary vein, the thoracodorsal vessels and nerve, the long thoracic nerve, and
often, where possible, the intercostobrachial nerve are preserved. Careful hemosta-
sis and suction drains are placed to the chest wall and axilla. Absorbable interrupted
deep dermal sutures followed by a running absorbable monofilament subcuticular
skin suture are used.
Anatomical Points
Breast tissue in males is located in the subareolar area predominantly, being much
more confined than in females. The majority of male breast cancer therefore
occurs close to the areola. Spread to the overlying skin, chest wall, and axillary
nodes is a common feature. Occasionally, a duplicated axillary vein is present.
Variations in the vascular structures of the axilla are uncommon, but care should
be taken to identify the important neurovascular structures during axillary sur-
gery. There are reports of aberrant slips of muscle that span the axilla. They may
be low-lying deltoid fibers or, more commonly, a slip of latissimus extending
anterior to the axillary vein.
Perspective
See Table 2.9. Despite the extent of surgery, major complications are usually not
severe or frequent, and are mostly related to the axillary surgery. Hemorrhage after
mastectomy is usually caused from perforating vessels that retract into the pecto-
ralis muscle and then rebleed when the patient coughs or moves. Seroma is fairly
common and usually occurs within the first postoperative week, after the drains
are removed. Small seromas may resolve, but larger seromas may need aspiration
or the drain replaced. Lymphedema of the arm is a complication of axillary clear-
ance that occurs in 3–80 % of patients who undergo axillary dissection. Injury to
the intercostobrachial nerve is common and results in sensory changes to the upper
inner arm and axilla. Patients complain of numbness and tingling as well as changes
in sweating. The affected area usually decreases in size over time, but never fully
resolves. Injury to the thoracodorsal nerve leads to paralysis of the latissimus dorsi
muscle. The motor deficits include slight weakness in arm adduction and internal
rotation of the shoulder. It is not usually a very disabling injury and most patients
adapt to it well without changes in lifestyle. Injury to the long thoracic nerve leads
to paralysis of the serratus anterior muscle, causing “winging” of the scapula and
shoulder pain. The risk of infection after a mastectomy is minimal and prophylactic
antibiotics are rarely indicated. Wound infection is not very common, but it may
Table 2.9 Modified radical mastectomy (including axillary clearance) estimated frequency of
complications, risks, and consequences (male)
Infection 1–5 %
Need for aspiration (postoperative)a 1–5 %
Nerve injury (shorter term <12 weeks)a 50–80 %
Injury to nerve to lat. dorsi/nerve to serratus anterior 0.1–1 %
Brachial plexus injury <0.1 %
Neuropraxia/dysesthesia—permanent paina 0.1–1 %
Edema (swelling) of arm/handa
Minor 20–50 %
Severe 1–5 %
Skin flap necrosisb 1–5 %
Arm stiffness 1–5 %
Shoulder problems 5–20 %
Possibility of further treatment (surgery, radiotherapy, 50–80 %
Small 0.1–1 %
Axillary vein injury/thrombosis 0.1–1 %
Axillary artery injury (+/− spasm) 0.1–1 %
Edema of chestb 0.1–1 %
Lymphatic fluid leak/sinusa <0.1 %
Rib osteomyelitisb <0.1 %
Pneumothoraxb <0.1 %
Incomplete excision of lesion (procedure dependantb) 0.1–1 %
Mortality (operative)b <0.1 %
Pain/tenderness
Bruising >80 %
Axillary fibrous band/cord adhesionsa 1–5 %
Excess axillary skin 50–80 %
Wound scarringb
2 Breast Surgery 33

Note: The pathology of the lesion and chest wall tissue will largely determine the likelihood of
complete clearance and necessity for further procedures or treatment
a
Complications of axillary surgery are included as this is usually performed as part of the
procedure
b
occur and should be treated promptly with antibiotics. Skin flap necrosis can occur
and is usually caused by making the flaps too thin, diathermy, or trauma to the
skin edges. Pneumothorax is an extremely rare, but serious complication, requir-
ing prompt recognition, arising from needle puncture or dissection in a frail, thin
person. Poor cosmesis, dimpling, skin necrosis, and hypertrophic scarring are usu-
ally less severe, but more frequent complications. There may be some temporary
paresthesia surrounding the incision. Patients often describe it as burning or shoot-
ing pain. Acute postoperative pain is usually controlled with oral pain medication.
Chronic pain is rare.
The major complications of modified radical mastectomy include hemorrhage,

arm lymphedema, thrombosis or injury to axillary vessels, damage to the brachial
plexus, and injury of the long thoracic nerve. Hemorrhage may be intra- or postop-
erative. The latter is recognized by swelling or discoloration of the skin flaps, large
volumes of blood in the drains, or changes in the patient’s vital signs. Hemorrhage
requires a return to the operating room with evacuation of the hematoma and con-
trol of the bleeding vessel. Transfusion is rare, and there are usually no long-term
consequences of postoperative hemorrhage. Large hematomas require surgical
evacuation. Infection and abscess formation may complicate large hematomas,
if left untreated, and can spontaneously drain. Draining of infected hematomas can
lead to open wounds that last for months. Recurrent large seromas or lymphatic
sinuses are rare, but also significant complications. Extensive skin flap necrosis
from ischemia as a result of very thin flaps may require dressings and/or excision
and rotation skin flap repair. Arm lymphedema can be temporary or permanent
varying widely in the literature from 3 % to 80 %. The incidence, as well as
the severity, usually increases with the number of lymph nodes removed. Other
risk factors for lymphedema include older age, obesity, postoperative infection,
and axillary radiation. If lymphedema is recognized early and treated promptly,
the development of chronic, severe lymphedema may be prevented. Early treat-
ment involves good skin care, nighttime elevation, fitted compression garments,
avoiding procedures on the arm, and manual lymph evacuation. Axillary vein
thrombosis may occur at the time of surgery or postoperatively. It may contribute

to arm swelling and discomfort. Acute thrombectomy may be useful. Axillary vein
or artery injury should be repaired using standard vascular surgery techniques.
Vein narrowing of >50 % should be relieved with a vein patch. Brachial plexus
injury may result from stretch and arm retraction overhead for a prolonged period
or from high dissection above the axillary vein. Microsurgical nerve repair may be
required. Stretch and strain injuries usually resolve with time and physical therapy.
Long-term brachial plexus injuries are rare, but devastating. Injury to the long
thoracic nerve to serratus anterior muscle results in a winged scapula and shoul-
der pain. Physical therapy can improve the condition somewhat. Pneumothorax
is very rare, but potentially fatal. Angiosarcoma of the upper extremity, known as
Stewart-Treves syndrome usually associated with postoperative radiation, is very
rare, but may develop many years after modified radical mastectomy. It is fatal if
not recognized and treated early.

• GA risk
• Wound infection
• Arm edema
• Paresthesias
• Further surgery
Gynecomastia
Description
preferred. Gynecomastia is enlargement of the male breast. The causes of gyneco-
mastia include chromosome abnormalities such as Klinefelter’s syndrome, renal
or hepatic disease, endocrine dysfunction, exogenous or endogenous hormones,
and other drugs, particularly cimetidine and marijuana. Incidence increases with
increasing age. There are additional peaks in incidence at puberty (gynecomastia
praecox) and ages 20–24. Mammography, U/S, and FNA or core-needle biopsy
2 Breast Surgery 35
usually secure the diagnosis. Gynecomastia can be treated medically by cessation

of the offending agent or therapy with tamoxifen, clomiphene, and danazol, with
up to 83 % resolving. Radiation therapy has also been used to treat gynecomastia.
Most adolescent gynecomastia will resolve without treatment; however, it may be
psychologically difficult to wait years. Surgical management is very effective for
all types of gynecomastia. Liposuction can be used alone or in conjunction with
open excision, but many of the patients treated with liposuction alone complain
of a residual subareolar mass and excess skin may be a problem. A peri-areolar
incision is made 50 % of the circumference of the areola and can be extended
laterally. Subcutaneous mastectomy is used with breast tissue dissected from the
nipple-areolar complex without devascularizing the nipple. Cosmesis is achieved
by tapering the edges or liposuction. Hemostasis and suction drainage can reduce
hematoma formation. Absorbable interrupted sutures and running subcuticular skin
suture are often used for closure.
Anatomical Points
Gynecomastia can be unilateral or bilateral even when caused by drugs. The pal-
pable mass of breast tissue is usually subareolar. Masses in other locations of the
breast are not likely to be gynecomastia.
Perspective
See Table 2.10. It is important to discuss with the patient the risk of poor cosmesis,
as the primary reason for surgery is often to improve appearance. Postoperative
hematoma is best avoidable by careful hemostasis. Infection is rare. Seroma for-
mation may occur and it can be aspirated if it is large or left to resolve if small.
Recurrent seromas can be unpredictable and tedious and last for >1 month. The
breasts may be unequal in size when the patient has recovered fully from surgery.
There may be excess skin that is unsatisfying to the patient. Both of these conditions
may require another operation. Acute postoperative pain is common and is easily
managed with oral analgesics. Chronic pain is rare. Some patients may experience
heightened sensation of the nipple temporarily, but this usually resolves. Numbness
or paresthesias of the nipple are also possible. The axilla complications are not pres-
ent as axillary surgery is not typically included.
Major Complications
A large hematoma may require evacuation and control of the bleeding with fur-
ther surgery. If a large hematoma is not drained, it may drain spontaneously or
Table 2.10 Gynecomastia surgery estimated frequency of complications, risks, and consequences
Infection 1–5 %
Small 1–5 %
Lymphocele/seroma formation 20–50 %
Need for aspiration (postoperative)a 1–5 %
Paresthesia/neuropraxia/dysesthesia of chest wall, inner armb
Short term (temporary) 1–5 %
Permanent 0.1–1 %
Nipple or areolar deformity/necrosis/painb 1–5 %
Fixity to pectoralis major fasciab 1–5 %
Lateral scar (due to lateral extension of incision for access)b 1–5 %
Lymphatic leak 0.1–1 %
Edema of chestb 0.1–1 %
Incomplete excision of lesion (procedure dependent)b 0.1–1 %
Possibility of further treatment (surgery, radiotherapy, 0.1–1 %
Pneumothorax <0.1 %
Pain/tenderness
Bruising >80 %
Excess axillary skin 5–20 %
Wound scarring
Note: The pathology of the lesion and cause will largely determine the likelihood of complete
a
Dependent on such factors as the size of hematoma/seroma/collection and discomfort/symptoms
caused
b
rarely dissipate. Large hematomas also increase risk of infection. Although some-
times unpredictable, poor cosmesis may arise due to unequal breast size, excessive
skin, dimpling, scarring, or persistence of a subareolar mass, and may occasionally
necessitate further surgery to improve the outcome. However, most men do not
complain of breast deformity. Chronic pain or paresthesia is not common, but can
be significant problems.
2 Breast Surgery 37

• GA risk
• Wound infection
• Recurrent aspirations
• Further surgery
Reconstructive Breast Surgery
Breast Implants: Insertion of Saline- or Silicone-Filled

Prosthesis
Description
Implants are normally inserted under general anesthesia, as adequate local anes-
thesia is difficult to achieve. Implants are artificial devices for providing additional
breast volume and are of various types, shapes, sizes, and contents (saline, sili-
cone, emulsion, or other). They are used in three main areas of surgical practice.
Firstly, for cosmetic bilateral breast augmentation, secondly to achieve symme-
try in patients with congenital conditions leading to asymmetry or where breast
reconstruction has failed to achieve symmetry, and thirdly as an integral part of
immediate or delayed subpectoral reconstruction or with latissimus dorsi breast
reconstruction.
Anatomical Points
Breast implants are commonly inserted into one of three different sites, including
the subpectoral and submammary positions during breast augmentation and deep
to myocutaneous flaps during breast reconstruction. It is important to ensure that
the space developed or constructed for the implant matches the base dimensions of
the native or reconstructed breast. Congenital abnormalities of pectoralis major are
usually associated with absence of the lower third of the muscle. Poland’s syndrome
is a rare congenital condition characterized by unilateral hypoplasia of the breast,
thorax, and pectoral muscles. Previous radical surgery, nerve division, and radio-
therapy may lead to muscle atrophy or muscle loss, which in turn may dictate the
anatomical position of the implant and risk of complications.
Perspective
See Table 2.11. Breast implants currently have a finite lifespan and will typically
need replacement within the 20 years after surgery. The complications of breast
implants are related to the type of implant, the context in which they are used,
and the length of follow-up. Implants have been used for breast augmentation and
reconstruction for more than 30 years, and outside the USA, silicone-gel implants
remain the most popular choice. Implants contain a filler, within a shell made from
polydimethylsiloxanes and amorphous silica, and include silicone gel, saline, and
polyvinylpyrrolidine. Most early complications are related to inappropriate case
selection and surgical technique, which can often be reduced by experience, careful
planning, and attention to operative detail. Patients require comprehensive informa-
tion and advice backed up by printed materials providing a realistic expectation of
outcomes. It needs to be explained that implants are long term and not permanent
devices, which require regular surveillance and replacement if the outer shell rup-
tures or fatigues or other complications develop. The design of silicone-gel implants
has been modified progressively since their introduction. The first generation
implants had a smooth surface, and the second-generation devices had a textured
surface, while the current third generation implants have improved surface texture
with a filler of cohesive silicone-gel associated with lower levels of “silicone bleed”
into the surrounding tissues. Saline implants are used widely in the USA, but have
a less natural consistency and are more prone to leakage, deflation, auto-inflation,
visible surface rippling, and folding. Implant wrinkles and ripples are more obvious
in the reconstructed than in the augmented breast, as they lie closer to the surface
and are not usually able to be covered by breast parenchyma.
Major Complications
Major complications following the use of breast implants are uncommon and occur
either shortly after surgery or many months to years later. Early complications in the
first 24 h include hemorrhage and implant displacement, which in turn are usually
related to surgical technique. Significant hemorrhage requires re-exploration, as
conservative treatment of a peri-prosthetic hematoma is likely to lead to progres-
sive capsule formation. A clear-cut infection in a toxic patient should be managed
by implant removal and appropriate antibiotics. Infection is more common follow-
ing implant-based breast reconstruction, as this is a prolonged procedure which is
associated with more extensive dissection than breast augmentation. Tissue tension
and devascularization are key contributors to ischemia and consequent infection.
A sterile peri-prosthetic seroma can lead to mild reddening of the breast several
days or weeks after implantation, leading to diagnostic confusion. It can be man-
aged by careful ultrasound-guided aspiration and culture to reduce confusion with
pyogenic infection. Overzealous tissue expansion of relatively ischemic or irradi-
ated tissues can lead to overlying tissue necrosis and extrusion of the expander.
2 Breast Surgery 39
Table 2.11 Breast implants estimated frequency of complications, risks, and consequences
Infection 1–5 %
Bleeding/hematoma formation 1–5 %
Skin necrosis 1–5 %
Rippling of implant shell 5–20 %
Calcification of capsule 5–20 %
Asymmetry 5–20 %
Loss of shape 5–20 %
Displacement/rotation of prosthesis position 1–5 %
Symptomatic capsular contracture (moderate/severe) 5–20 %
Saline leakage and prosthesis collapse (early/late)a 5–20 %
Need for replacement/revision 20–50 %
Subpectoral implant
Medial pectoral nerve injury and pectoral muscle atrophy 1–5 %
Fixity to pectoralis major fascia 1–5 %
Suboptimal cosmetic result (symmetry/placement/projection, etc.)b 5–20 %
Silicone leakage and disruption of shell (early/late)a 0.1–1 %
Puncture of prosthesis (inadvertent) 0.1–1 %
Rib osteomyelitis or pressure necrosis <0.1 %
Pneumothorax <0.1 %
Mortality (operative)a <0.1 %
Peri-areolar incision insertion problems
Nipple or areolar deformity/necrosis/pain/sensory loss 5–20 %
Lateral scar (due to lateral extension of scar for access) 1–5 %
With expander prostheses
Failure to expand 0.1–1 %
Injection port rotation/displacement 1–5 %
Puncture of prosthesis (inadvertent intra- or postoperatively) 0.1–1 %
Disconnection of injection port tube 0.1–1 %
Difficulty locating injection port 1–5 %
Difficulty removing filler tube 1–5 %
Difficulty deflating expander 1–5 %
Pain/tenderness
Seroma 1–5 %
Wound scarring and poor cosmesis 1–5 %
Wound drain tube(s)a 50–80 %
a
Dependent on pathology, anatomy, surgery type, and surgeon preference
b
Dependent on pathology, associated surgery, anatomy, surgery type, and patient and surgeon
perception
Implants may also extrude through recent incisions if they are closed under tension,
irradiated, become infected, or have been inadequately sutured. The most frequent
and frustrating late complication is adverse capsular contracture (ACC), which
may occur in up to 70 % of cases. The etiology is unknown, but possible causes
include a foreign body reaction, hematoma, infection, and radiotherapy. The use
of textured implants reduces this risk. ACC is more common after reconstruction,
when using larger implants and with longer follow-up. If ACC is symptomatic, it
is treated by open capsulotomy or capsulectomy and replacement of the implant
with a textured device, but recurrence is common. Prosthesis rupture is the second
most common late complication which may be symptomatic or asymptomatic. It is
detectable in up to 20 % of patients with silicone-gel implants who are followed up
for more than 10 years. Rupture can be detected by ultrasound or, more specifically,
MRI scanning and should be treated by removal and replacement of the implant.

• GA risk
• Wound infection
• Prosthesis mobility
• Capsular contraction
• Need for replacement
• Further surgery
Latissimus Dorsi Flap Breast Reconstruction
Description
The operation is performed under general anesthetic, often supplemented by a

paravertebral block. Adequate preoperative planning and preparation is key to the
success of latissimus dorsi (LD) breast reconstruction. Good lighting, careful posi-
tioning, and high-quality equipment simplify the procedure. Appropriate intrave-
nous antibiotics are given for 24 h. An island of skin and underlying latissimus
dorsi muscle is raised from the back attached to its thoracodorsal vascular pedicle
and tunneled anteriorly to reach the ipsilateral chest. Immediate LD breast recon-
struction (IBR) is carried out at the same time as mastectomy. It avoids the need
to recreate the breast pocket and re-dissect the axilla, which comprise the initial
steps of delayed LD breast reconstruction (DBR). Outcomes are closely related
2 Breast Surgery 41
to the accuracy of the preoperative markup. This should include the position and
size of the breast pocket, the exact extent of the flap harvest, and the position of the
anterior skin incisions and the posterior skin island. The markup should always be
performed prior to surgery and never in the operating theater. The use of templates
helps in the selection of the most appropriate expander or implant and defines the
exact limits of the breast pocket. The patient should be preloaded with intravenous
crystalloid solution to maximize flap perfusion.
Anatomical Points
Variations in the anatomy of the chest wall and axilla are encountered only occa-
sionally during breast reconstruction and include Poland’s syndrome (hyperplasia
of the breast, pectoralis muscle, and chest wall) and an additional head to LD, which
passes anterior to the axillary vein. Variations in vascular anatomy are more com-
mon. The subscapular trunk normally lies deeply in the lateral aspect of the axilla,
as it approaches the tendinous part of LD. It gives off one or two branches to ser-
ratus anterior, before continuing as the thoracodorsal artery. Two variations can give
rise to intraoperative confusion and may lead to inadvertent damage. First, the trunk
may lie more medially in the axilla. In this situation, the subscapular vein may
be mistaken for one of the lateral thoracic veins. The subscapular vein drains into
the posterior wall of the axillary vein, but the lateral thoracic veins drain into the
inferior wall of the axillary vein and are intimately related to the intercostobrachial
nerves. This relationship should be confirmed before dividing them, in order to
avoid inadvertent division of the subscapular vein near its origin. Secondly, a lateral
thoracic vein occasionally drains into the subscapular vein rather than directly into
the axillary vein. Failure to recognize this variation may again lead to ligation and
division of the subscapular vein, which is mistaken for the proximal segment of a
lateral thoracic vein. Two further anatomical variations may be encountered when
performing DBR in a patient with a previously dissected axilla. First, the thora-
codorsal trunk may be plastered to serratus anterior by scar tissue on the medial wall
of the axilla. Careful identification and dissection are vital to avoid confusion and
inadvertent damage to the trunk. This is made easier by identifying the vessels low
down in the axilla as they enter LD and dissecting them free from surrounding scar
tissue, working in a cranial direction. Second, the subscapular trunk may have been
divided during a previous radical axillary dissection. This leads to a reversal of the
blood flow in the serratus anterior branches through a rich network of anastomoses
with the intercostal vessels. Providing the serratus anterior branches are patent and
reversed pulsatile flow can be demonstrated, it should be possible to elevate the LD
flap on this alternative blood supply.
Perspective
See Table 2.12. Serious complications following LD reconstruction which require

immediate intervention are rare. They include total or partial flap loss, major
Table 2.12 Latissimus dorsi breast reconstruction estimated frequency of complications, risks,
and consequences
Without prosthesis insertion
Infection 0.1–1 %
Loss of (latissimus dorsi) muscle function (nerve preserved)a 1–5 %
Paresthesia and dysesthesia (reconstructed breast) >80 %
Total/large partial flap lossa 0.1–1 %
Asymmetry 50–80 %
Loss of volume/atrophy 20–50 %
Need for later revision 5–20 %
Scalloping of back donor site 1–5 %
Dehiscence of wound
Chest 0.1–1 %
Back 1–5 %
Suboptimal cosmesis 20–50 %
Need for later flap revision/replacement with a prosthesisa 1–5 %
With prosthesis insertion
Infection 1–5 %
Skin necrosis (breast) 1–5 %
Dehiscence of wound
Chest 1–5 %
Back 1–5 %
Asymmetry 20–50 %
Loss of shape 5–20 %
Displacement/rotation of prosthesis position 1–5 %
Symptomatic capsular contracture (without radiotherapy) 5–20 %
Symptomatic capsular contracture (with radiotherapy) 50–80 %
Saline leakage and prosthesis collapsea (early/late) 5–20 %
Silicone bleeda, b (early/late) >80 %
Silicone leakage or disruption of shella, b (early/late) 0.1–1 %
Silicon granuloma formationb 0.1–1 %
Need for replacement/revision (>10 years) 5–20 %
Subpectoral implant
Medial pectoral nerve injury and pectoral muscle atrophy 1–5 %
Fixity to pectoralis major fascia 1–5 %
Puncture of prosthesis (inadvertent) 0.1–1 %
Rib osteomyelitis or pressure necrosis <0.1 %
Suboptimal cosmesis (symmetry/placement/projection, etc)c 5–20 %
With expander prosthesis
Injection port rotation/displacement 1–5 %
Difficulty locating injection port 1–5 %
Difficulty removing filler tube 1–5 %
Difficulty deflating expander 1–5 %
2 Breast Surgery 43

Disconnection of injection port tube 0.1–1 %
Puncture of prosthesis (inadvertent intra- or postoperatively) 0.1–1 %
Failure to expand 0.1–1 %
Tissue necrosis—pedicle flap 0.1–1 %
Skin necrosis—back 0.1–1 %
Skin necrosis—breast 0.1–1 %
Flap-related DIC (disseminated intravascular coagulation) <0.1 %
Pneumothorax <0.1 %
Mortality (operative)a <0.1 %
Pain/tenderness
Chronic (>12 weeks) 5–20 %
Seroma formation (requiring aspiration)a
Chest 1–5 %
Back 50–80 %
Wound scarring (hypertrophic scar) or deformity
Chest 1–5 %
Back 1–5 %
Phantom breast painc 5–20 %
Wound scarring and poor cosmesis 5–20 %
a
Dependent on pathology, anatomy, prosthesis type, surgery type, and surgeon preference
b
If silicone prosthesis is used
c
Dependent on pathology, anatomy, surgery type, and patient and surgeon perception
hemorrhage, and fulminating primary infection. Careful dissection, hemostasis,

appropriate antibiotic cover, and adequate experience should help to reduce the
incidence of these events to well under 1 %. It is much more common to encounter
less major complications, either early in the postoperative period or later. The most
frequent early problems include malposition of the flap, the skin island, or the pros-
thesis. These can be avoided by careful planning, flap design, and a well-stocked
implant bank. Asymmetry is another early common problem which can be mini-
mized by the use of tissue expanders, allowing adjustment of the size and shape of
the breast. Prolonged drainage of serous fluid and recurrent donor site seroma for-
mation are very common sequelae to this type of surgery, rather than complications.
The most common late complications include those relating to implants (see sec-
tion on implants), the flap, and the donor site. The risk of a malpositioned implant
is greater after DBR, and the risk of capsule formation is greater after radiotherapy.
A number of late problems may be encountered with the flap. These include an axil-
lary “bulge,” which can be prevented by high division of the tendon. This allows the
flap to drop down out of the axilla into the breast pocket and helps to create a more
ptotic breast. Spontaneous, unsightly and sometimes painful contraction of the flap
may be prevented by prophylactic division of the thoracodorsal nerve or treated

by secondary division of the nerve in the few patients who are affected. Failure to
suture the perimeter of the flap all around the resection defect can result in incom-
plete muscle cover, leading to physical wrinkling and creasing of the implant where
it lies immediately under the skin.
Up to 30 % of patients experience some loss of shoulder mobility and
strength, affecting adduction, extension, and external rotation of the arm. Donor
site seroma formation may be reduced by using “quilting” sutures to obliterate
the donor cavity. A few patients develop chronic seromas which may require
treatment by excision of the cavity wall and insertion of a secondary drain.
Chronic donor site pain is uncommon and difficult to treat and may respond to a
paravertebral block.
Major complications: Major complications can be divided into those which
require early intervention and those which present later and are debilitating enough
to affect quality of life.
Early Complications
Total or partial flap loss is a rare disaster which can be avoided by understanding
axillary anatomy, its anomalies, and the pitfalls associated with previous axillary
dissection. A necrotic flap should be excised as soon as the diagnosis has been
confirmed. Skin envelope necrosis is becoming more common with the advent of
skin-sparing mastectomy. It may be treated by excision and primary suture or exci-
sion and grafting, depending on the extent of skin loss.
Significant hemorrhage into the donor site or around the prosthesis requires early
exploration. It is common to find several bleeding points which require control.
Conservative treatment by continuing with closed drainage delays recovery and
increases the risks of late capsule formation.
A clear-cut postoperative peri-prosthetic infection settles down rapidly after
removal of the implant, which can be replaced some 4–6 months later. Displacement
of the implant into the axilla or even into the donor site requires prompt replace-
ment and re-suturing of the lateral wall of the implant pocket, in order to prevent
recurrence.
Debilitating Late Complications
Adverse capsular contracture (ACC) is a progressive condition occurring in up to

20 % of patients within 10 year of implantation. It leads to pain, distortion, and
asymmetry and may be reduced by meticulous hemostasis and an aseptic tech-
nique. Implant-based breast reconstruction should be avoided when radiotherapy is
planned in view of the very high risk of ACC in patients undergoing radiotherapy
after implant-based breast reconstruction. ACC, poor wound closure, and overambi-
tious tissue expansion may lead to implant extrusion. The underlying cause should
be corrected before attempting reinsertion.
2 Breast Surgery 45
A number of factors may lead to progressive asymmetry, including the use of a

prosthesis of inappropriate size, poor positioning, progressive contralateral ptosis,
and ACC. Asymmetry occurs in up to 50 % of reconstructed patients. It requires
correction when it affects quality of life, either by contralateral augmentation or
reduction or by ipsilateral revisional surgery. Symmastia is an extreme form of
asymmetry resulting from loss of the cleavage. It is almost impossible to correct.
Finally, the rate of local recurrence in the reconstructed breast is less than 1 %
per annum. Recurrences deep to the prosthesis are extremely rare and treatment
will depend on presentation. “Spot” recurrences in nonirradiated reconstructions
may be managed by local excision and radiotherapy, providing clear margins can be
achieved. “Field” recurrences will require additional systemic therapy.

• GA risk
• Wound infection
• Wound dehiscence
• Seromas and aspirations
• Further surgery
Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM)

Flap Reconstruction
Description
The operation is performed under general anesthetic, sometimes supplemented by

a paravertebral or epidural block. Adequate preoperative planning and preparation
is key to the success of TRAM flap breast reconstruction. Good lighting, careful
positioning, and high-quality equipment simplify the procedure. Appropriate intra-
venous antibiotics are given for 24 h or more. An island of skin and underlying
rectus Abdominis muscle is raised from the lower abdomen attached to its supe-
rior vascular pedicle (superior epigastric vessels) and tunneled anteriorly to reach
the contralateral or sometimes the ipsilateral chest. Immediate TRAM flap breast
reconstruction (ITRAM) is carried out at the same time as mastectomy. It avoids the
need to recreate the breast pocket and re-dissect the medial axilla, which comprise
the initial steps of delayed TRAM flap breast reconstruction (DTRAM). Outcomes
are closely related to the accuracy of the preoperative markup. This should include
the position and size of the breast pocket, the exact extent of the flap harvest, and
the position of the anterior abdominal wall skin incisions. The markup is usually
performed prior to surgery with the patient standing up, rather than in the operat-
ing theater. Some authors raise the unilateral pedicled flap for use immediately in
TRAM reconstruction, while others prefer to prior ligate (even laparoscopically)
the inferior epigastric vessels several months before the TRAM flap is raised to
effectively expand or “supercharge” the superior epigastric supply. Other surgeons
advocate harvesting both rectus muscles (bipedicled TRAMs), to gain more vol-
ume. Expanders or implants are almost never used, and the exact limits of the breast
pocket need to be planned. The patient should be preloaded with intravenous crys-
talloid solution to maximize flap perfusion.
Anatomical Points
Significant variations in the anatomy of the chest wall, axilla, and abdominal wall
are uncommon. The rectus muscle may be broader and attached more laterally. The
inferior epigastric vessels are usually larger than the superior; rarely the inferior
vessels may be small. The epigastric veins are often duplex (double), and rarely
the artery may also be duplex. The rectus muscle is usually supplied predominantly
from below via the inferior epigastric vessels. The small branches of the inferior
epigastric piercing the anterior rectus fascia to supply the abdominal wall skin are
critical for the survival of the skin and subcutaneous tissue comprising the TRAM
flap. These branches can be very small and highly variable in location and number.
A preoperative vascular duplex U/S may be of use in locating and mapping these
vessels. The shape of the chest wall and rectus insertion may dictate the relative ease
of positioning of the pedicle for the tissue to be fashioned to form the “new” breast
mound. Kinking or constriction must not be allowed; otherwise the flap may suffer
vascular compromise and fail, due to either poor arterial inflow or reduced venous
outflow. Previous abdominal surgery and scarring may alter the operative approach.
Perspective
See Table 2.13. Most complications from TRAM flap reconstructions are minor and
less serious. However, serious complications which require immediate intervention
are not uncommon. The most frequent early problems include venous congestion of
the distal part of the flap, leading to partial or rarely total flap necrosis/loss. Other
major complications include pulmonary emboli (~1 %), major hemorrhage (~1:500),
and infection of the chest or abdominal wound site(s). Prevention of DVT, careful
dissection, hemostasis, appropriate antibiotic cover, and adequate experience should
help to reduce the incidence of these events to well under 2 %. Risk of total flap loss
is generally higher for free than pedicled TRAM flaps. It is much more common to
2 Breast Surgery 47
Table 2.13 Transverse rectus Abdominis myocutaneous (TRAM) flap reconstruction superior
pedicle flap estimated frequency of complications, risks, and consequences
Complications, risks, and consequences Estimated
(Without prosthesis insertion) frequency
Total flap loss 0.1–1 %
Infectiona
Breast site 1–5 %
Abdominal site 1–5 %
Breast site 1–5 %
Major skin necrosis
TRAM flap 1–5 %
Abdomen 1–5 %
Dehiscence (major) of wounda
Chest 1–5 %
Abdomen 1–5 %
DVT and pulmonary emboli 1–5 %
Flap-related DIC (disseminated intravascular coagulation) <0.1 %
Serious infection and wound breakdowna 0.1–1 %
Multisystem organ failurea, b 0.1–1 %
Mortalitya, b 0.1–1 %
Pain/tenderness (incl. rib/back/arm/shoulder/abdominal)
Paresthesia and dysesthesia (altered sensation abdomen/chest) 50–80 %
Traction/pressure injury (brachial plexus/ulnar/neuropathy) 1–5 %
Seroma formation
Chest 1–5 %
Abdomen 5–20 %
Fat necrosisa 20–50 %
Small partial flap necrosisa 20–50 %
Asymmetry (major)c 5–20 %
Loss of volume atrophya 5–20 %
Abdominal skin necrosis (minor)a 5–20 %
Abdominal hernia 1–5 %
Loss of rectus muscle/abdominal wall function 20–50 %
Arm/chest/abdominal swelling 1–5 %
Shoulder/back stiffness 1–5 %
Suture granuloma/suture sinus 1–5 %
Umbilicus necrosis/malposition 1–5 %
(continued)

Complications, risks, and consequences Estimated
(Without prosthesis insertion) frequency
Wound scarring (hypertrophic scar) or deformity/dimpling
Chest 1–5 %
Abdomen 1–5 %
Blood transfusion (autologous or allogeneic) 1–5 %
Wound drain tube(s) >80 %
a
Notes: (1) Most of these risks, complications, or consequences are increased in patients who are
diabetic, smokers, over 60 years of age, and immunosuppressed, or who have had previous breast
or abdominal surgery or radiotherapy#. (2) Breast cancer in the opposite breast after reconstruction
of one side may present unique problems and limitations for reconstruction, over and above uni-
lateral TRAM reconstruction. Recurrence of tumor in the reconstructed breast is more a conse-
quence of tumor biology and initial treatment(s)
b
c
Dependent on pathology, anatomy, surgery type, and patient and surgeon perception
encounter less major complications, either early in the postoperative period or later.
The most frequent early problems include malposition of the flap or the skin island.
These can often be reduced by careful planning of flap design. Asymmetry is another
early common problem which can be minimized by intraoperative adjustment of the
size and shape of the breast. Prolonged drainage of serous fluid and recurrent donor
site seroma formation are very common sequelae to this type of surgery, rather than
complications. Implants are very seldom used under TRAM flap breast reconstruc-
tion, but if used can be associated with prosthetic specific complications (see section
on complications of implants). Patients may experience some loss of shoulder mobil-
ity and strength or back pain, due to positioning of the arms during the prolonged pro-
cedure. The abdominal donor site is a common source of complications, relating to
discomfort, pain, seroma formation, and sometimes later hernia formation. Chronic
donor site pain is not common and may be difficult to treat. Further “remodeling”
surgery is frequently necessary to attain the desired cosmetic outcome, includ-
ing reshaping of the flap, liposuction/lipofilling, nipple/areolar reconstruction, and
reduction of the opposite breast, which the patient needs to be made aware of.
Major Complications
Major complications can be divided into those which require early (often immedi-
ate) intervention and those which present later and are debilitating enough to affect
quality of life.
Early Complications
Total flap loss is infrequent which might be reduced by careful selection of

patients, understanding anatomy, any anomalies, pitfalls associated with any previ-
ous surgery, and avoidance of tension. Full-thickness partial flap necrosis is not
2 Breast Surgery 49
uncommon and often only over a small area, but typically requires excision and
prolonged dressings. Skin envelope necrosis can arise after skin-sparing mastec-
tomy. It may be treated by excision and primary suture or excision and grafting,
depending on the extent of skin loss. Significant hemorrhage beneath the flap or
into the donor site usually requires early exploration. Control of any bleeding points
can then be attained. Conservative treatment by continuing with closed drainage
may delay recovery and increase the risks of tension, flap ischemia, and infection.
Traction injuries to the brachial plexus and back pain are not uncommon after
prolonged surgery, and this risk may be reduced by careful padding and position-
ing. Ulnar nerve paresis is higher in prolonged procedures with inadvertent arm
misplacement. Abdominal wall hematoma is relatively uncommon, but may inter-
nal to the reconstructed abdominal wall and hence concealed. Multisystem organ
failure is very rare and together with fatal pulmonary emboli constitutes the usual
cause of mortality, which is rare.
Debilitating Late Complication
Later complications can arise in the reconstructed breast and/or in the abdomi-
nal wall donor site. Rarely, severe infection or cellulitis of the chest wall, flap or
abdominal wall can arise, and wound dehiscence, skin ulceration, sinus forma-
tion, and a chronic discharging wound and prolonged dressings may occur. This
may lead to cosmetic deformity resulting in breast asymmetry or abdominal wall
deformity. Seroma formation may occur in the breast/axillary region or at the
abdominal donor site. Abdominal wall hernia formation may occur and require
later surgical repair. Use of only part of the rectus muscle and limited use of mesh
may reduce the risks. Chronic infection of the mesh can also occur. Chronic pain
of the breast or abdominal wall is usually low grade if it occurs, but can rarely
be severe and unpredictable. Contraction of the reconstructed breast is rarely a
problem after free-TRAM flap reconstruction (compared with breast implant proce-
dures), but can occur with fat necrosis and infection with tissue loss, and after radio-
therapy. Umbilical distortion due to contraction and/or misplacement can occur
and may need surgical correction.
Progressive contralateral ptosis, fat necrosis, and changes in the flap can lead to
progressive asymmetry, lumpiness, and cosmetic deformity, which may require
further surgery. This can be a serious problem as a late consequence of recon-
structive surgery coincident with the effects of changing body shape during aging.
Severe systemic infection and multisystem organ failure are exceedingly rare, as
is mortality.
Local breast cancer recurrence in the reconstructed breast is typically <1 %
per annum. Recurrences deep to the flap are extremely rare and treatment will
depend on presentation. Localized “spot” recurrences in nonirradiated reconstruc-
tions may be managed by local excision and radiotherapy, providing clear margins
can be achieved. “Field” recurrences will usually require additional systemic ther-
apy. Systemic recurrence is a more serious issue and related to the primary tumor
biology, rather than a consequence of reconstructive surgery.

• GA risk
• Wound infection
• Abdominal dysfunction
• Flap necrosis
• Flap loss
• Further surgery
Free Transverse Rectus Abdominis Myocutaneous

(TRAM) Flap Reconstruction
Description
The operation is performed under general anesthesia, sometimes supplemented by a

paravertebral or epidural block. Adequate preoperative planning and preparation is key
to the success of TRAM flap breast reconstruction. Good lighting, careful positioning,
and high-quality equipment simplify the procedure. Appropriate intravenous antibiotics
are given for 24 h or more. An island of skin and underlying rectus abdominis muscle is
raised from the lower abdomen attached to its inferior vascular pedicle (inferior epigas-
tric vessels) and divided. Immediate free-TRAM flap breast reconstruction (ITRAM)
is carried out at the same time as mastectomy (Figs. 2.6, 2.7 and 2.8). It avoids the need
to recreate the breast pocket and re-dissect the medial axilla, which may comprise the
initial steps of delayed free-TRAM flap breast reconstruction (DTRAM). Further reten-
tion of native breast envelope provides superior aesthetic results. Aesthetic outcomes
are closely related to the accuracy of the preoperative markup. This should include the
position and size of the breast pocket, the exact extent of the flap harvest, and the posi-
tion of the anterior abdominal wall skin incisions. The markup is usually performed
prior to surgery, with the patient standing. Expanders or implants are seldom required.
The patient should be warmed perioperatively to maximize tissue perfusion. Further
smaller procedures are often required for improved cosmetic appearance later, such as
nipple reconstruction and fat grafting. The patient must be maintained normovolemic
and normothermic throughout the operation and postoperatively.
Anatomical Points
Significant variations in the anatomy of the chest wall, axilla, and abdominal wall
are uncommon, but minor variations do occur, especially with vascular supply. The
2 Breast Surgery 51
Fig. 2.6 Early result of free-TRAM bilateral breast reconstruction
Fig. 2.7 Later TRAM reconstruction result

Fig. 2.8 Very late TRAM results
rectus abdominis muscle may be broader and attached more laterally. The infe-
rior epigastric vessels are usually larger than the superior; rarely the inferior ves-
sels may be small. The epigastric veins are often duplex (double), and rarely the
artery may also be duplex. The rectus muscle may be rarely supplied predominantly
from above via the superior epigastric vessels, but usually the main supply is via
the inferior epigastric vessels. The origin of the inferior epigastric artery from and
entry point of the vein(s) into the iliac vessels can vary significantly. The perforator
branches of the inferior epigastric artery piercing the anterior rectus fascia to supply
the abdominal wall skin are critical for the survival of the skin and subcutaneous
tissue comprising the TRAM flap. These branches can be very small and highly
variable in location and number. A preoperative vascular duplex U/S may be of use
in locating and mapping these vessels. With accurate localization of these vessels
using vascular Doppler, multi-slice CT scan, or MRI, the muscle can be spared and
a DIEP (deep inferior epigastric perforator) flap can be performed. The shape of the
chest wall and rectus insertion may dictate the relative ease of positioning of the
pedicle for the tissue to be fashioned to form the “new” breast mound. Kinking or
constriction must not be allowed; otherwise the flap may suffer vascular compro-
mise and fail, due to either poor arterial inflow or reduced venous outflow. Previous
abdominal surgery and scarring may alter the operative approach.
2 Breast Surgery 53
Perspective
See Table 2.14. Most complications from TRAM flap reconstructions are minor and
less serious. However, serious complications, which may require immediate inter-
vention, can occur. These include arterial or venous occlusion, total or partial flap
loss, major hemorrhage, and fulminating primary infection. Risk of total flap loss is
generally higher for free than pedicled TRAM flaps, but partial loss is usually less.
Early reoperation with re-anastomosis may be acutely required. Careful dissection,
hemostasis, appropriate antibiotic cover, and adequate experience should help to
reduce the incidence of these events to <5 %. The most frequent early problems
include malposition of the flap or the skin island. These can often be reduced by care-
ful planning of flap design. Asymmetry is another early common problem, which
can be minimized by intraoperative adjustment of the size and shape of the breast.
Prolonged drainage of serous fluid and recurrent donor site seroma formation are
very common sequelae to this type of surgery, rather than complications. Implants
are very seldom used with TRAM flap breast reconstruction but, if used, can be
associated with prosthetic specific complications (see section on complications of
implants). Patients may experience some loss of shoulder mobility and strength
or back pain, due to positioning of the arms during the prolonged procedure. The
abdominal donor site is a common source of complications, relating to discomfort,
pain, seroma formation, and, sometimes, later hernia formation. Chronic donor site
pain is not common and may be difficult to treat. Further “remodeling” surgery
is frequently necessary to attain the desired cosmetic outcome, including liposuc-
tion, nipple/areolar reconstruction, and reduction of the opposite breast, which the
patient needs to be made aware of.
Major Complications
Major complications can be divided into those which require early (often immedi-
ate) intervention and those which present later and are debilitating enough to affect
quality of life.
Table 2.14 Transverse rectus Abdominis myocutaneous (TRAM) flap reconstruction free
microvascular inferior pedicle flap estimated frequency of complications, risks, and consequences
(Without prosthesis insertion) Estimated frequency
Total flap lossa 1–5 %
Infectiona
Breast site 1–5 %
(continued)

(Without prosthesis insertion) Estimated frequency
Bleeding/hematoma formationa
Breast site 1–5 %
Major skin necrosisa
TRAM flap 1–5 %
Abdomen 1–5 %
DVT and pulmonary emboli 1–5 %
Serious infection and wound breakdowna 0.1–1 %
Mortalitya, b 0.1–1 %
Pain/tenderness (incl. rib/back/arm/shoulder/abdominal)
Paresthesia and dysesthesia (altered sensation abdomen/chest) 50–80 %
Traction/pressure injury (brachial plexus/ulnar/neuropathy) 1–5 %
Fat necrosisa 5–20 %
Small partial flap necrosisa 1–5 %
Asymmetry (major) 5–20 %
Loss of volume atrophy 5–20 %
Seroma formation
Chest 1–5 %
Abdomen 5–20 %
Dehiscence (major) of wound
Chest 1–5 %
Abdomen 1–5 %
Abdominal herniaa 1–5 %
Loss of rectus muscle/abdominal wall functiona 20–50 %
Arm/chest/abdominal swelling 1–5 %
Shoulder/back stiffness 1–5 %
Suture granuloma/suture sinus 1–5 %
Umbilicus necrosis/malposition 1–5 %
Wound scarring (hypertrophic scar) or deformity/dimpling
Chest 1–5 %
Abdomen 1–5 %
Blood transfusion (autologous or allogeneic) 1–5 %
Wound drain tube(s) >80 %
a
Notes: (1) Most of these risks, complications, or consequences are increased in patients who are
diabetic, smokers, over 60 years of age, and immunosuppressed or who have had previous breast
or abdominal surgery or radiotherapy#. (2) Breast cancer in the opposite breast after reconstruction
of one side may present unique problems and limitations for reconstruction, over and above unilat-
eral TRAM reconstruction. Recurrence of tumor in the reconstructed breast is more a consequence
of tumor biology and initial treatment(s)
b
2 Breast Surgery 55
Early Complications
Occlusion of the artery or vein, usually due to thrombosis, tension, or kinking, is

serious early complication often requiring immediate revision of the anastomosis.
Total flap loss is infrequent, and risk of this might be reduced by understanding
the anatomy and anomalies, the pitfalls associated with the surgery, the effects
of any previous surgery, and avoidance of tension. Full-thickness partial flap
necrosis is possible and often only over a small area, but typically requires exci-
sion and prolonged dressings. Skin envelope necrosis can arise after skin-sparing
mastectomy. It may be treated by excision and primary suture or excision and
grafting, depending on the extent of skin loss. Significant hemorrhage beneath
the flap or into the donor site usually requires early exploration. Conservative
treatment by continuing with closed drainage may delay recovery and increase the
risks of tension, flap ischemia, and infection. Traction injuries to the brachial
plexus and back pain can occur after prolonged surgery, and this risk may be
reduced by careful padding and positioning. Ulnar nerve paresis is higher in pro-
longed procedures with inadvertent arm misplacement. Abdominal wall hema-
toma is relatively uncommon, but may be internal to the reconstructed abdominal
wall and hence concealed.
Debilitating Late Complications
Later complications can arise in the reconstructed breast and/or in the abdominal
wall donor site. Rarely, severe infection or cellulitis of the chest wall, flap or abdom-
inal wall can arise, and wound dehiscence, skin ulceration, sinus formation, and
a chronic discharging wound and dressings may occur. This may lead to cosmetic
deformity resulting in breast asymmetry or abdominal wall deformity. Seroma
formation may occur in the breast/axillary region or at the abdominal donor site.
Abdominal wall hernia formation may occur and require later surgical repair.
Use of only part of the rectus muscle and limited use of mesh may reduce the risks.
Chronic pain of the breast or abdominal wall is usually low grade if it occurs, but
can rarely be severe and unpredictable. Contraction of the reconstructed breast
is rarely a problem. Umbilical distortion due to contraction and/or misplacement
can occur and may need surgical correction. Progressive contralateral ptosis, fat
necrosis, and changes in the flap can lead to progressive asymmetry, lumpiness,
and cosmetic deformity, which may require further surgery. This can be a serious
problem as a late consequence of reconstructive surgery coincident with the effects
of changing body shape during aging. Severe systemic infection and multisystem
organ failure are exceedingly rare, as is mortality.
Local breast cancer recurrence in the reconstructed breast is typically <1 %
per annum. Recurrences deep to the flap are extremely rare and treatment will
depend on presentation. Localized “spot” recurrences in nonirradiated reconstruc-
tions may be effectively managed by local excision, and radiotherapy, providing
clear margins can be achieved. “Field” recurrences will usually require additional
systemic therapy. Systemic recurrence is a more serious issue and related to the
primary tumor biology rather than a consequence of surgery.

• GA risk
• Wound infection
• Abdominal dysfunction
• Flap necrosis
• Flap loss
• Further surgery
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Kajikawa A, Ueda K, Tateshita T, Katsuragi Y. Breast reconstruction using tissue expander
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ipsilateral pedicled TRAM flap as a safe alternative. Ann Plast Surg. 2005;54(4):356–60.
Ng RL, Youssef A, Kronowitz SJ, Lipa JE, Potochny J, Reece GP. Technical variations of the
bipedicled TRAM flap in unilateral breast reconstruction: effects of conventional versus
microsurgical techniques of pedicle transfer on complications rates. Plast Reconstr Surg.
2004;114(2):374–84. discussion 385–8.
Olding M, Emory RE, Barrett WL. Preferential use of the ipsilateral pedicle in TRAM flap breast
reconstruction. Ann Plast Surg. 1998;40(4):349–53.
Rinker BD, Bowling JT, Vasconez HC. Blood transfusion and risk of metastatic disease or recur-
rence in patients undergoing immediate TRAM flap breast reconstruction: a clinical study and
meta-analysis. Plast Reconstr Surg. 2007;119(7):2001–7.
Schwartz GF, Veronesi U, Clough KB, Dixon JM, Fentiman IS, Heywang-Köbrunner SH, Holland
R, Hughes KS, Margolese R, Olivotto IA, Palazzo JP, Solin LJ, Consensus Conference
Committee. In: Proceedings of the consensus conference on breast conservation, 28 April to 1
May 2005, Milan. Cancer. 2006;107(2):242–50. Jul 15.
Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications
in pedicled TRAM breast reconstruction. Plast Reconstr Surg. 2005;116(7):1873–80.
Trus TL, Collins ED, Demas C, Kerrigan C. Initial experience with laparoscopic inferior epi-
gastric vessel ligation for delayed transverse rectus abdominus musculocutaneous flap breast
reconstruction. Arch Surg. 2007;142(4):362–4.
Tseng CY, Lang PO, Cipriani NA, Song DH. Pedicle preservation technique for arterial and
venous turbocharging of free DIEP and muscle-sparing TRAM flaps. Plast Reconstr Surg.
2007;120(4):851–4. Sep 15.
Wagner DS, Michelow BJ, Hartrampf Jr CR. Double-pedicle TRAM flap for unilateral breast
reconstruction. Plast Reconstr Surg. 1991;88(6):987–97.
Wilkins EG, Cederna PS, Lowery JC, Davis JA, Kim HM, Roth RS, Goldfarb S, Izenberg PH,
Houin HP, Shaheen KW. Prospective analysis of psychosocial outcomes in breast reconstruc-
tion: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study.
Plast Reconstr Surg. 2000;106(5):1014–25. discussion 1026–7.
Free Transverse Rectus Abdominis Myocutaneous (TRAM)

Flap Reconstruction
Allen RJ. DIEP versus TRAM for breast reconstruction. Plast Reconstr Surg. 2003;111(7):2478.
Allen R, Heitland A. Autogenous augmentation mammaplasty with microsurgical tissue transfer.
Plast Reconstr Surg. 2003;112:91–100.
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breast reconstruction. Plast Reconstr Surg. 2006;118(2):333–9.
Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast
Surg. 1994;32(1):32–8.
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plications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps
for breast reconstruction. Ann Plast Surg. 2008;60(5):562–7.
Atisha D, Alderman AK. A systematic review of abdominal wall function following abdominal
flaps for postmastectomy breast reconstruction. Ann Plast Surg. 2009;63(2):222–30.
Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospec-
tive comparison with TRAM and DIEP flaps. Plast Reconstr Surg. 2004;114(5):1077–83.
discussion 1084–5.
Wilkins; 1997.
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Reconstr Surg. 1973;52:111–7.
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struction. Plast Reconstr Surg. 2004;113(4):1153–60.
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reconstruction using the superficial inferior epigastric artery flap revisited. Plast Reconstr Surg
2005;116(3). [Supplement: 133].
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Oncol. 2006;94(6):441–54. Nov 1, Review.
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flaps. J Plast Reconstr Aesthet Surg. 2006;59(6):614–21.
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1985;76:948–52.
2 Breast Surgery 65
Hamdi M, Khuthaila DK, Van Landuyt K, Roche N. Monstrey S Double-pedicle abdominal

perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue
transfer to the breast. J Plast Reconstr Aesthet Surg. 2007;60(8):904–12. discussion 913–4.
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flap. Plast Reconstr Surg. 1982;69(2):216–25.
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breast reconstruction: are they as safe as contralateral techniques? J Plast Reconstr Aesthet
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TRAM flap with vascular enhancement procedures. J Plast Reconstr Aesthet Surg. 2008; Jul
9. [Epub ahead of print].
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flaps. Ann Plast Surg. 1992;29(1):12–7.
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rence in patients undergoing immediate TRAM flap breast reconstruction: a clinical study and
meta-analysis. Plast Reconstr Surg. 2007;119(7):2001–7.
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perforator flap. Plast Reconstr Surg. 2002;109(6):1919–24.
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culocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perfo-
rator flap. Microsurgery. 2008;28(8):650–5.
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J Surg. 1973;43:1–3.
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1975;56(3):243–53.
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venous turbocharging of free DIEP and muscle-sparing TRAM flaps. Plast Reconstr Surg.
2007;120(4):851–4. Sep 15.
Chapter 3
Thyroid and Parathyroid Surgery
Armando Giuliano, Samuel Wells Jr., Thomas Reeve,

Hisham Abdullah, and Brendon J Coventry
The relative risks and complications increase proportionately according to the site
of the mass or problem, extent of the procedure performed, technique, or complex-
ity of the problem. Large masses may carry higher risks of bleeding and infection
than smaller ones, in general terms, and especially when sternotomy is required.
Similarly, risk is relatively higher for recurrent and complex surgery and for those
closer to or involving neural structures (e.g., laryngeal nerves).
Knowledge of the anatomy and the variations commonly seen is helpful in
minimizing nerve and vessel injury. Surgeons argue the benefits of one approach
over the other, but there is limited data to demonstrate differences in terms of the
observed or reported complications. Other surgeons will argue that the use of
drains adds to the complication rates, but that is perhaps less of a consideration in
the current era.
A. Giuliano, MD, FACS, FRCSEd (*)

Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
Samuel Oschin Comprehensive Cancer Institute,
A Project of Women’s Guild, Cedars-Sinai Medical Center, Los Angeles, CA, USA
S. Wells Jr., MD • T. Reeve, MBBS
Medical Oncology Branch and Affiliates,
National Cancer Institute at the National Institutes of Health, Bethesda, MD, USA
H. Abdullah, MD
Putrajaya Hospital, Putrajaya, Malaysia

68 A. Giuliano et al.
Possible reduction in the risk of misunderstandings over complications or

consequences from thyroid or parathyroid surgery might be achieved by:
• Good explanation of the risks, aims, benefits, and limitations of the
procedure(s)
Important Note
such are often representative of a number of studies, which include differ-
ent patients with differing comorbidities and different surgeons. In addition,
the risks of complications in lower- or higher-risk patients may lie outside
these estimated ranges, and individual clinical judgement is required as to the
expected risks communicated to the patient, staff, or for other purposes. The
range of risks is also derived from experience and the literature; while risks
outside this range may exist, certain risks may be reduced or absent due to
variations of procedures or surgical approaches. It is recognized that different
patients, practitioners, institutions, regions, and countries may vary in their
requirements and recommendations.
For neck surgery, see Volume 2, or for lymph node surgery, see Chap. 5, or for
other biopsies used to obtain diagnosis, refer to the relevant chapter.
Thyroid Surgery
Overview
Useful Risk Reduction and Management Strategies
Acute respiratory distress following thyroidectomy can be of several types:

• Postoperative hemorrhage and hematoma – usually within 24 h, often 6–8 h after
thyroidectomy, causing laryngeal edema, which if uncorrected may prove fatal
• Excessive wound edema – causing pressure on the larynx and surrounding tissues
• Post-traumatic from endotracheal intubation
• Idiopathic – no apparent cause
3 Thyroid and Parathyroid Surgery 69
Management
• Treat major bleeding with urgent surgical drainage.
• Ice packs on the neck after thyroidectomy – routine use may reduce wound
edema.
• Humidified respiratory environment can relieve all local forms of laryngeal
edema.
• Check for inspissated subglottic mucus sputum retention (plug) – endotracheal
suction.
• Tracheostomy is rarely required.
Post-thyroidectomy hemorrhage into a tightly closed neck can lead to severe
respiratory obstruction requiring urgent reoperation but by “noncontinuously”
closing the fascia leaving “weep holes” to relieve pressure can perhaps avoid
reoperation. External pressure on the neck with a handheld sponge pack until
complete extubation can prevent the venous pressure rise if coughing occurs dur-
ing extubation. Drains do not cope with sudden severe hemorrhage or clotted
blood, but are useful in very extensive dissection especially in retrosternal goiter
and in neck dissection. If bleeding is substantial, reopening the wound and hemo-
static control are imperative. Delay may result in substantial laryngeal edema
requiring tracheostomy to ensure an adequate airway. Tracheostomy is rarely nec-
essary, if bleeding is promptly controlled. Thorough and meticulous hemostasis
and Valsalva testing before closure at the completion of surgery are two risk
reduction strategies for avoiding postoperative bleeding that can be used.
Postoperative hemorrhage is a small, but recognized and significant risk, which if
corrected promptly and urgently is reversible, however, if missed or unaddressed
can prove fatal.
Injury to the external laryngeal nerve is essentially avoidable. To avoid it
requires a sound anatomical knowledge of the area, and this needs to be applied
during the mobilization of the upper pole of the thyroid lobe. Mobilization entails
separating the thyroid lobe from overlying muscle and opening cricothyroid
space, which is frequently called the “avascular” space (of Reeve), so allowing
separation of the cricothyroid muscle and the thyroid gland. There may be a
“crossing” branch from the superior thyroid artery across the space. When the
space is fully mobilized, the external branch of the superior laryngeal nerve can
be viewed. Careful retraction of overlying muscles cephalad and the thyroid gland
caudad helps to improve the view. Mobilizing the cricothyroid space as a first step
in thyroidectomy with cephalad mobilization helps to protect the nerve should it
not be seen. The voice damage that ensues if the nerve is injured is subtle and may
not be noticed. However, if a patient has a voice-dependent occupation, resultant
loss of vocal high pitch and projection can be a problem, as can voice fatigue fol-
lowing extended use of the voice. Bilateral nerve injury tends to magnify the
problem. Many patients, however, do not seem to notice any change, or perhaps
more correctly, rapidly adapt to the change. Vocal cord change can be difficult to
demonstrate other than by video-stroboscopic examination. The use of nerve
monitoring devices may improve the localization and detection of nerve branches
to preserve.
Currently, dysphonia is difficult to treat; speech therapy and elapse of time are
useful elements of management. The cricothyroid muscle deserves careful attention
during operation, as muscle injury or intramuscular hematoma can lead to some
subtle voice changes observed after injury to the external branch of the superior
laryngeal nerve.
Death is a rare, but important, risk of thyroid surgery, from bleeding or other
complications, especially in elderly patients and/or those with significant comor-
bidities. The risk of death from thyroid or parathyroid surgery equates approxi-
mately with that of the risk of general anesthesia.
Partial Thyroidectomy (Hemithyroidectomy,

Thyroid Lobectomy)
Description
General anesthesia is used. Partial thyroidectomy is the removal of an entire thyroid

lobe and isthmus or a portion of a lobe. The nature of the lesion has almost always
been determined prior to the operation. Nodules are confined to a single thyroid
lobe or the isthmus. Most often a certain or suspected diagnosis of malignancy is
the indication for surgery; less often the nodule(s) is either hyperfunctional or is
enlarged and causing obstructive symptoms. The patient is supine with a roll placed
transversely under the scapulae to allow optimal neck extension. To prevent neck
hyperextension, the head is supported on a supporting “donut” head ring. A curved
transverse “skin crease” incision is made in the anterior neck about two finger-
breadths above the clavicular heads, continuing deep to the platysma muscle. The
strap muscles are separated in the midline after incision of the fascia and retracted
laterally. The non-diseased thyroid lobe is inspected, and the thyroid lobe to be
removed is mobilized anteromedially by transecting vessels laterally. This exposes
the thyroidal vessels and fine attachments of Berry’s ligament. The vessels sup-
plying the thyroid must be dissected carefully and divided as close to the gland as
possible. Care must be taken to identify the upper and lower parathyroid glands and
the recurrent laryngeal nerve early, before starting to remove the thyroid lobe. The
nerve is most easily identified where the inferior thyroid artery crosses it and is fol-
lowed until it enters the larynx. Great care should be taken not to injure the nerve
by applying too much traction, direct pressure, or injuring it with electrocautery.
The external branch of the superior laryngeal nerve can be identified before divid-
ing and ligating the superior pole vessels. Identification of the cricothyroid avascu-
lar space can assist to localize the nerve as described elsewhere. The use of nerve
to preserve. If the blood supply to a parathyroid gland cannot be preserved with
certainty, it should be removed, sliced into 1 mm slivers, placed into iced saline,
and implanted into muscle pockets in a strap (or forearm) muscle at the end of the
case. The thyroid lobe should always be removed from lateral to medial, and as the
last step it is sharply removed from the trachea. The cut edge of the thyroid should
be sutured for hemostasis. If the removed nodule is found to be malignant, either
by frozen section examination or the presence of metastatic disease in the cervical
lymph nodes, a total or near total resection of the contralateral lobe is indicated dur-
ing the same operation. Frozen section may not discern benign from malignant, and
delayed completion thyroidectomy may be performed later. Meticulous dissection
and impeccable hemostasis may obviate the need for a drain in the neck, but many
surgeons still use a drain.
Anatomical Points
The thyroid gland arises from the foramen caecum of the posterior base of the
tongue and descends in the midline of the neck to reach the 2nd tracheal ring
in the adult. Variations in the course of the recurrent laryngeal nerve, typically
on the right side, occur in about 1 % of cases. The nerve may be anterior, poste-
rior, or between branches of the inferior thyroid artery. The right subclavian artery
can arise directly from the descending aorta so that the right nerve is “nonrecur-
rent,” exiting from the vagus nerve at a 45° angle. The nonrecurrent nerve may
be mistaken for a vessel and divided, resulting in paralysis of the ipsilateral vocal
cord. About 0.2 % of patients have both a recurrent and nonrecurrent laryngeal
nerve on the right. Left-sided “nonrecurrent” laryngeal nerves are very rare and
are seen with situs inversus. The course of the superior laryngeal nerve, includ-
ing its external and internal branches, is also variable. The external branch of the
superior laryngeal nerve is usually closely associated with the inferior pharyngeal
constrictor and may be covered entirely by its muscle fibers. In 15 % of patients
the nerve travels with the superior thyroid artery. In 6 % of patients it contin-
ues to accompany the superior thyroid artery even after branching of the main
trunk. During embryogenesis, the parathyroid glands migrate a great distance, and
their anatomical location may vary greatly. The presence of a large thyroid nodule
may further complicate the identification of these structures, and it takes great
patience and tenacity to identify them. Fifteen percent of patients have more than
four parathyroid glands. The inferior parathyroid glands arise from the third pha-
ryngeal pouch and are closely associated with the thymus. As they migrate during
development, they may finally rest anywhere from the pharynx to the posterior
mediastinum. The superior glands are more reliable in their position because they
arise from the fourth pharyngeal pouch along with the lateral thyroid. Intrathyroid
parathyroids occur in about 1 % of patients. Some patients have large pyramidal
lobes of the thyroid. Other variations include lingual thyroid and thyroglossal duct
cysts. Dysphagia lusoria or lusus naturae describes dysphagia due to extrinsic
compression by an aberrant right subclavian artery. This congenital vascular prob-
lem occurs in 0.5–1.8 % of the general population, being the most common con-
genital non-valvular aortic root anomaly.
Table 3.1 Partial thyroidectomy estimated frequency of complications, risks, and consequences
Hoarse voice
Transient (including intubation or recurrent/superior laryngeal 5–20 %
nerve injury)
Permanent (recurrent/superior laryngeal nerve injury) 0.1–1 %
Hypocalcemia (low calcium level)a
Transient 5–20 %
Permanent (parathyroid injury/excision, oral calcium therapy) 0.1–1 %
Oral thyroid hormone therapy (later hypothyroidism)b 1–5 %
Hyperthyroidism (recurrence after functioning nodule excision)a 1–5 %
Cricopharyngeal spasm 1–5 %
Acute respiratory distress 0.1–1 %
Need for further surgery/radioiodine therapya Individual
Recurrent tumor or nodulesa 0.1–1 %
Infection 0.1–1 %
Tracheal injury <0.1 %
Horner’s syndrome <0.1 %
Deatha <0.1 %
Pain or tenderness (sore throat; sore neck, transient)
Acute (<4 weeks) >80 %
Cutaneous numbness/altered sensation 20–50 %
Dimpling/deformity of the skin (including fascial and tracheal tethering) 0.1–1 %
Wound scarring (poor cosmesis) 1–5 %
Wound draina >80 %
a
Dependent on pathology, anatomy, comorbidities, surgery type, surgical clearance, surgeon pref-
erence, and technique
b
Initial thyroxine therapy may not be required; later hypothyroidism may occur, dependent on
pathology
Perspective
See Table 3.1. The major risk from unilateral thyroid lobectomy is damage to the
recurrent or superior laryngeal nerves. Any damage may not be apparent until any
vocal cord swelling from the endotracheal tube settles on the second or third postop-
erative day. Intraoperative electromyography electrode monitoring may reduce the
incidence of recurrent laryngeal nerve injury. Damage to both parathyroid glands
may go unnoticed, unless the contralateral parathyroid glands have been damaged
or removed. In this situation parathyroid gland grafting/transplanting usually averts
permanent hypoparathyroidism. Hypocalcemia is due to temporary or permanent
disruption of normal parathyroid function. This may be due to manipulation of
the blood supply, direct trauma, or removal of the glands. Most hypocalcemia is
transient, and the glands will resume function after several days or weeks. If the
glands have been permanently injured or removed, then the patient will require
lifelong calcium and vitamin D supplementation, together with appropriate clini-
cal oversight. Bleeding is uncommon, unless the thyroid mass is very large and
associated with increased vasculature in the neck. Drains rarely provide adequate
drainage if the bleeding is heavy. Severe bleeding can cause tracheal compression
and acute respiratory failure, requiring prompt recognition, surgical decompression,
and control of bleeding. Cutaneous numbness and tingling of the anterior neck is
common and due to division of cervical plexus branches during incision. It often
improves with time, but can make shaving and application of cosmetics difficult.
Although very rare, Horner’s syndrome is caused by retraction damage to the cervi-
cal sympathetic chain. It usually resolves, but may not. Neck wounds usually heal
rapidly with low infection risk and are rarely unsightly. Keloid reaction at the scar
may occur being difficult to prevent or treat.
Major Complications
A serious complication is damage to the recurrent laryngeal nerve or to the

external branch of the superior laryngeal nerve. Some factors for increased risk
or nerve injury are the inexperienced surgeon, invasive malignancy, very large thy-
roid masses, and reoperative surgery. With time the changes in phonation associated
with these injuries will improve; however, in patients who depend on their voice
for a livelihood, the injuries can be devastating. Management of a divided recurrent
laryngeal nerve is controversial. Anastomosis of the nerve restores some bulk to the
vocal cord; however, there is anomalous regeneration, and phonation may not return
to normal. When the recurrent laryngeal nerve is known to be intact, the patient
should be referred for a trial of speech therapy. An injection of a material (e.g.,
gelatin, Teflon, Silastic fat) into the vocal cord may be helpful in voice restoration.
In some cases, regardless of the integrity of the nerve, medialization thyroplasty
(using a variety of methods) may be indicated to improve the vocal quality and
decrease aspiration. There is little that can be done to restore the integrity of a dam-
aged external branch of the superior laryngeal nerve. Pre- and postoperative video-
strobic testing can be useful in defining preexisting or surgically induced voice and
laryngeal functional changes. Transient mild hypocalcemia is not uncommon after
surgery. Major hypocalcemia in the postoperative period is indicative of injury to
the parathyroid glands, which is usually transient, but in some cases may be per-
manent, although uncommon after a partial thyroidectomy because the two glands
on the contralateral side typically remain untouched. Oral calcium and vitamin D
therapy for several weeks usually corrects this and is then reduced to test for recov-
ery. Meticulous surgical technique, sometimes with autotransplantation, can almost
prevent this complication. Serious postoperative bleeding <48 h, requiring urgent
reoperative drainage, is a rare but well-recognized complication patients should be
informed about. Thorough hemostasis and Valsalva testing before closure at the
completion of surgery are two risk reduction strategies often used.

• Recurrent or superior laryngeal nerve injury
• Bleeding
• Respiratory obstruction
• Hypoparathyroidism/hypocalcemia
• Thyroxine/calcium therapy
• Further surgery
• Risks without surgery
Subtotal Thyroidectomy
Description
General anesthesia is used. Subtotal thyroidectomy is the removal of greater than

90 % of the thyroid gland, leaving the posterior aspects of the gland, and is used
for patients with hyperthyroidism due to diffuse hyperfunction, or rarely for mul-
tinodular goiter. The nature of the pathology has almost always been determined
prior to surgery. The thyroid gland is usually diffusely enlarged, and hyperthyroid-
ism may produce a range of different clinical features, which may influence the
incidence of complications. The patient is supine with a roll placed transversely
under the scapulae to allow optimal neck extension. To prevent neck hyperexten-
sion, the head is supported on a supporting “donut” head ring. A curved transverse
“skin crease” incision is made in the anterior neck about two fingerbreadths above
the clavicular heads, continuing deep to the platysma muscle. The strap muscles are
separated in the midline and retracted laterally. Each thyroid lobe is sequentially
mobilized anteriorly and medially by transecting vessels laterally. This exposes the
thyroidal vessels and fine attachments of Berry’s ligament. The vessels supplying
the thyroid must be dissected carefully and divided as close to the gland as possible
(extracapsular dissection). The major portions of both thyroid lobes are removed
with the isthmus, to leave a posterior cuff of each lobe of thyroid on each side.
The size of the retained portion of thyroid is critical to creating euthyroid function,
while alleviating hyperthyroidism. One of the aims of subtotal thyroidectomy is
to transect the thyroid gland away from the upper and lower parathyroid glands
and the recurrent laryngeal nerve and the external branch of the superior laryngeal
nerve. Thus, theoretically avoiding risk to these structures. The recurrent laryn-
geal nerve is most easily identified where the inferior thyroid artery crosses it, but
the nerve may be anterior, posterior, or between branches of the artery, unless it is
nonrecurrent. The nerve should be followed until it enters the larynx. Great care
should be taken to avoid injury from too much traction, direct pressure, or elec-
trocautery. The use of nerve monitoring devices may improve the localization and
detection of nerve branches to preserve. In practice, many surgeons regard a careful

total thyroidectomy as almost as safe as a subtotal resection and preferable.
Anatomical Points
tongue and descends in the midline of the neck to reach the 2nd tracheal ring in
the adult. Variations in the course of the recurrent laryngeal nerve, typically on
the right side, occur in about 1 % of cases. The nerve may be anterior, posterior,
or between branches of the inferior thyroid artery. The right subclavian artery
can arise directly from the descending aorta so that the right nerve is “nonrecur-
rent,” exiting from the vagus nerve at a 45° angle. The nonrecurrent nerve may
be mistaken for a vessel and divided, resulting in paralysis of the ipsilateral vocal
cord. About 0.2 % of patients have both a recurrent and nonrecurrent laryngeal
nerve on the right. Left-sided “nonrecurrent” laryngeal nerves are very rare and
are seen with situs inversus. The course of the superior laryngeal nerve, includ-
ing its external and internal branches, is also variable. The external branch of the
superior laryngeal nerve is usually closely associated with the inferior pharyngeal
constrictor and may be covered entirely by its muscle fibers. In 15 % of patients
the nerve travels with the superior thyroid artery. In 6 % of patients it continues
to accompany the superior thyroid artery even after branching of the main trunk.
During embryogenesis, the parathyroid glands migrate a great distance, and their
anatomical location may vary greatly. The presence of a large thyroid nodule may
further complicate the identification of these structures, and it takes great patience
and tenacity to identify them. Fifteen percent of patients have more than four
parathyroid glands. The inferior parathyroid glands arise from the third pharyn-
geal pouch and are closely associated with the thymus. As they migrate during
development, they may finally rest anywhere from the pharynx to the posterior
mediastinum. The superior glands are more reliable in their position because they
arise from the fourth pharyngeal pouch along with the lateral thyroid. Intrathyroid
parathyroids occur in about 1 % of patients. Some patients have large pyramidal
lobes of the thyroid. Other variations include lingual thyroid and thyroglossal duct
cysts.
Perspective
See Table 3.2. Bleeding is more common with a hypervascular thyroid gland, even
after oral iodine pretreatment which can render the gland firmer. Drains rarely
provide adequate drainage if the bleeding is heavy. Severe bleeding can cause
tracheal compression and acute respiratory failure, requiring prompt recogni-
tion, surgical decompression, and control of bleeding. However, the major risk
from subtotal thyroidectomy is inadvertent damage to the recurrent or superior
laryngeal nerves. Any damage may not be apparent until any vocal cord swell-
ing from the endotracheal tube settles on the second or third postoperative day.
Table 3.2 Subtotal thyroidectomy estimated frequency of complications, risks, and consequences
Hoarse voice
nerve injury)
Hypocalcemia (low calcium level)
Transient 5–20 %
Oral thyroid hormone therapy (early hypothyroidism)a 1–5 %
Hypothyroidism (late)a 50–80 %
Recurrent hyperthyroidisma 1–5 %
Thyroid storm 0.1–1 %
Infection 0.1–1 %
Tracheal injury <0.1 %
Need for further surgery/radioiodine therapy Individual
Deatha <0.1 %
Wound draina >80 %
a
Dependent on pathology, anatomy, comorbidities, surgery type, surgical clearance, surgeon
preference, and technique
Intraoperative electromyography electrode monitoring may reduce the incidence

of recurrent laryngeal nerve injury. Bilateral recurrent laryngeal nerve injury is
a rare but particularly devastating complication. Injury occurs by traction, pres-
sure, or cautery. The patient will inevitably require a tracheostomy acutely for
airway management. Some patients require a permanent tracheostomy, but some
recover function or are able to manage their airways after vocal cord injections.
This injury is psychologically difficult for the patient to endure. Damage to both
parathyroid glands is not common because the posterior parts of the gland are
not resected. Hypocalcemia is due to temporary or permanent disruption of nor-
mal parathyroid function. This may be due to manipulation of the blood supply,
direct trauma to the glands, or removal of the glands. Most hypocalcemia is tran-
sient, and the glands will resume function after several days or weeks. Patients are
treated with calcium supplementation until the parathyroids resume function. If

the glands have been permanently injured or removed, the patient will require life-
long calcium and vitamin D supplementation. Thyroid storm (crisis) is exceed-
ingly rare with adequate preoperative preparation, but potentially life threatening
if it occurs. Horner’s syndrome is very rare, caused by retraction damage to the
cervical sympathetic chain. It usually resolves, but can be permanent. Cutaneous
numbness and tingling of the anterior neck is common and due to division of cer-
vical plexus branches during incision. It often improves with time, but can make
shaving and application of cosmetics difficult. Neck wounds usually heal rapidly
with low infection risk and are rarely unsightly. Keloid reaction at the scar may
occur being difficult to prevent or treat.
Major Complications
A serious complication is damage to the recurrent laryngeal nerve or to the

external branch of the superior laryngeal nerve. Some factors for increased risk
or nerve injury are the inexperienced surgeon, invasive malignancy, very large thy-
roid masses, and reoperative surgery. With time the changes in phonation associated
with these injuries will often improve; however, in patients who depend on their
voice for a livelihood, the injuries can be devastating. Management of a divided
recurrent laryngeal nerve is controversial. Anastomosis of the nerve restores some
bulk to the vocal cord; however, there is anomalous regeneration, and phonation
may not return to normal. When the recurrent laryngeal nerve is known to be intact,
the patient should be referred for a trial of speech therapy. Injection of material (e.g.,
gelatin, Teflon, Silastic fat) into the vocal cord(s) may be helpful in voice restora-
tion. In some cases, regardless of the integrity of the nerve, medialization thyro-
plasty (using a variety of methods) may be indicated to improve the vocal quality
and decrease aspiration. There is little that can be done to restore the integrity of
a damaged external branch of the superior laryngeal nerve. Pre- and postoperative
videostrobic testing can be useful in defining preexisting or surgically induced voice
and laryngeal functional changes. Transient mild hypocalcemia is not uncom-
mon after surgery. Major hypocalcemia in the postoperative period is indicative
of injury to the parathyroid glands, which is usually transient, but in <3 % cases
is permanent, although uncommon after a subtotal thyroidectomy because the pos-
terior aspects of the thyroid glands are less disturbed. Oral calcium and vitamin D
therapy for several weeks usually corrects this and is then reduced to test for recov-
ery. Meticulous surgical technique, sometimes with autotransplantation, can almost
prevent this complication. Serious postoperative bleeding <48 h, requiring urgent
reoperative drainage, is a rare but well-recognized complication that patients should
be informed about. Thorough hemostasis and Valsalva testing before closure at the
completion of surgery are two risk reduction strategies often used. Thyroid storm
is very rare but serious. Infection and scar deformity with the need for revision
surgery are also uncommon.

• Bleeding
• Further surgery
Total Thyroidectomy
Description
General anesthesia is used. The aim is surgical extirpation of the entire thyroid
gland. It is indicated for a wide variety of benign and malignant conditions of
the thyroid including multinodular goiter, toxic multinodular goiter, papillary
carcinoma, follicular carcinoma, Hürthle cell carcinoma, and other conditions,
including for obstructive symptoms or cosmesis. The nature of the lesion has
almost always been determined prior to the operation. The structures at particular
risk are the recurrent and superior laryngeal nerves and the parathyroid glands.
The patient is supine with a roll placed under the scapulae to allow optimal neck
extension. To prevent neck hyperextension the head is supported on a supporting
“donut” head ring. A curved transverse “skin crease” incision is made in the ante-
rior neck about two fingerbreadths above the clavicular heads, continuing deep to
the platysma muscle. The strap muscles are separated in the midline after incision
of the fascia and retracted laterally. Each thyroid lobe is sequentially mobilized
anteriorly and medially. This exposes the thyroidal vessels and fine attachments
of Berry’s ligament. The vessels supplying the thyroid must be dissected carefully
and divided as close to the gland as possible (extracapsular dissection). Care must
be taken to identify the upper and lower parathyroid glands bilaterally and the
recurrent laryngeal nerve before starting to remove the thyroid lobe. The external
branch of the superior laryngeal nerve can be identified before dividing and ligat-
ing the superior pole vessels. Identification of the cricothyroid avascular space
can assist to localize the nerve as described elsewhere. The use of nerve moni-
toring devices may improve the localization and detection of nerve branches to
preserve. If the blood supply to a parathyroid gland cannot be preserved with
certainty, it should be removed and autotransplanted into skeletal muscle (usu-
ally sternomastoid or brachioradialis). The thyroid is sharply dissected from the
trachea. In cases of carcinoma it is important to examine the entire thyroid gland
to determine the extent of the malignancy and whether or not there is invasion of
local anatomical structures, particularly the strap muscles, the trachea, and the
esophagus to carefully plan the surgical procedure. It is also important to deter-
mine if there are enlarged lymph nodes and suspicions of malignancy in the lateral
neck and to dissect these (Fig. 3.1).
a b
Fig. 3.1 a, b, c, d and e Advanced fungating thyroid cancer presenting considerable management
difficulties, and high risk of complications with or without surgery
Fig. 3.1 (continued)

d
Anatomical Points
tongue and descends in the midline of the neck to reach the 2nd tracheal ring in the
adult. Variations in the course of the recurrent laryngeal nerve, typically on the right
side, occur in about 1 % of cases. The nerve may be anterior, posterior, or between
branches of the inferior thyroid artery. The right subclavian artery can arise directly
from the descending aorta so that the right nerve is “nonrecurrent,” exiting from
the vagus nerve at a 45° angle. The nonrecurrent nerve may be mistaken for a ves-
sel and divided, resulting in paralysis of the ipsilateral vocal cord. About 0.2 % of
patients have both a recurrent and nonrecurrent laryngeal nerve on the right. Left-
sided “nonrecurrent” laryngeal nerves are very rare and are seen with situs inver-
sus. The course of the superior laryngeal nerve, including its external and internal
branches, is also variable. The external branch of the superior laryngeal nerve is
usually closely associated with the inferior pharyngeal constrictor and may be cov-
ered entirely by its muscle fibers. In 15 % of patients the nerve travels with the supe-
rior thyroid artery. In 6 % of patients it continues to accompany the superior thyroid
artery even after branching of the main trunk. During embryogenesis, the parathy-
roid glands migrate a great distance, and their anatomical location may vary greatly.
The presence of a large thyroid nodule may further complicate the identification of
these structures, and it takes great patience and tenacity to identify them. Fifteen
percent of patients have more than four parathyroid glands. The inferior parathyroid
glands arise from the third pharyngeal pouch and are closely associated with the
thymus. As they migrate during development, they may finally rest anywhere from
the pharynx to the posterior mediastinum. The superior glands are more reliable
in their position because they arise from the fourth pharyngeal pouch along with
the lateral thyroid. Intrathyroid parathyroids occur in about 1 % of patients. Some
patients have large pyramidal lobes of the thyroid. Other variations include lingual
thyroid and thyroglossal duct cysts. Dysphagia lusoria or lusus naturae describes
dysphagia due to extrinsic compression by an aberrant right subclavian artery. This
congenital vascular problem occurs in 0.5–1.8 % of the general population, being
the most common congenital non-valvular aortic root anomaly.
Perspective
See Table 3.3. The major risk from total thyroidectomy is damage to the recurrent or
superior laryngeal nerves. Injury is due to traction, pressure, or cautery. Identifying
the recurrent laryngeal nerves is essential, and in 80–90 % of cases, the external
branch of the superior laryngeal nerve can be identified. However, if not identified,
the superior pole vessels should be separately divided. Bilateral recurrent laryn-
geal nerve injury is a particularly devastating complication, usually requiring a
tracheostomy acutely for airway management. Some patients require a permanent
tracheostomy, but some recover function or can manage their airway after vocal
cord injections. This injury is often psychologically difficult for the patient. Any
damage may not be apparent until any vocal cord swelling from the endotracheal
tube settles on the second or third postoperative day. Pre- and postoperative vid-
eoscopic testing can be useful in defining preexisting or surgically induced voice
and laryngeal functional changes. Hypocalcemia is due to temporary or permanent
disruption of normal parathyroid function. This may be due to manipulation of the
Table 3.3 Total thyroidectomy estimated frequency of complications, risks, and consequences
Hoarse voice
nerve injury)
Transient 5–20 %
Bleeding/hematoma Formation 0.1–1 %
Hyperthyroidism (recurrence after functioning nodule excision)a 1–5 %
Recurrent tumor or nodulesa 0.1–1 %
Infection 0.1–1 %
Sternal mediastinal splita 0.1–1 %
Tracheal injurya <0.1 %
Esophageal perforationa <0.1 %
Horner’s Syndromea <0.1 %
Need for further surgery/radioiodine therapya Individual
Deatha <0.1 %
Oral thyroid hormone therapy (hypothyroidism)a All
Wound draina 50–80 %
a
Dependent on pathology, anatomy, comorbidities, surgery type, surgical clearance, surgeon
preference, and technique
blood supply, direct trauma to the glands, or removal. Most hypocalcemia is tran-
sient, and the glands will resume function after several days or weeks. If damaged
the parathyroid glands can be grafted/autotransplanted to avert permanent hypo-
parathyroidism. Patients are treated with calcium supplementation until the para-
thyroids resume function. If the glands have been permanently injured or removed,
the patient will require lifelong calcium and vitamin D supplementation. Resection
of tumor en bloc may be required including structures densely adherent or invaded
by malignancy (e.g., strap muscle overlying to the gland, or the larynx or trachea).
Some 30–50 % of the tracheal diameter can be resected depending on the patient’s
age, size, and body habitus. In total thyroidectomy for malignant tumors, the cen-
tral compartment cervical lymph nodes are often removed, usually from the hyoid
bone to the sternal notch. Obvious metastases in lateral lymph nodes require a
modified or standard neck dissection. Lower left neck lymph node resection is
associated with increased risk of damage to the thoracic duct with lymphatic fis-
tula or lymphocele. With properly performed lymph node dissections, it may be
difficult to preserve the parathyroid glands. It is in this setting that autologous
parathyroid transplantation is most often indicated. If in situ parathyroid viability
is in doubt, it is better to remove and transplant it in a muscle bed, rather than dis-
cover postoperatively too late that a patient has become a parathyroid, unless cryo-
preserved autologous parathyroid tissue has been stored. Bleeding is uncommon,
unless the thyroid mass is very large and associated with increased vasculature in
the neck, but can cause tracheal compression and acute respiratory decompensa-
tion, requiring prompt recognition and surgical decompression with control of the
bleeding. A bleeding point is seldom found, and drains are not usually effective
for large bleeds. Horner’s syndrome is caused by retraction damage to the cervi-
cal sympathetic chain. It is very rare and usually resolves, but can be permanent.
Cutaneous numbness and tingling of the anterior neck is common due to division
of cervical plexus branches during incision and often improves with time, but can
make shaving and application of cosmetics difficult. Neck wounds usually heal
rapidly with low infection risk and are rarely unsightly. Keloid reaction at the scar
may occur being difficult to prevent or treat. In some patients surgical revision of
the scar may be necessary.
Major Complications
A serious complication of thyroidectomy is damage to the recurrent laryngeal

nerve or the external branch of the superior laryngeal nerve. Some factors
for increased risk or nerve injury are the inexperienced surgeon, invasive malig-
nancy, very large thyroid masses, and reoperative surgery. With time the changes
in phonation associated with these injuries often improve; however, in patients who
depend on their voice for a livelihood, the injuries can be devastating. Management
of a divided recurrent laryngeal nerve is controversial. Anastomosis of the nerve
restores some bulk to the vocal cord; however, there is anomalous regeneration,
and phonation may not return to normal. When the recurrent laryngeal nerve is
known to be intact, the patient should be referred for a trial of speech therapy.
Injection of material (e.g., gelatin, Teflon, Silastic fat) into the vocal cord(s) may
be helpful in voice restoration. In some cases, regardless of the integrity of the
nerve, medialization thyroplasty (using a variety of methods) may be indicated to
improve the vocal quality and decrease aspiration. There is little that can be done to
restore the integrity of a damaged external branch of the superior laryngeal nerve.
There is a greater risk of injury to these structures during a total thyroidectomy
compared to a thyroid lobectomy. If both nerves are injured, the patient may have
difficulty breathing, and repeat intubation, or even tracheostomy, may be neces-
sary in the immediate postoperative period. Post-thyroidectomy hemorrhage into
a tightly closed neck wound can lead to severe respiratory obstruction requiring
urgent reoperation to open and drain the neck hematoma. Tracheostomy is rarely
necessary if bleeding is promptly controlled. Damage to the parathyroid glands

is also more likely in total thyroidectomy, as both sides of the neck are explored.
Parathyroid autotransplantation (minced into <1 mm pieces) into skeletal muscle
(sternocleidomastoid or brachioradialis) is indicated whenever the viability of a
parathyroid gland is questionable. Transient mild hypocalcemia is not uncom-
mon after surgery. Major hypocalcemia in the postoperative period is indicative
of injury to the parathyroid glands, which is usually transient, but in <3 % cases
is permanent. Oral calcium and vitamin D therapy for several weeks usually cor-
rects this and is then reduced to test for recovery, but may be indicated permanently
if patients develop intractable hypoparathyroidism and cannot be weaned from
the medications. Meticulous surgical technique, sometimes with autotransplanta-
tion, can almost prevent this complication. Serious postoperative bleeding <48 h,
requiring urgent reoperative drainage, is a rare but well-recognized complication
that patients should be informed about. Thorough hemostasis and Valsalva test-
ing before closure at the completion of surgery are two risk reduction strategies
often used. A lymphocele or lymph fistula may develop if the thoracic duct is
injured during lymph node dissection low in the left neck. Either of these compli-
cations is managed conservatively with a pressure dressing and closed drainage.
Thyroid hormone replacement will be necessary following total thyroidectomy,
but should be withheld until the patient has received radioactive iodine to ablate
any remaining thyroid tissue. Obstructive symptoms with difficult breathing
or swallowing may occur in patients with large tumors or with cancerous inva-
sion of the trachea or the esophagus. Tracheomalacia may occur after massive
compressive thyroidectomy and require ventilation. Tumor recurrence is always
a risk following total thyroidectomy for tumor, especially if it is ruptured during
resection, if there is malignant invasion of the trachea or esophagus or if there are
extensive lymph node metastases. Horner’s syndrome may occur if the cervical
sympathetic chain is injured during ligation of the inferior thyroid artery or pos-
terior medial dissection to the carotid sheath (see additional risk reduction strate-
gies). Infection and scar deformity with the need for revision surgery are also
uncommon.

• Bleeding
• Further surgery
Parathyroid Surgery
Overview
Useful Risk Reduction and Management Strategies
• The superior laryngeal nerve should be identified while dissecting the upper pole
of the thyroid. The external branch of the superior laryngeal nerve innervates the
cricothyroid muscle, which tenses the vocal cord. Superior laryngeal nerve injury
results in inability to tense the vocal cord. Vocal cord tension is necessary to
produce high-pitched sounds and to project the voice. The nerve usually lies on
the lateral surface of the inferior pharyngeal constrictor muscle. It descends
medially to the superior thyroid artery as it enters the larynx. The use of nerve
to preserve.
• All four parathyroid glands must be identified. The superior parathyroid glands
are usually found behind the upper pole of the thyroid at the cricothyroid junc-
tion approximately one centimeter above the intersection of the recurrent laryn-
geal nerve and the inferior thyroid artery. They are usually more posterior than
the inferior parathyroids. The inferior parathyroids are usually just below the
inferior thyroid artery. The location of the inferior glands is more variable than
the superior glands. All four glands must be identified before proceeding with
resection. The size of each gland must be compared to the others. If all four
glands appear approximately equally enlarged, then three and a half glands can
be removed. The blood supply to the remaining half gland must be preserved.
Most glands are supplied by an end-artery branch of the inferior thyroid artery.
Occasionally, a superior gland is supplied by a branch of the superior thyroid
artery.
• Intraoperative PTH monitoring can be useful to help determine when an ade-
quate amount of parathyroid tissue has been removed. A PTH level should be
drawn at the beginning of the case. Following removal of diseased glands, 5 min
should be allowed to clear the parathyroid hormone from the patient’s blood.
A drop of greater than 50 % and a fall into the normal range of PTH are positive
signs that the hyperparathyroidism has been cured. Once these levels have been
achieved, the wound should be irrigated and hemostasis achieved.
Death is a rare, but important, risk of parathyroid surgery, from bleeding or other
complications, especially in elderly patients and/or those with significant comorbidi-
ties. The risk of death from thyroid or parathyroid surgery equates approximately
with that of the risk of general anesthesia. Thorough and meticulous hemostasis and
Valsalva testing before closure at the completion of surgery are two risk reduction
strategies for avoiding postoperative bleeding that can be used. Postoperative hemor-
rhage is a small but recognized and significant risk, which if corrected promptly and
urgently is reversible, however, if missed or unaddressed can prove fatal.
Parathyroid Exploration and Parathyroidectomy
Description
General anesthesia is used. The aim of the procedure is to identify and remove
the affected or enlarged parathyroid gland(s). Hyperparathyroidism is the result of
overproduction of parathyroid hormone by the parathyroid gland. It may be from an
adenoma or four-gland hyperplasia. Eighty-five percent of primary hyperparathy-
roidism is caused by a single adenoma, 2–4 % is caused by double adenomas, and
the remainder is caused by hyperplasia of all four glands. The goal of the operation
is to remove the adenoma or enough parathyroid tissue to bring the calcium level
back to normal and cure the hyperparathyroidism while avoiding hypoparathyroid-
ism with hypocalcemia. A subtotal parathyroidectomy is the removal of three and a
half glands (or all glands and implantation of ½ a gland into a skeletal muscle), to
restore normal PTH secretion. The location of the lesion has often been determined
prior to the operation, using CT, U/S, venous sampling, or nuclear imaging proce-
dures. Ultrasound is essentially a routine investigation. Parathyroidectomy can be
performed as a classical open exploration or as a more targeted minimally invasive
procedure (see later), usually with a smaller incision. The main indication for para-
thyroid surgery is primary hyperparathyroidism and to a lesser degree secondary
and tertiary hyperparathyroidism. The patient is supine with a roll placed under
the scapulae to allow optimal neck extension. To prevent neck hyperextension, the
head is supported on a supporting “donut” head ring. A curved transverse collar
“skin crease” incision is made in the anterior neck about two fingerbreadths above
the clavicular heads, continuing deep to the platysma muscle. The strap muscles
are separated, after incision of the fascia in the midline, and retracted laterally. The
size and location of the incision can be directed using the preoperative investiga-
tions. The thyroid is usually inspected during the dissection, partly depending on
the extent of the procedure. The thyroid lobe is reflected anteromedially to expose
the parathyroid gland(s). Care must be taken to identify the upper and lower para-
thyroid glands and the recurrent laryngeal nerve by dissecting parallel to the course
of the nerve, before starting to remove the parathyroid. The nerve should be fol-
lowed until it enters the larynx. Great care should be taken not to injure the nerve by
applying too much traction, direct pressure, or injuring it with electrocautery. The
external branch of the superior laryngeal nerve should be identified before dividing
and ligating the superior pole vessels, if this is required. The use of nerve monitor-
ing devices may improve the localization and detection of nerve branches to pre-
serve. If the blood supply to a remaining parathyroid gland cannot be preserved with
certainty, it should be removed, sliced into 1 mm slivers, placed into iced saline,
and implanted into muscle pockets in a strap/sternomastoid or forearm muscle at
the end of the case. The thyroid lobe is raised from lateral to medial, to expose the
parathyroid gland(s). The conventional approach is to explore all of the parathy-
roid glands and remove the enlarged gland(s). Recent improvements in the localiza-
tion of affected glands have often refined the procedure to permit more selective
exploration of abnormal glands only. Improvement in the serum parathormone

levels postoperatively indicates a successful procedure, and this measure has even
been used intraoperatively. If meticulous dissection has been practiced throughout
the process of removing the lobe, it is not usually necessary to leave a drain in the
neck. The strap muscles and platysma should be loosely re-approximated using
interrupted sutures to permit any ooze leakage, and the skin is closed with a run-
ning subcuticular stitch. The patient should usually be monitored for hypocalcemia
overnight in hospital, with a blood calcium test next day.
Anatomical Points
During embryogenesis, the parathyroid glands migrate a distance, and consequently

their anatomical location may vary greatly. The upper (superior) parathyroids arise
from the 4th branchial pouch, are associated with the lateral thyroid, and are more
consistent in their position; while the lower (inferior) parathyroids develop from the
3rd branchial pouch and are closely associated with the thymus, resting anywhere
from the pharynx to the posterior mediastinum. There are typically four parathyroid
glands, but supernumerary glands are found in up to 15 % of people. Intrathyroid
parathyroids occur in about 1 % of patients. Fewer than four glands are very rare.
Sestamibi scans should include the neck and upper mediastinum to ensure detection
of ectopic glands. The usual location of the upper parathyroids is at about mid- to
upper-thyroid level posteriorly, and the lower parathyroids typically lie at the base
of the lower thyroid lobe. The thyroid gland arises from the foramen caecum of the
posterior base of the tongue and descends in the midline of the neck to reach the 2nd
tracheal ring in the adult. It can be arrested at any level, altering the anatomy. The
recurrent laryngeal nerve course may vary. Its relationship to the inferior thyroid
artery is variable. The nerve may be anterior, posterior, or between branches of the
artery. The inferior thyroid artery and the recurrent laryngeal nerve always cross,
except in the case of the nonrecurrent laryngeal nerve. The nonrecurrent laryngeal
nerve arises directed from the vagus and travels medially to the larynx. A right
nonrecurrent laryngeal nerve occurs in 0.5–1 % of patients. About 0.2 % of patients
have both a recurrent and nonrecurrent laryngeal nerve on the right. Left-sided non-
recurrent laryngeal nerves are very rare and are seen with situs inversus. The right
subclavian artery can arise directly from the descending aorta so that the right nerve
is nonrecurrent, exiting from the vagus nerve at a 45° angle. The nonrecurrent nerve
can be mistaken for a vessel and then divided and ligated, resulting in paralysis of
the ipsilateral vocal cord. The course of the superior laryngeal nerve, including its
external and internal branches, is also variable. The external branch of the superior
laryngeal nerve is usually closely associated with the inferior pharyngeal constric-
tor and may be covered entirely by its muscle fibers. In 15 % of patients the nerve
travels with the superior thyroid artery. In 6 % of patients it continues to accompany
the superior thyroid artery even after branching of the main trunk. The presence of
a large thyroid nodule may further complicate the identification of these structures,
and it takes great patience and tenacity to identify them.
Table 3.4 Parathyroidectomy estimated frequency of complications, risks, and consequences

Hoarse voice
Transient (intubation or minor recurrent laryngeal nerve injury) 5–20 %
Permanent (superior or recurrent laryngeal nerve injury) 0.1–1 %
Transient 50–80 %
Permanent (oral calcium therapy) 1–5 %
Failure to localize and remove abnormal parathyroid tissuea 1–5 %
Recurrent hyperparathyroidism/parathyroidosisa 1–5 %
Need for further surgerya 1–5 %
Infection 0.1–1 %
Thyroiditisa transient thyrotoxicosis 0.1–1 %
Sternal mediastinal split 0.1–1 %
Tissue necrosisa (CVC line calcium administration) 0.1–1 %
Esophageal perforation <0.1 %
Deatha <0.1 %
Cutaneous numbness and nerve problems (cervical plexus) 20–50 %
Dimpling/deformity of the skin (tethering trachea) 0.1–1 %
Wound draina >80 %
a
Dependent on pathology, anatomy, comorbidities, biochemical response, surgery type, and
surgeon preference
Perspective
See Table 3.4. The major risk from parathyroid surgery is damage to the recurrent or
superior laryngeal nerves. Any subtle damage may not be apparent until any vocal
cord swelling from the endotracheal tube settles on the second or third postoperative
day. Pre- and postoperative videoscopic testing can be useful in defining preexisting
or surgically induced voice and laryngeal functional changes. Recurrent or supe-
rior laryngeal nerve injury must be avoided by careful identification and dissection.
Intraoperative electromyography electrode monitoring may reduce the incidence of
recurrent laryngeal nerve injury. Damage to retained parathyroid glands may occur if
the contralateral parathyroid glands are explored, as blood supply is typically by fine
end arteries. If recognized at operation, parathyroid gland autografting/transplanting
into skeletal muscle usually averts permanent hypoparathyroidism. Hypocalcemia
is common due to temporary or permanent disruption of parathyroid function. This
may be due to manipulation of the blood supply or direct trauma to the remaining
gland. Most hypocalcemia is transient and will resolve in several days. Patients are
treated with calcium supplementation until the parathyroid resumes function. If the
hypoparathyroidism persists, the patient will require lifelong calcium and vitamin
D supplementation. Persistent hyperparathyroidism reflects either failure to remove
all of the hyperfunctioning parathyroid tissue or later recrudescence of disease, and
this will require localization of the other parathyroid glands and removal of the
abnormal ones. Minor hematoma after subtotal parathyroidectomy is fairly com-
mon because of the vascularity of the area and the many small vessels that require
careful ligation. Severe bleeding causing tracheal compression and acute respiratory
decompensation is uncommon, unless the exploration is extensive or difficulties are
encountered, requiring urgent surgical reoperation for drainage. A bleeding point
is seldom found. Acute postoperative pain is common and responds well to oral
analgesics. Chronic pain is rare. Horner’s syndrome is caused by retraction damage
to the cervical sympathetic chain. It is very rare and usually resolves, but can be
permanent. Cutaneous numbness and tingling of the anterior neck is common due to
division of cervical plexus branches during incision and often improves with time,
but can make shaving and application of cosmetics difficult. Neck wounds usually
heal rapidly with low infection risk and are rarely unsightly. Keloid reactions at the
scar may occur being difficult to prevent or treat. In some patients surgical revision
of the scar may be necessary. Risk of many of these complications is increased
when reoperative parathyroidectomy is performed.
Major Complications
A serious complication of parathyroidectomy is damage to the recurrent laryn-

geal nerve or the external branch of the superior laryngeal nerve. Some factors
for increased risk or nerve injury are the inexperienced surgeon, extensive explora-
tion, bleeding, concurrent very large thyroid masses, and reoperative surgery. The
paralyzed cord rests in a paramedian position. Symptoms are hoarseness, dyspnea
with exertion, and aspiration. With time, the changes in phonation associated with
these injuries will improve; however, in patients who depend on their voice for a
livelihood, the injuries can be devastating. Management of a divided recurrent
laryngeal nerve is controversial. Anastomosis of the nerve restores some bulk to the
vocal cord; however, there is anomalous regeneration, and phonation may not return
to normal. When the recurrent laryngeal nerve is known to be intact, the patient
should be referred for speech therapy. Injection of material (e.g., gelatin, Teflon,
Silastic fat) into the vocal cord(s) may be helpful in voice restoration. In some cases,
regardless of the integrity of the nerve, medialization thyroplasty (using a variety
of methods) may be indicated to improve the vocal quality and decrease aspiration.
There is little that can be done to restore the integrity of a damaged external branch of
the superior laryngeal nerve. There is a greater risk of injury to these structures dur-
ing a 4-gland parathyroidectomy compared to a single parathyroidectomy. Bilateral
recurrent laryngeal nerve injury is a particularly physically and psychologically
devastating complication causing difficulty breathing, requiring urgent intubation

or tracheostomy in the immediate postoperative period for acute airway manage-
ment. Prolonged ICU admission is often needed. Serious postoperative bleeding
(<48 h) into a tightly closed neck wound is uncommon, causing severe respiratory
obstruction, requiring urgent reoperative drainage, and is a well-recognized com-
plication that patients should be informed about. Thorough hemostasis and Valsalva
testing before closure at the completion of surgery are two risk reduction strategies
used. Hypoparathyroidism and hypocalcemia postoperatively can be temporary
or permanent. Most patients have some transient hypoparathyroidism and accom-
panying hypocalcemia, due to bone remineralization and/or true hypoparathyroid-
ism. Oral calcium and vitamin D therapy for several weeks usually corrects this
and is then reduced to test for recovery. Injury to (or removal of) the parathy-
roid glands can cause major hypocalcemia in the postoperative period, which
is usually transient, but in some cases may be permanent requiring calcium and
vitamin D supplementation for life. Meticulous surgical technique, sometimes with
autotransplantation, can almost prevent this complication. Persistent or recurrent
hyperparathyroidism can arise after surgery, but occurs in only 2–4 % of patients,
in experienced hands.

• Bleeding
• Hypoparathyroidism
• Persistent or recurrent hyperparathyroidism
• Further surgery
Minimally Invasive Parathyroidectomy
Description
General anesthesia is commonly used, but in selected patients local and IV seda-
tion may be adequate. Minimally invasive parathyroidectomy is indicated for
hyperparathyroidism caused by a parathyroid adenoma. Hyperparathyroidism is
usually detected by an elevated calcium level, found on routine laboratory tests.
The diagnosis is confirmed by measuring parathyroid hormone and ruling out
secondary and tertiary hyperparathyroidism. A preoperative sestamibi scan/CT

scan is used to determine the location of the hyperfunctioning gland. In 85 % of
cases the hyperparathyroidism is caused by a single gland adenoma. Four-gland
hyperplasia must be differentiated from a solitary adenoma preoperatively. About
1 % of primary hyperparathyroidism is caused by a parathyroid carcinoma. The
patient is positioned supine with a roll placed transversely under the scapulae to
allow optimal neck extension. To prevent neck hyperextension, the head is sup-
ported on a supporting “donut” head ring. A small transverse collar incision is
made two fingerbreadths above the sternal notch on the side of the abnormality.
Subplatysmal flaps are elevated superiorly and inferiorly. The use of nerve moni-
toring devices may improve the localization and detection of nerve branches to
preserve. A gamma probe can be used to locate the radioactive gland intraopera-
tively. Ultrasound, both preoperatively and intraoperatively, is sometimes used for
guidance localization of the parathyroid mass. Once the parathyroid is identified,
its blood supply is ligated and it is removed. Five minutes after the gland has been
removed, blood is sampled for parathyroid hormone level. This level is compared
to baseline. A 50 % decrease in parathyroid hormone level indicates a successful
procedure, and the operation can be concluded. If the gland is not identified or the
PTH level remains elevated, then a four-gland exploration should be performed.
The wound is irrigated and closed with absorbable suture. Most patients are dis-
charged shortly after surgery or the next day.
Anatomical Points
The locations of the parathyroid glands vary widely due to differences in migration
patterns during embryologic development. The inferior parathyroid glands arise
from the third pharyngeal pouch and are closely associated with the thymus. As
they migrate they may finally rest anywhere from the pharynx to the posterior medi-
astinum. The superior glands are more consistent in their position because they arise
from the fourth pharyngeal pouch and are associated with the lateral thyroid. Most
patients have four parathyroid glands, but supernumerary glands are found in up
to 15 % of people. Intrathyroid parathyroids occur in about 1 % of patients. Fewer
than four glands are very rare. Sestamibi scans should include the neck and upper
mediastinum to ensure detection of ectopic glands.
Perspective
See Table 3.5. Minimally invasive parathyroidectomy involves minimal dissection

of the structures around the adenoma. Unilateral recurrent laryngeal nerve injury,
hematoma, and infection are uncommon complications. Persistent hyperparathy-
roidism reflects failure to remove all of the hyperfunctioning parathyroid tissue,
and this will require localization of the other parathyroid glands and removal of the
abnormal ones.
Table 3.5 Minimally invasive parathyroidectomy estimated frequency of complications, risks,

and consequences
Hoarse voice
Transient (intubation or minor recurrent laryngeal nerve injury) 5–20 %
Permanent (superior or recurrent laryngeal nerve injury) 0.1–1 %
Transient 50–80 %
Permanent (oral calcium therapy) 1–5 %
Failure to localize and remove abnormal parathyroid tissuea 1–5 %
Recurrent hyperparathyroidism/parathyroidosisa 1–5 %
Need for further surgerya 1–5 %
Infection 0.1–1 %
Thyroiditisa transient thyrotoxicosis 0.1–1 %
Tissue necrosisa (CVC line calcium administration) 0.1–1 %
Esophageal perforation <0.1 %
Deatha <0.1 %
Cutaneous numbness and nerve problems (cervical plexus) 20–50 %
Dimpling/deformity of the skin (tethering trachea) 0.1–1 %
Wound draina 0.1–1 %
a
Dependent on pathology, anatomy, comorbidities, biochemical response, surgery type, and
surgeon preference
Major Complications
Recurrent laryngeal nerve injury leads to vocal cord paralysis. The paralyzed
cord rests in a paramedian position. The voice becomes weak, breathy, or hoarse.
Some patients complain of dyspnea with exertion and aspiration. Vocal cord
paralysis can be treated with Teflon paste, Gelfoam, fat injections, bovine colla-
gen, or calcium hydroxyapatite to mobilize the cord medially. These treatments
show promise, but longer-term follow-up results are needed. They improve the
vocal quality and decrease aspiration. Bleeding and hematoma formation can be
avoided through careful hemostasis. Persistent hyperparathyroidism and hyper-
calcemia is a complication of minimally invasive parathyroidectomy. Intraoperative
rapid PTH testing may help to avoid this complication by identifying patients who
have a second adenoma or four-gland hyperplasia prior to the conclusion of the ini-
tial operation. If hyperparathyroidism persists, all four glands must be explored, and
hyperplastic or adenomatous glands must be removed. It is important to remember

that the hyperfunctioning gland may be found in the mediastinum.

• Bleeding
• Hypoparathyroidism
• Persistent or recurrent hyperparathyroidism
• Further surgery
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hyperparathyroidism in Hong Kong: changes in clinical pattern over 3 decades. Arch Surg.
2004;139(1):77–82; discussion 82.
Mittendorf EA, Merlino JI, McHenry CR. Post-parathyroidectomy hypocalcemia: incidence, risk
factors, and management. Am Surg. 2004;70(2):114–19.
National Institute of Health Conference. Diagnosis and management of asymptomatic primary hyper-
parathyroidism: consensus development conference statement. Ann Int Med. 1991;114:593.
Skinner MA, Moley JA, Dilley WG, Owzar K, Debenedetti MK, Wells Jr SA. Prophylactic thy-
roidectomy in multiple endocrine neoplasia type 2A. N Engl J Med. 2005;353(11):1105–13.
Weber KJ, Misra S, Lee KJ, et al. Intraoperative PTH monitoring in parathyroid hyperplasia
requires stricter criteria for success. Surgery. 2004;136(6):1154–9.
Wells Jr SA, Debenedetti MK, Doherty GM. Recurrent or persistent hyperparathyroidism. J Bone
Miner Res. 2002;17 Suppl 2:N158-62. Review.
Minimally Invasive Parathyroidectomy
Agarwal G, Barraclough BH, Reeve TS, Delbridge LW. Minimally invasive parathyroidectomy
using the ‘focused’ lateral approach. II. Surgical technique. ANZ J Surg. 2002;72(2):147–51.
Review.
Agarwal G, Barraclough BH, Robinson BG, Reeve TS, Delbridge LW. Minimally invasive para-
thyroidectomy using the ‘focused’ lateral approach. I. Results of the first 100 consecutive
cases. ANZ J Surg. 2002;72(2):100–4.
Baliski CR, Stewart JK, Anderson DW, Wiseman SM, Bugis SP. Selective unilateral parathy-
roid exploration: an effective treatment for primary hyperparathyroidism. Am J Surg.
2005;189(5):596–600; discussion 600.
Baliski C, Nosyk B, Melck A, Bugis S, Rosenberg F, H Anis A. The cost-effectiveness of three
strategies for the surgical treatment of symptomatic primary hyperparathyroidism. Ann Surg
Oncol. 2008;15(10):2653–60.
Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combina-
tion of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid
hormone assay. Surgery. 1999;126:1016–21.
Wilkins; 1997.
Giraldez-Rodriguez LA, Giraldez-Casasnovas LJ. Minimally invasive parathyroidectomy as treat-
ment for primary hyperparathyroidism. Bol Asoc Med P R. 2008;100(1):27–32.
Henry JF. Minimally invasive thyroid and parathyroid surgery is not a question of length of the
incision. Langenbecks Arch Surg. 2008;393(5):621–6.
Henry JF, Iacobone M, Mirallie E, Deveze A, Pili S. Indications and results of video-assisted para-
thyroidectomy by a lateral approach in patients with primary hyperparathyroidism. Surgery.
2001;130(6):999–1004.
Henry JF, Sebag F, Cherenko M, Ippolito G, Taieb D, Vaillant J. Endoscopic parathyroidectomy:
why and when? World J Surg. 2008;32(11):2509–15.
Irvin III GL, Carneiro DM. Rapid parathyroid hormone assay guided exploration. Oper Tech Gen
Surg. 1999;1:18–27.
Livingston; 2006.
Norman JG. Minimally invasive radioguided parathyroidectomy: an endocrine surgeon’s perspec-
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Norman J, Chheda H, Farrell C. Minimally invasive parathyroidectomy for primary hyperpara-
thyroidism: decreasing operative time and potential complications while improving cosmetic
results. Am Surg. 1998;64(5):391–5.
Pang T, Stalberg P, Sidhu S, Sywak M, Wilkinson M, Reeve TS, Delbridge L. Minimally invasive
parathyroidectomy using the lateral focused mini-incision technique without intraoperative
parathyroid hormone monitoring. Br J Surg. 2007;94(3):315–19.
Sackett WR, Barraclough B, Reeve TS, Delbridge LW. Worldwide trends in the surgical treatment
of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Arch
Surg. 2002;137(9):1055–9.
Shah S, Win Z, Al-Nahhas A. Multimodality imaging of the parathyroid glands in primary hyper-
parathyroidism. Minerva Endocrinol. 2008;33(3):193–202.
Yen TW, Wang TS, Doffek KM, Krzywda EA, Wilson SD. Reoperative parathyroidectomy: an
algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results
in a successful focused approach. Surgery. 2008;144(4):611–19; discussion 619–21.
Chapter 4
Adrenal Gland Surgery
Sarah Thompson, David Walsh, and Brendon J. Coventry
The relative risks and complications increase proportionately according to the type
of surgery, site of the adrenal lesion, extent of procedure performed, technique, the
complexity of the problem, and lesion size. Extensive or complex surgery usually
carries higher risks of bleeding and infection than smaller procedures, in general
terms. Similarly, risk is relatively higher for recurrent and complex adrenal prob-
lems, for associated lymph node dissections, and especially for those masses closer
to or involving major vascular or neural structures (e.g., aorta, vena cava, renal ves-
sels, or lumbar plexus). Bilateral and transabdominal dissection procedures are typi-
cally associated with a higher frequency and greater range of complications
compared to procedures involving the one side alone. This is principally related to
the surgical accessibility and risk of organ/tissue/vascular/nerve/lymphatic injury.
In general, for many unilateral adrenal operations, the complications are similar
in type and frequency. Laparoscopic approaches carry specific risks of gas embo-
lism and trocar injury, but open procedures often carry risk of more direct tissue
injury and longer convalescence. Knowledge of the anatomy and the variations
S. Thompson, MD, PhD, FRACS (*)

Oesophagogastric and Upper GI Unit, Discipline of Surgery,
University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
e-mail: sarah.thompson@adelaide.edu.au
D. Walsh, MBBS, FRACS
Breast, Endocrine and Surgical Oncology Unit, Discipline of Surgery,
The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, Australia

104 S. Thompson et al.
commonly seen is helpful in minimizing nerve, vessel, and organ injury. Surgeons
argue the benefits of one approach over the other, but there is somewhat variable
tangible data to demonstrate differences in terms of the observed or reported com-
plications. Other surgeons will argue that the use of drains adds to the complication
rates, but this needs to be balanced with the extent and risks of bleeding and lym-
phatic leakage.
quences from adrenal surgery might be achieved by:
• Review by an endocrinologist if hormone-secreting adenoma and medical opti-
mization for surgery
Multisystem failure, systemic sepsis, and death are uncommon after adrenal
surgery, even with extensive resection, but are reported and remain a risk.
Positioning on the operating table has been associated with increased risk of
deep venous thrombosis and nerve palsies, especially in prolonged
procedures.
multidisciplinary input, and high-quality postoperative care is essential to the
success of complex adrenal surgery overall and can significantly reduce risk of com-
plications or aid early detection, prompt intervention, and cost.
Important Note
represent derived figures. These figures are the best estimates of relative
frequencies across most institutions, not merely the highest-performing
ones, and as such are often representative of a number of studies, which
include different patients with differing comorbidities and different sur-
geons. In addition, the risks of complications in lower- or higher-risk
patients may lie outside these estimated ranges, and individual clinical
judgement is required as to the expected risks communicated to the patient,
staff, or for other purposes. The range of risks is also derived from experi-
ence and the literature; while risks outside this range may exist, certain
risks may be reduced or absent due to variations of procedures or surgical
approaches. It is recognized that different patients, practitioners, institu-
tions, regions, and countries may vary in their requirements and
recommendations.
4 Adrenal Gland Surgery 105
For diagnostic fine or core needle biopsy complications, see Volume 3, Lymph Node
Surgery (Chap. 5), Laparotomy Volume 4, or other relevant volumes and chapters.
Laparoscopic Adrenalectomy
Description
General anesthetic is used. The aim is to resect the adrenal gland on the affected
side(s) using minimal access laparoscopic techniques. The laparoscopic (usually
transperitoneal) approach is now regarded as standard of care for both unilateral and
bilateral adenomas and/or lesions. Usual contraindications to the laparoscopic
approach include a known primary adrenal gland malignancy and pheochromocytoma
over 10 cm in size. Depending on the reason for the adrenalectomy, there may be other
endocrine or biochemical disorders that need to be corrected and allowed for, in the
surgical management of the patient. Primary aldosteronism, hypercortisolism, and
pheochromocytoma are the most common examples. The patient is positioned in full
lateral decubitus with the operative side upward. The bed is flexed in order to increase
the distance between the costal margin and the iliac crest, and the patient is secured in
place with a “beanbag” (to wall suction). Pillows are placed between the legs, and
occasionally an axillary roll is necessary. Ports are placed in a semicircle approxi-
mately 2 cm from the costal margin once the abdomen has been insufflated with a
Veress needle or open cut-down technique. A 30° camera is recommended. For the
right adrenal gland, dynamic liver retraction (using either a Diamond-Flex liver retrac-
tor or a 10-mm fan liver retractor) is needed for resection. Dissection on the left adre-
nal gland begins with dividing the “white line” at the splenic flexure, followed by the
suspensory ligament of the spleen to rotate it medially. The adrenal gland is exposed
with either cautery or ultrasonic coagulation. Adrenal arteries are small and divided
sequentially using cautery or ultrasonic coagulation. The adrenal vein is then identi-
fied with a 10-mm right angle and clipped. The anesthetist should be notified when the
adrenal vein is being divided if perioperative hormone replacement is required. The
adrenal gland is then removed from the abdomen in a laparoscopic retrieval bag.
Anatomical Points
The right adrenal (suprarenal) gland is pyramidal in shape, usually lying more
medially than the left and against the IVC. The inferior leaf of the coronary ligament
covers the lower surface of the right adrenal gland. The left adrenal gland tends to be
crescentic in shape and lies above the upper left renal pole. Congenital anomalies of
the kidney include lobulation in two or three separate parts, unilateral absence, or a
single-fused horseshoe-shaped kidney. However, the adrenal position is not usually
affected by these anatomical variants. Adrenal blood supply can vary. Multiple small
arteries supply each adrenal gland, derived from the aorta, renal artery, and inferior
phrenic artery. Typically, 1–2 adrenal veins drain into the inferior vena cava on the
right side and into the left renal vein on the left. CT arteriographic scanning can assist
in preoperative planning. Large tumor size, or the presence of local infiltration, may
alter the access and increase the difficulty of surgery.
Perspective
See Table 4.1. Complications of laparoscopic adrenalectomy should be considered

as two separate entities depending on whether the surgeon is removing the right or
left adrenal gland. Partial adrenalectomy is not generally recommended. The sig-
nificant potential complication on the right side is severe hemorrhage from a tear or
injury to the inferior vena cava during adrenal gland mobilization or division of the
adrenal vein. These patients should always have good venous access during the case
and should be cross-matched in the event of a significant bleed. Risk of injury to the
adjacent duodenum is also possible. The other pertinent preoperative consideration
is whether the patient is obese and would benefit from 3 weeks of a low-calorie diet
(usually 800–1,000 cal/d) in order to reduce the size of the liver. This and careful
retraction may improve access and lessen the risk of injury to the liver. Significant
complications on the left side are almost always related to localizing the adrenal
gland. In the obese patient, this can be challenging and requires complete mobiliza-
tion of the splenic flexure, spleen, and pancreatic tail, which are all at risk of injury.
The left adrenal gland is almost always located directly across from the splenic
artery once the spleen has been mobilized medially. It may not be immediately rec-
ognizable if the patient is very obese or suffers from Cushing’s syndrome.
Conversion to an open procedure may be necessary. Injury to the spleen (requiring
splenectomy), pancreas (pancreatitis), and colon (perforation) may occur. Care
must be taken not to enter Gerota’s fascia as this will hinder localization of the left
adrenal vein and introduce the potential of injury to the kidney. With either a right
or left laparoscopic adrenalectomy, if the surgeon suspects invasion to adjacent
structures, the procedure should be immediately converted to an open procedure in
order to achieve a negative microscopic resection margin (R0).
Medical Considerations
If an adrenalectomy is planned to remove a hormone-producing adenoma, the patient

should be reviewed preoperatively by an endocrinologist to ensure optimization for
surgery. Patients with a pheochromocytoma must be α- and β-blocked preoperatively.
Extremely labile BP can occur intraoperatively with incomplete preparation and
blockade, potentially leading to an adrenal hypertensive crisis due to effects of
Table 4.1 Laparoscopic adrenalectomy estimated frequency of complications, risks, and

consequences
Infection
Wound/subcutaneous 1–5 %
Intra-abdominal 0.1–1 %
Pneumonia/atelectasis 1–5 %
Conversion to open surgical procedurea 1–5 %
Injury to other organs/vessels (overall) 1–5 %
[bowel, liver/duodenum/IVC (right adrenal), spleen/pancreas/colon
(left adrenal), renal vessels]
Myocardial infarction/stroke 1–5 %
Adrenal function disturbance (depending on underlying disease)a 5–20 %
Need for blood transfusion 0.1–1 %
Respiratory compromise (from pneumoperitoneum) 0.1–1 %
Pneumothorax 0.1–1 %
Gas embolism <0.1 %
DVT and venous thromboembolisma 0.1–1 %
Adrenal failurea 0.1–1 %
Nelson’s syndrome (only after bilateral adrenalectomy)a 0.1–1 %
Recurrent disease (usually in Cushing’s disease)a 0.1–1 %
Nerve injury (especially pressure palsies from positioning)a 0.1–1 %
Right adrenalectomyb
IVC injury, serious hemorrhage, duodenal injury 0.1–1 %
Left adrenalectomyb
Splenic, pancreatic, colonic, renal injury 0.1–1 %
Multisystem organ failurea 0.1–1 %
Deatha 0.1–1 %
Pain/tenderness
Paralytic ileus/SBO (most often early) 1–5 %
Port-site hernia formation <0.1 %
Wound scarring (poor cosmesis) 0.1–1 %
Wound drain(s) 1–5 %
a
b
Dependent of operative side, underlying pathology, and technique
unblocked excess released catecholamines. Stroke may ensue during such a crisis,
before, during, or even after surgery. Following removal of a pheochromocytoma,
patients may become hypotensive and may also become hypoglycemic. Patients with
an aldosterone-producing adenoma are generally hypokalemic and hypertensive.
Care must be taken to follow their potassium levels closely during the perioperative
period. Cortisol-producing adenomas may suppress cortisol production in the

remaining adrenal gland. Postoperatively, adrenal insufficiency and in its most severe
form an Addisonian crisis, due to continued suppression of production of glucocor-
ticoid and/or mineralocorticoid, may occur, if replacement is not given. Bilateral
adrenalectomy for persistent or recurrent Cushing’s disease will require lifelong glu-
cocorticoid and mineralocorticoid replacement. All of the above patients should be
monitored in a step-down unit or intensive care unit for 24–48 h postoperatively.
Major Complications
Severe bleeding from vascular injury is perhaps the most severe intraoperative
complication of adrenalectomy, more common on the right side. Right adrenalec-
tomy is associated with risk of IVC, liver, and duodenal injury. Left adrenalec-
tomy is associated with risk of splenic, pancreatic, renal, colonic, and aortic
injury. Infection and abscess formation are also potentially very serious and may
lead to multisystem organ failure. Mortality is rare, but due principally to cata-
strophic bleeding or sepsis. Mobilization of adjacent organs may cause bowel per-
foration, pancreatitis, or vascular injury. These all increase the relative risk of the
surgery. Pneumothorax from breaching of the pleura during access may be either
intentional or inadvertent. Involvement of other organs with adrenal malignancy
may necessitate resection of other organs, perhaps with reconstruction, associated
then with the attendant risks of the additional surgery performed. Conversion to
open operation may be desirable early, if bleeding or difficulty with adequate
resection is encountered. Planning and tailored patient discussion is appropriate in
these more complex situations, where possible. Postoperatively, endocrine compli-
cations include adrenal insufficiency; if severe an Addisonian crisis, for pheo-
chromocytoma, extremely labile BP can occur precipitating a hypertensive crisis,
and if uncontrolled, a stroke may ensue. Gas embolism is a very rare but serious
complication, as are the risks of bowel and vascular injury. Port-site hernia for-
mation is uncommon and may require surgical repair. Multisystem organ failure
and death are rare complications of adrenal surgery and are more commonly associ-
ated with systemic sepsis and malignancy.

• GA risk
• Infection (local/systemic)
• Pain/discomfort
• Possible tumor recurrence*

• Possible abdominal organ/vessel/bowel injury
• Respiratory complications
• Venous thromboembolism
• Myocardial infarction, stroke
• Possible blood transfusion
• Gas embolism
• Possible open operation
*Dependent on pathology and type of surgery performed
Open Adrenalectomy
Description
General anesthetic is used. The aim is to resect the adrenal gland on the affected
side(s) either via a retroperitoneal (posterolateral) approach or by supine transperi-
toneal laparotomy. The supine approach is more commonly used for bilateral adre-
nalectomy and for malignant disease involving the adrenal gland. The transperitoneal
approach is via either the anterior midline inverted “V” or subcostal laparotomy
incision. A thoracoabdominal approach can also be used. The posterolateral
approach is frequently via a subcostal incision or through the bed of the 12th rib,
often also excising the rib. Depending on the reason for the adrenalectomy, there
may be other endocrine or biochemical disorders that need to be corrected and
allowed for in the surgical management of the patient. Primary aldosteronism,
hypercortisolism, and pheochromocytoma are examples. Occasionally, adrenalec-
tomy is indicated for resection of a primary adrenal gland malignancy or for a soli-
tary metastatic adrenal deposit. The adrenal vessels are usually initially serially
ligated, and the gland is dissected free from the upper renal pole.
Anatomical Points
The right adrenal (suprarenal) gland is more pyramidal, usually lying more medially
than the left and against the IVC. The left adrenal tends to be crescentic in shape and lies
above the upper left renal pole. The kidney can be lobulated, in two or three separate
parts, absent, or horseshoe in shape, all congenital anomalies, which are not uncommon.
The adrenal position may be affected by these anatomical variants. Adrenal blood sup-
ply can also vary. Three arteries from the aorta, renal artery, and phrenic artery usually
supply each adrenal gland. One to two veins drain into the vena cava on the right and left
renal vein on the left. This arrangement can vary, but it is infrequent and usually associ-
ated with anatomical variations of the kidney. CT scanning will usually permit preopera-
tive planning. Polycystic renal disease, excessive tumor size, or the presence of local
infiltration or lymphatic metastases can alter the access and difficulty of surgery.
Perspective
See Table 4.2. Complications of open adrenalectomy should be considered as two

separate entities depending on whether the surgeon is removing the right or left
adrenal gland, or if bilateral, with both combined. Partial adrenalectomy is not gen-
erally recommended. The significant potential complication on the right side is
severe hemorrhage from a tear or injury to the inferior vena cava during adrenal
gland mobilization or division of the adrenal vein. These patients should always
have good venous access during the case and should be cross-matched in case of the
event of a significant bleed. However, most often, any bleeding is of a minor nature.
Risk of injury to the adjacent duodenum is also possible. Careful retraction will
improve access and lessen the risk of injury to the liver. Significant complications
on the left side are almost always related to localizing the adrenal gland. In the
obese patient, this can be challenging and requires complete mobilization of the
splenic flexure, spleen, and pancreatic tail, all of which are at risk of injury. The left
adrenal gland is almost always located directly across from the splenic artery once
the spleen has been mobilized medially. It may not be immediately recognizable if
the patient is very obese. Hydrocortisone cover may be required to prevent postop-
erative adrenal insufficiency, if bilateral adrenalectomy is performed or for a unilat-
eral adrenalectomy for hypercortisolism. Hypertension may be a problem after
adrenalectomy for pheochromocytoma and hypercortisolism, with hypotension
possibly afterwards. Bilateral adrenalectomy requires corticosteroid and mineralo-
corticoid replacement. Rarely pituitary hypertrophy (Nelson’s syndrome) can arise
after bilateral adrenalectomy. Wound infection and abscess formation are not
uncommon in patients with hypercortisolism. Pneumothorax may be associated
with thoracoabdominal and posterior approaches. Splenectomy may be required for
iatrogenic injury. Later hypertension can occur with residual aldosterone producing
adenoma, prolonged hyperaldosteronism, and rarely posttraumatic renal artery ste-
nosis. Recurrence of hyperfunctional states or tumor recurrence may be a conse-
quence of incomplete surgery, for whatever reason. Hernia formation is a potential
complication especially after muscle cutting incisions or infection.
Major Complications
Severe bleeding from vascular injury is perhaps the most severe intraoperative
complication of adrenalectomy. Right adrenalectomy is associated with risk of
Table 4.2 Open adrenalectomy estimated frequency of complications, risks, and consequences
Infection
Wound, subcutaneous 1–5 %
Intra-abdominal (abscess) 0.1–1 %
Pneumothorax (posterior, thoracoabdominal incisions) 1–5 %
Adrenal function disturbance (depending on underlying disease)a 1–5 %
Respiratory compromise (from pneumo(retro)peritoneum) 1–5 %
Failure to alleviate problem (symptom/tumor recurrence)b 1–5 %
Left adrenalectomyb
Splenic, pancreatic, colonic, renal injury 0.1–1 %
Right adrenalectomyb
IVC injury, serious hemorrhage, duodenal injury 0.1–1 %
Hypertensive crisis (incl. stroke)b 0.1–1 %
Injury to other organs 0.1–1 %
[bowel, liver/duodenum (right adrenal), spleen/pancreas (left adrenal),
renal, intercostal nerves]
Adrenal failure 0.1–1 %
SBO (early or late; transperitoneal approach, adhesion formation) 0.1–1 %
Renovascular hypertension (usually from left renal vascular injury) 0.1–1 %
Pain/tenderness
Blood pressure fluctuationb 5–20 %
Lymphocele 1–5 %
Delayed heavy lifting/straining (6–8 weeks) >80 %
Hernia formation 1–5 %
a
b
Relevant to surgery for pheochromocytoma
injury to the IVC, liver, and duodenum. Left adrenalectomy is associated with
risk of splenic, pancreatic, renal, colonic, and aortic injury. Infection and
abscess formation are also potentially very serious and may lead to multisystem
failure. Mobilization of adjacent organs may cause bowel perforation, pancreati-
tis, or vascular injury. These all increase the relative risk of the surgery.
Pneumothorax from breaching of the pleura during access may be either inten-
tional or inadvertent. Involvement of other organs with adrenal malignancy may
necessitate resection of other organs, perhaps with reconstruction, associated then
with the attendant risks of the additional surgery performed. Planning and tailored
patient discussion is appropriate in these more complex situations, where possible.
Postoperatively, adrenal insufficiency and in its most severe form an Addisonian
crisis, due to continued suppression of production of glucocorticoid and/or miner-

alocorticoid, can rarely occur, if replacement is not given. With adrenalectomy for
pheochromocytoma, extremely labile BP can occur perioperatively with incom-
plete preparation and blockade, potentially leading to an adrenal hypertensive cri-
sis due to effects of unblocked excess-released catecholamines. Stroke may ensue
during such a crisis, before, during, or even after surgery. Wound scarring and
deformity and hernia formation are later complications that may require surgery.
Multisystem organ failure and death are rare complications of adrenal surgery
and are more commonly associated with systemic sepsis and malignancy.

• GA risk
• Pain/discomfort/neuralgia
• Possible abdominal organ/vessel/bowel injury
• Myocardial infarction, stroke
Laparoscopic Adrenalectomy
Brunt LM. The positive impact of laparoscopic adrenalectomy on complications of adrenal sur-
gery. Surg Endosc. 2002;16(2):252–7.
Wilkins; 1997.
Corcione F, Esposito C, Cuccurullo D, Settembre A, Fusco F, Bianco A, Cusano T. Vena cava
injury. A serious complication during laparoscopic right adrenalectomy. Surg Endosc.
2001;15(2):218.
Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A. Laparoscopic adrenalectomy: lessons
learned from 100 consecutive procedures. Ann Surg. 1997;226(3):238–46.
Henry JF, Defechereux T, Raffaelli M, Lubrano D, Gramatica L. Complications of laparoscopic
adrenalectomy: results of 169 consecutive procedures. World J Surg. 2000;24(11):1342–6.
Henry JF, Sebag F, Iacobone M, Mirallie E. Results of laparoscopic adrenalectomy for large and
potentially malignant tumors. World J Surg. 2002;26(8):1043–7.
Jamieson G, Swanstrom L. Chapter 18. Adrenalectomy: the anatomy of the adrenal gland and open
and laparoscopic approaches to the retroperitoneum. In: Glyn J, editor. The anatomy of general
surgical operations. 2nd ed. London: Elsevier; 2006. p. 90–3.
Kuruba R, Gallagher SF. Current management of adrenal tumors. Curr Opin Oncol.
2008;20(1):34–46.
MacGillivray DC, Khwaja K, Shickman SJ. Confluence of the right adrenal vein with the acces-
sory right hepatic veins. A potential hazard in laparoscopic right adrenalectomy. Surg Endosc.
1996a;10(11):1095–6.
MacGillivray DC, Shichman SJ, Ferrer FA, Malchoff CD. A comparison of open vs laparoscopic
adrenalectomy. Surg Endosc. 1996b;10(10):987–90.
Porpiglia F, Destefanis P, Fiori C, Giraudo G, Garrone C, Scarpa RM, Fontana D, Morino M. Does
adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?
Urology. 2002;60(5):801–5.
Porpiglia F, Fiori C, Bovio S, Destefanis P, Alì A, Terrone C, Fontana D, Scarpa RM, Tempia A,
Terzolo M. Bilateral adrenalectomy for Cushing’s syndrome: a comparison between laparos-
copy and open surgery. J Endocrinol Invest. 2004a;27(7):654–8.
Porpiglia F, Fiori C, Tarabuzzi R, Giraudo G, Garrone C, Morino M, Fontana D, Scarpa RM. Is
laparoscopic adrenalectomy feasible for adrenocortical carcinoma or metastasis. BJU Int.
2004b;94(7):1026–9.
Singh PK, Buch HN. Adrenal incidentaloma: evaluation and management. J Clin Pathol.
2008;61(11):1168–73.
Terachi T, Yoshida O, Matsuda T, Orikasa S, Chiba Y, Takahashi K, Takeda M, Higashihara E,
Murai M, Baba S, Fujita K, Suzuki K, Ohshima S, Ono Y, Kumazawa J, Naito S. Complications
of laparoscopic and retroperitoneoscopic adrenalectomies in 370 cases in Japan: a multi-
institutional study. Biomed Pharmacother. 2000;54 Suppl 1:211s–4.
Thompson SK, Hayman AV, Ludlam WH, Deveney CW, Loriaux DL, Sheppard BC. Improved
quality of life after bilateral adrenalectomy for Cushing’s disease: a 10-year experience. Ann
Surg. 2007;245(5):790–4
Open Adrenalectomy
Wilkins; 1997.
Jamieson G, Swanstrom L. Chapter 18. Adrenalectomy: the anatomy of the adrenal gland and open
and laparoscopic approaches to the retroperitoneum. In: Glyn J, editor. The anatomy of general
surgical operations. 2nd ed. London: Elsevier; 2006. p. 90–3.
Kuruba R, Gallagher SF. Current management of adrenal tumors. Curr Opin Oncol.
2008;20(1):34–46.
MacGillivray DC, Shichman SJ, Ferrer FA, Malchoff CD. A comparison of open vs laparoscopic
adrenalectomy. Surg Endosc. 1996;10(10):987–90.
Porpiglia F, Fiori C, Bovio S, Destefanis P, Alì A, Terrone C, Fontana D, Scarpa RM, Tempia A,
Terzolo M. Bilateral adrenalectomy for Cushing’s syndrome: a comparison between laparos-
copy and open surgery. J Endocrinol Invest. 2004c;27(7):654–8.
Singh PK, Buch HN. Adrenal incidentaloma: evaluation and management. J Clin Pathol.
2008;61(11):1168–73.
Thompson SK, Hayman AV, Ludlam WH, Deveney CW, Loriaux DL, Sheppard BC. Improved
quality of life after bilateral adrenalectomy for Cushing’s disease: a 10-year experience. Ann
Surg. 2007;245(5):790–4
Chapter 5
Lymphatic Surgery
John Thompson, Armando Giuliano, Guy Rees, Douglas Tyler,

Brendon J. Coventry, Nora Hansen, and Helen Mabry
Biopsy of lymph nodes is primarily for definitive diagnosis of enlarged palpable

lymph nodes or undefined masses at different locations in the body. Most lymph
nodes and other palpable masses are relatively superficial in location and in the typi-
cal lymph node areas in the cervical, axillary, and inguinal regions. However, the
increased usage of radiological imaging, including ultrasounds, CT scans, MRI
scans, and PET scans, has revealed an increased number of masses and presumed
lymph nodes at deeper sites which are often impalpable or might not have been eas-
ily felt during clinical examination. Fine-needle aspiration biopsy and core biopsy
have also assisted in improving diagnosis without the need for formal open surgical
biopsy of lymph nodes and other masses. The use of immunohistochemistry and
molecular techniques has also improved diagnostic accuracy further, such that even
poorly differentiated tumors can often be diagnosed more specifically. However,
open surgical lymph node biopsy is still required in many instances to obtain a tis-
sue diagnosis and definitively diagnose the nature of a presumed lymph node or
J. Thompson, MD (*)
Department of Surgery, Royal Prince Alfred Hospital and Melanoma Institute Australia,
Central Clinical School, The University of Sydney, Sydney, Australia
A. Giuliano, MD, FACS, FRCSEd
Department of Surgery, Surgical Oncology, Los Angeles, CA, USA
Samuel Oschin Comprehensive Cancer Institute, Surgical Oncology, Los Angeles, CA, USA
Saul and Joyce Brandman Breast Center – A Project of Women’s Guild, Los Angeles, CA, USA

116 J. Thompson et al.
G. Rees, MBBS, FRCS, FRACS

Discipline of Surgery, Otolaryngology, Head and Neck Surgery, The Queen Elizabeth
Hospital, Royal Adelaide Hospital, and Lyell McEwin Hospital, The University of Adelaide,
Adelaide, Australia
D. Tyler, M.D.
Chief, Division of Surgical Oncology, Department of Surgery, Duke University Medical
Center, Durham, NC, USA
Department of Surgery, Duke University Medical Center, Durham, NC, USA
L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia
N. Hansen, M.D.
Departments of Surgical Oncology and General Surgery, Northwestern Memorial Hospital,
Chicago, IL, USA
H. Mabry, M.D.
Breast Cancer Surgeon, Center for Breast Care, The University of Toledo Medical Center,
Toledo, OH, USA
other mass. One of the main indications for surgical open biopsy is the staging of
lymphoma, or determination of the disease process, especially where an equivocal
finding is present.
For larger lymph nodes and masses that are presumed to be lymph nodes, the
degree of difficulty with surgical dissection can sometimes be higher than for
smaller more normal-appearing lymph nodes. The amount of fixity or adherence of
enlarged nodes can vary considerably with the underlying pathological process,
and this fact together with the location can alter the risk of associated complica-
tions, including bleeding, hematoma formation, lymphocele, fistula, and nerve
injury.
Selective Lymph Node Tracing, Mapping,

and Dissection (Biopsy)
The advent of selective (sentinel) lymph node tracing and dissection (biopsy) has
also introduced another dimension into the biopsy of lymph nodes and the detection
of metastases to lymph nodes, including microscopic deposits of malignant cells. In
general, sentinel nodes are smaller and usually impalpable as compared with the
larger palpable lymph nodes that were the main indication(s) for open lymph node
biopsy in the pre-sentinel node era. This means that the relative risks and complica-
tions are slightly different, and the type of complication can be significantly differ-
ent also. For example, the smaller nature of the sentinel node compared to the larger
palpable node makes blood vessels and nerves usually more definable and less at
5 Lymphatic Surgery 117
risk of injury, and bleeding more easily controllable, in most cases. Necrosis of the
lymph node is uncommon with sentinel nodes, and rupture with spillage of contents
is less of a risk for sentinel nodes. Infection risk may also be at the lower end of the
spectrum. However, unique problems due to the use of radioactive substances,
namely, radiation exposure and potential risk to a pregnancy in females, and blue
dye allergies, including anaphylaxis, and blue dye staining or even permanent tat-
tooing, may occur.
The aim of this chapter is to detail some of the relative risks of lymph node
biopsy, including for sentinel node tracing and biopsy, using combined preopera-
tive lymphoscintigraphy and intraoperative blue dye techniques. Many of the
procedures have been taken together, since the risk profile is very similar, with
the addition of the risks unique to SNB. These risks represent a spectrum,
attempting to cover the range of relative risk of complications associated with the
particular procedures discussed. Sentinel node tracing and biopsy is initially
described in general terms to detail some of the generic risks associated with
these techniques.
With these factors and facts in mind, the information given in these chapters
must be appropriately and discernibly interpreted and used.
success of complex lymphatic surgery overall and can significantly reduce risk of
complications or aid early detection, prompt intervention, and cost.
Important Note
such are often representative of a number of studies, which include different
patients with differing comorbidities and different surgeons. In addition, the
risks of complications in lower- or higher-risk patients may lie outside these
estimated ranges, and individual clinical judgement is required as to the
expected risks communicated to the patient, to staff, or for other purposes.
For procedures often associated with lymph node dissections, such as cutaneous
(Chap. 3 of Volume 2), neck (Chap. 7 of Volume 2), breast (Chap. 2), or thyroid
(Chap. 4), refer to the relevant chapter and volume.
Selective (Sentinel) Lymph Node Biopsy (General: All Sites)
Description
General anesthesia is usual, but sometimes local anesthesia and IV sedation are
used. The aim is to selectively biopsy the first draining lymph node in the lymphatic
pathway draining the cancer, the sentinel node (SN), usually following lymphatic
mapping by nuclear medicine lymphoscintigraphy to locate and mark the SN.
Intraoperative lymphatic mapping and sentinel (selective) lymph node (SLN) biopsy
is most commonly utilized in melanoma and breast cancer as a staging procedure
for evaluation of regional lymph nodes. The techniques are slightly different for
melanoma versus breast cancer and for different lymphatic basins (see site-specific
descriptions). Both radioactive sulfacolloids (usually with lymphoscintigraphy) and
blue (1 % lymphazurin/Patent Blue V) dye are generally injected close to the pri-
mary tumor site preoperatively for improved localization of the sentinel lymph
node, including in-transit nodes. A skin incision is made, and blue lymphatic chan-
nels are identified, leading to the typically radioactive and blue sentinel lymph node.
The SN is dissected. Clipping small lymphatic channels can help minimize the risk
of a seroma. To define an SLN and how many SLNs should be removed, McMasters
et al. have proposed a relatively user-friendly definition of an SLN after evaluating
over 1300 SLN biopsies as part of the Sunbelt Melanoma Trial, where pathology,
node color, and node counts were all carefully examined. By defining an SLN as
any blue node or any node with > 10 % of the counts of the hottest node, a false-
negative rate of 0.4 % was obtained. The appeal of this type of definition is that
since the hottest node is frequently the first lymph node removed, surgeons can
quickly get an idea as to what level the counts in a basin need to drop to before
terminating the procedure. The group from MD Anderson went a step further and
found that in a large group of SLN biopsies (>750), that removal of more than two
SLNs did not provide information that upstaged any patient with primary mela-
noma. In addition, removal of additional non-blue, “SLNs” that contained radioac-
tive counts of at least twice background basin level, but lower than two thirds of the
maximal SLN radiotracer uptake, affected patient management in less than 0.2 % of
all cases.
Anatomical Points
The major variation with intraoperative lymphatic mapping and SLN biopsy is
that the SLN especially in melanoma is not always in a defined nodal basin.
These nodes can be located in in-transit locations. The location of the SN can
determine specific anatomical risks, for example, an intra-parotid SN close to
the facial nerve, or axillary SN close to the intercostobrachial nerve, or axillary
vein.
Table 5.1 Selective (sentinel) lymph node biopsy (general) estimated frequency of complications,
risks, and consequences
Infectiona 1–5 %
Bleeding/hematoma formationa 1–5 %
Neural injury (cervical, axillary, epitrochlear, inguinal, popliteal, or in-transit lymph node
biopsy)a
Paresthesia (e.g., cutaneous nerve) 1–5 %
Motor 0.1–1 %
Lymphocele, lymphatic leak/fistula, seroma formationa 1–5 %
Vascular injury 1–5 %
Incomplete/inaccurate biopsy (or insufficient tissue for diagnosis)a 1–5 %
Dehiscence (wound breakdown)a 0.1–1 %
Leg/arm/facial edemaa 0.1–1 %
Flap or graft necrosis (when used)a 0.1–1 %
Skin ulceration (rare) <0.1 %
Allergic reaction to blue dye <0.1 %
Risk from radiation exposureb <0.1 %
Risk to (undetected) pregnancyb <0.1 %
Multisystem organ failurea <0.1 %
Deatha <0.1 %
Pain/tenderness [wound pain]
Blue staining of skin (permanent) <0.1 %
Blue discoloration of urine (transitory) >80 %
Wound scarring/dimpling/deformity of the skina 1–5 %
Wound drain tube(s)c 0.1–1 %
a
Dependent on pathology, anatomy, comorbidities, surgery type, and surgeon preference
b
Although individual, risk of radiation appears low
c
Many surgeons do not drain SN dissections at all; occasional use only
Perspective
See Table 5.1. Although a relatively small procedure, several bothersome complica-
tions of intraoperative lymphatic mapping and sentinel lymph node biopsy can
occur, most notably seromas and paresthesia related to nerve injury. In an attempt to
minimize these complications, a safe dissection in the nodal basin should be per-
formed. Small vessels should be clipped/tied. Sensory nerves should be ideally
identified to avoid injury. Infection, and hematoma formation, is usually low grade,
but may be severe. It should be noted that wide local excision of the primary tumor
is usually performed with SNB and complications of both should be considered and
may interrelate, for example, with infection or nerve injury. Discomfort may be
considerable on occasions, and the patient should be warned to avoid heavy activi-
ties for 1–2 weeks to reduce risk of infection, bleeding, and other wound complica-
tions. SN biopsy has less morbidity compared with complete lymph node dissection
(CLND). Incidences of complications are wound separation (0.2–1.2 %), lymph-
edema (0.6–0.7 %), seroma/hematoma (2.3–5.5 %), and surgical site infection
(1.1–4.6 %).
Major Complications
One of the most serious complications of sentinel node biopsy is a false-negative

sentinel node, which may affect both treatment and prognosis for the patient. The
false-negative rate has been found to decrease with surgeon and pathologist experi-
ence. A potentially serious complication of lymphatic mapping is the very rare ana-
phylactic reaction to the dye injection. Blue dye staining can be unsightly on the
face, head, neck, or forearms/hand, but is rarely permanent. Knowledge of this com-
plication can help recognize it in its early stage, so it can be treated promptly with
circulatory support and adrenaline. Infection and bleeding can be serious and may
lead to wound dehiscence and rarely to severe systemic sepsis and multisystem
organ failure, which exceedingly rarely may cause death. Nerve injury to sensory
or motor nerves causing numbness or weakness can be persistent, and sometimes
severe, for example, with facial nerve palsy. A small percentage of people also
develop lymphedema, which is rarely severe. However, the incidence is signifi-
cantly lower as compared to formal nodal dissection.

• Discomfort
• Reduced activity
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Allergic reactions
• Blue staining
• Radiation risk
• Risk to pregnancy
• Further surgery
Cervical Lymph Node Biopsy (Anterior Triangle)

(Including Sentinel Node Biopsy)
Description
General anesthesia is usually used, but local anesthesia and IV sedation can be
used. The aim is to remove a node (or part of a node, if it is large, matted, fixed,
or inflamed), usually for diagnostic purposes only, without damaging surround-
ing structures. If sentinel node tracing and biopsy is performed, then the aim is
to selectively biopsy the first draining radioactive and blue node in the lym-
phatic pathway draining the tumor. The node may appear very superficial, but is
always deep to platysma and usually deeper than first anticipated. Careful liga-
tion of afferent and efferent lymphatics to obtain complete hemostasis may
obviate the need for wound drainage. An incision of appropriate size should be
used, oriented in the line of natural skin creases to minimize the risk of unsightly
scarring.
Anatomical Points
In the upper neck, particular care must be taken to avoid damage to the marginal
mandibular branch of the facial (VII) nerve, which is variable in position. This is
best done by placing the skin incision >2 cm below the lower border of the mandi-
ble. For deeply placed nodes in the jugular chain, care must be taken not to damage
adjacent large vessels and the vagus, hypoglossal, lingual, and phrenic nerves
(depending on location).
Perspective
See Table 5.2. This procedure can be particularly difficult if the node is inflamed
or deeper than anticipated, especially if local anesthesia is being used. Bleeding
from deep in a small wound can be troublesome, but vision can be improved
using suction or by packing with gauze for 5–10 min. Venous ooze after surgery
is the main cause of delayed bleeding, hematoma formation, respiratory com-
promise, and return to theater for drainage. Lymphatic collection after lymph
node removal can occur and may be reduced by ligation of lymphatic channels
during surgery. Nerve injury is rare if appropriate care is taken. Discomfort may
be considerable on occasions, and the patient should be warned to avoid heavy
activities for 1–2 weeks to reduce risk of infection, bleeding, and other wound
complications.
Table 5.2 Cervical lymph node biopsy (anterior triangle) (including sentinel node biopsy)
Infectiona 0.1–1 %
Bleeding/hematoma formationa 0.1–1 %
Neural injury (high cervical biopsy)a 1–5 %
Paresthesia (e.g., cervical plexus) 1–5 %
Motor (e.g., VII facial nerve injury) 0.1–1 %
Incomplete/inaccurate biopsya 1–5 %
Dehiscence [wound breakdown]a 0.1–1 %
Vascular injurya 0.1–1 %
Allergic reaction to blue dyeb <0.1 %
Blue staining of skin (permanent)b <0.1 %
Blue discoloration of urine (transitory)b >80 %
Wound drain tube(s)a 0.1–1 %
a
b
Complications and risks when sentinel node tracing and biopsy are used
Major Complications
Nerve injury is uncommon, but can include facial nerve or accessory nerve dam-
age. Acute hemorrhage into the neck wound rarely requires re-operation with
return to theater, especially when associated with severe respiratory distress from
neck swelling, which are serious and potentially distressing complications.
Lymphocele is rarely severe, but can require aspiration drainage. Infection can
rarely be severe and lead to systemic sepsis; especially at risk are immunocompro-
mised patients. If sentinel node biopsy is performed, then the risks associated with
this need to be included. These include anaphylaxis and allergic reactions,
radiation risk, and in females, risk to a pregnancy. Blue dye staining can be
unsightly on the face, head, or neck, but is rarely permanent.

• Discomfort
• Bleeding
• Infection
• Lymphocele
• Nerve injury
• Blue staining
• Radiation risk
• Further surgery
Scalene Node Biopsy (Including Sentinel Node Biopsy)
Description
General anesthesia is preferred. Although local anesthesia can be used, the opera-
tion becomes considerably more difficult, and the risk of complications is signifi-
cantly increased due to suboptimal operating conditions (resulting from
inadequate exposure, patient discomfort and movement, etc.). The aim is to
remove the scalene node for diagnostic purposes. This is best accomplished via a
horizontal incision above and parallel to the medial end of the clavicle. If sentinel
node tracing and biopsy is performed, then the aim is to selectively biopsy the
first draining radioactive and blue node in the lymphatic pathway draining the
tumor.
Anatomical Points
The true scalene node is quite constant in position, deeply placed behind the medial
end of the clavicle. Particular care must be taken to avoid damage to major vessels
and to avoid damage to the thoracic duct as it enters the junction of the internal jugu-
lar and subclavian veins. The phrenic nerve lies behind the scalene node on the
surface of the scalenus anterior muscle covered by fascia, being the only nerve tra-
versing lateral to medial in the neck.
Perspective
See Table 5.3. This procedure can be challenging if the scalene node is adherent to
surrounding tissues. Bleeding from deep in a small wound can be troublesome, but
vision can be improved using suction or by packing with gauze for 5–10 min. Venous
Table 5.3 Scalene node biopsy (including sentinel node biopsy) estimated frequency of
complications, risks, and consequences
Neural injury (low cervical biopsy)a 1–5 %
Paresthesia (e.g., cervical plexus, medial supraclavicular nerve) 1–5 %
Motor (e.g., phrenic nerve, vagus or sympathetic chain) 0.1–1 %
Lymphatic leak/chyle fistulaa 1–5 %
Lymphocele/seroma formationa 1–5 %
a
b
ooze after surgery is the main cause of delayed bleeding, hematoma formation, respi-
ratory compromise, and return to theater for drainage. Lymphatic collection after
lymph node removal can occur and may be reduced by ligation of lymphatic channels
during surgery. Nerve injury is rare if appropriate care is taken. Discomfort may be
considerable on occasions, and the patient should be warned to avoid heavy activities
for 1–2 weeks to reduce risk of infection, bleeding, and other wound complications.
Major Complications
These are rare, but injury to the phrenic nerve can be catastrophic causing dia-
phragmatic hemi-paralysis and acute respiratory difficulty. An acute hemorrhage
into the neck wound requiring reoperation with return to theater is also sometimes
associated with severe respiratory distress from neck swelling, all potentially seri-
ous and distressing complications. Lymphocele, seroma, hematoma formation,
and lymphatic leakage are all relatively problematic complications. Infection can
rarely be severe and lead to systemic sepsis; especially at risk are immunocompro-
mised patients. If sentinel node biopsy is performed, then the risks associated with
this need to be included. These include anaphylaxis and allergic reactions, radia-
tion risk, and in females, risk to a pregnancy. Blue dye staining can be unsightly
on the face, head, or neck, but is rarely permanent.

• Discomfort
• Bleeding
• Infection
• Lymphocele
• Nerve injury
• Blue staining
• Radiation risk
• Further surgery
Cervical Lymph Node Biopsy (Posterior Triangle)

Description
General anesthesia is usually used, but local anesthesia and IV sedation can be used.
The aim is to remove a node (or part of a node, if it is large, matted, fixed, or
inflamed), usually for diagnostic purposes only, without damaging surrounding
structures. If sentinel node tracing and biopsy is performed, then the aim is to selec-
tively biopsy the first draining radioactive and blue node in the lymphatic pathway
draining the tumor. The node may appear very superficial, but is always deep to
platysma and usually deeper than first anticipated. Careful ligation of afferent and
efferent lymphatics to obtain complete hemostasis may obviate the need for wound
drainage. An incision of appropriate size should be used, oriented in the line of
natural skin creases to minimize the risk of unsightly scarring. The accessory nerve
lies very superficially in the posterior triangle. Sometimes a pathological node is
located in the mid- or upper jugular chain, and to obtain access to it, the posterior
border of the sternomastoid muscle must be retracted forward. Such nodes are often
intimately related to the internal jugular vein, which should be identified and pre-
served. Bleeding may obscure vision and it is important to ensure satisfactory
hemostasis, to minimize the risk of damaging important structures such as the
accessory nerve, and also to minimize the risk of hematoma formation. The external
jugular vein is at particular risk in the lower neck and may require formal ligation
and division. The deep fascia is closed and the skin separately sutured.
Anatomical Points
The node to be biopsied may be closely related to the accessory (XI) nerve, so par-
ticular care must be taken to avoid damage to this structure, which is quite superfi-
cially located in the posterior triangle. This travels fairly constantly from the
junction of the upper 1/3 and lower 2/3 of the posterior border of sternomastoid
muscle to the junction of the upper 2/3 and lower 1/3 of the anterior border of trape-
zius muscle. In the upper neck, the great auricular nerve should be identified and
preserved as it emerges from the midpoint of the posterior border of the sternomas-
toid muscle and passes upwards over that muscle towards the ear lobe. Both the
accessory and great auricular nerves can vary in their courses.
Perspective
See Table 5.4. This procedure can be challenging if the lymph node is adherent to
surrounding tissues. Bleeding from deep in a small wound can be troublesome, but
vision can be improved using suction or by packing with gauze for 5–10 min. Nerve
injury is uncommon if appropriate care is taken. Venous ooze after surgery is the
main cause of delayed bleeding, hematoma formation, respiratory compromise, and
return to theater for drainage. Lymphatic collection after lymph node removal can
occur and may be reduced by ligation of lymphatic channels during surgery. Nerve
injury is rare if appropriate care is taken. Discomfort may be considerable on occa-
sions, and the patient should be warned to avoid heavy activities for 1–2 weeks to
reduce risk of infection, bleeding, and other wound complications.
Major Complications
Injury to the accessory XI nerve can be debilitating causing trapezius muscle

paralysis and drooping of the ipsilateral shoulder. Because the accessory nerve lies
relatively superficially in the shallow posterior triangle, it is potentially one of the
most easily injured nerves. An acute hemorrhage into the neck wound requiring
reoperation with return to theater is less commonly associated with respiratory
Table 5.4 Cervical lymph node biopsy (posterior triangle) (including sentinel node biopsy)
Infectiona 1–5 %
Bleeding/hematoma formationb 1–5 %
Neural injurya (overall) 1–5 %
Paresthesia (e.g., cervical plexus) 1–5 %
Motor (e.g., XI, accessory nerve injury) 0.1–1 %
Lymphatic leak/chyle fistulaa (for low medial neck biopsies) 0.1–1 %
Vascular injurya 1–5 %
Wound drain tube(s) 0.1–1 %
a
b
distress from neck swelling than anterior cervical biopsies. Lymphocele, seroma,
hematoma formation, and lymphatic leakage are all relatively problematic com-
plications. Infection can rarely be severe and lead to systemic sepsis; especially at
risk are immunocompromised patients. If sentinel node biopsy is performed, then
the risks associated with this need to be included. These include anaphylaxis and
allergic reactions, radiation risk, and in females, risk to a pregnancy. Blue dye
staining can be unsightly on the face, head, or neck, but is rarely permanent.

• Discomfort
• Bleeding
• Infection
• Lymphocele
• Nerve injury
• Blue staining
• Radiation risk
• Further surgery
Axillary Lymph Node Biopsy
Description
General anesthesia is highly preferable for any axillary lymph node biopsy proce-
dure, although in very thin or severely debilitated patients, local anesthesia can be
employed. The aim is to remove a palpable lymph node (or part of a node, if it is
large, matted, fixed, or inflamed) or perform sentinel node tracing and biopsy (SNB
– see later) for non-palpable nodes usually for diagnostic purposes, without damag-
ing surrounding structures. The main indications for SNB are melanoma and breast
cancer. SNB for breast cancer management is specifically described separately next
in this chapter. Care must be taken not to crush or damage the lymph node. Other
palpable lymph normal-appearing nodes are usually not removed when doing a
purely diagnostic procedure. A fine-needle aspiration biopsy may assist in prior diag-
nosis. Consideration may be given to a preferable larger procedure in certain malig-
nancies (e.g., melanoma). The node may appear very superficial but is usually deeper
than first anticipated. An incision of appropriate size should be used, placed trans-
versely or obliquely to facilitate subsequent axillary dissection if required. The
lymph node can be defined and lifted into the wound using forceps placed under-
neath (or Allis or Babcock clamps), before ligation and division of the lymphovascu-
lar supply, reducing bleeding, lymphocele, and seroma formation, and may obviate
the need for wound drainage. Hemostasis is achieved, interrupted absorbable sutures
are used to close the deep layers, and a subcuticular skin suture is placed.
Anatomical Points
Abnormal lymph nodes can occur anywhere in the axilla. Those most readily pal-
pable are usually in level I. Sebaceous (epidermoid) and sweat gland cysts are
attached to skin and more superficial, although some lymph nodes can appear
Table 5.5 Axillary lymph node biopsy (including sentinel node biopsy) estimated frequency of
Infectiona 1–5 %
Neural injury (axillary biopsy)a
Paresthesia (e.g., intercostobrachial nerve, brachial plexus, 1–5 %
lateral cutaneous nerve of arm and forearm)
Motor (e.g., brachial plexus, nerve to latissimus dorsi muscle, 0.1–1 %
nerve to serratus anterior muscle)
Vascular injurya 1–5 %
Arm edemaa <0.1 %
Wound scarring/dimpling/deformity of the skin 1–5 %
a
surprisingly superficial. The intercostobrachial nerve(s) can vary in location,

branching, and number, while deeper in the axilla, the nerves to serratus anterior
and latissimus dorsi and the relevant vessels are more anatomically constant. The
lateral cutaneous nerves of the arm and forearm, and rarely the main brachial plexus
cords, may lie below the axillary vein where they are at risk of injury. “Islands” of
breast tissue isolated from the axillary tail can occur and may produce a mass, espe-
cially in the pregnant or lactating female. These can mimic a lymph node mass and
might be discernable on preoperative needle biopsy. Sentinel node tracing may
identify a lymph node in level I, II, or rarely level III of the axilla and/or occasion-
ally show drainage to an internal mammary lymph node.
Perspective
See Table 5.5. Complications are not very common after axillary node biopsy.
However, rare cases of significant lymphedema are reported, well recognized, and
mostly unpredictable. Nerve injury (especially the intercostobrachial nerve), lym-
phoceles, and seroma formation can be inconvenient, but may be a significant prob-
lem in some cases. Hematoma formation and infection are relatively rare, but can
cause disability, dressings, delayed return to activity, and rarely surgical drainage.
Scarring after biopsy may increase risks for subsequent surgery. Discomfort may be
considerable on occasions, and the patient should be warned to avoid heavy activi-
ties for 1–2 weeks to reduce risk of infection, bleeding, and other wound complica-
tions. If sentinel node tracing and biopsy is performed, the risks and complications
of this need to be considered, including blue dye staining and allergic reactions,
radiation risk, and in females, risk to a pregnancy.
Major Complications
Disrupted lymphatic channels can lead to seroma. Small seromas resolve on their
own; larger ones can be aspirated, sometimes repeatedly. Large or recurrent sero-
mas may be managed with drain placement. The major complication of axillary
lymph node biopsy is nerve injury, including to the intercostobrachial nerve caus-
ing bothersome paresthesias of the posterior upper inner arm, but no motor deficits.
If left intact, burning pain as it recovers function is often particularly distressing for
the patient. The risk of infection after lymph node biopsy is low, but may dictate
treatment with oral or IV antibiotics. The risk of infection increases with hema-
toma or seroma. An axillary incision is often uncomfortable, but chronic pain is
rare. Occasionally, skin flap necrosis can be due to thin flaps or diathermy applied
too closely. There is rarely dimpling or cosmetic deformity of the skin in the
axilla, since very little subcutaneous tissue is removed. Lymphedema may rarely
occur even after a small lymph node biopsy if major lymphatic channels are inter-
rupted. If sentinel node biopsy is performed, then the risks associated with this need
to be included. These include anaphylaxis and allergic reactions, radiation risk,
and in females, risk to a pregnancy. Blue dye staining can be unsightly on the
lower neck, trunk, arm, or hand, but is rarely permanent.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Blue staining
• Radiation risk
• Further surgery
Axillary Sentinel (Selective) Lymph Node Biopsy: Breast

Cancer
Description
General anesthesia and sometimes local anesthesia and IV sedation are used. The aim
is to selectively biopsy the first draining lymph node in the lymphatic pathway from a
breast cancer, the sentinel node (SN), usually following lymphatic mapping by nuclear
medicine lymphoscintigraphy. In 1991, the SN procedure was adapted and described
by Giuliano et al. for invasive breast cancer. The benefit is to determine and select
sentinel node-positive patients with metastases for completion axillary lymph node
dissection, sparing SN-negative patients further dissection and morbidity. Sentinel
nodes can be identified using vital blue dye, technetium-labeled radiocolloid, or both.
The success of the procedure depends on close coordination between surgeon, nuclear
physician, and pathologist. The breast can be injected peritumorally, subdermally,
intradermally, or subareolarly. All of these locations probably identify the same senti-
nel node or nodes. The breast is then massaged for 5 min. The gamma probe can also
be used to guide dissection and locate a hot lymph node. All blue and/or hot nodes
should be removed as well as any nodes that are clinically suspicious based on their
size and firmness. Upon removal of all blue, hot, and suspicious nodes, the back-
ground radioactive count within the axilla should be <10 % of the sentinel node count.
The procedure requires an experienced surgeon and team for accuracy. Pathological
assessment is then performed. Hemostasis is attained, a drain is rarely required, and
the wound is closed with absorbable deep interrupted and skin subcuticular sutures.
Anatomical Points
The location of the sentinel node is quite variable. It is often located at the lateral edge
of the pectoralis major muscle. Intramammary SNs, typically located in the lateral
breast parenchyma, are not uncommon. Occasionally, sentinel nodes will be identified
in the internal mammary chain. Many surgeons do not recommend removal of these
nodes unless the presence of internal mammary metastases will alter systemic treat-
ment. If these criteria are met, then the information obtained from the internal mam-
mary node might alter the patient’s prognosis and treatment. These nodes should be
removed with care not to violate the pleura and cause a pneumothorax.
Perspective
See Table 5.6. Serious complications are uncommon. A major complication of SNB
is failure to accurately identify/remove the sentinel node, which can lead to under-
staging and possible undertreatment. The reported false-negative rate for SNB is
Table 5.6 Axillary selective (sentinel) lymph node biopsy estimated frequency of complications,
Infectiona 1–5 %
Neural injury (axillary biopsy)a
Paresthesia (e.g., intercostobrachial nerve, brachial plexus, lateral 1–5 %
cutaneous nerve of arm and forearm)
Motor (e.g., brachial plexus, nerve to latissimus dorsi muscle, 0.1–1 %
nerve to serratus anterior muscle)
Vascular injury 1–5 %
Incomplete/inaccurate biopsy (or insufficient tissue for diagnosis)a 1–5 %
Arm edemaa 0.1–1 %
Flap or graft necrosisa 0.1–1 %
Skin ulceration (rare) <0.1 %
Blue staining of skin (permanent) <0.1 %
Allergic reaction to blue dye <0.1 %
Blue discoloration of urine (transitory) >80 %
a
b
Although individual, risk of radiation appears low
0–35 % but in experienced hands is <5 %. Allergic reactions to blue dye can range
from blue urticaria to severe life-threatening anaphylaxis. ACOSOG reported an
incidence of severe reaction to be blue dye of 0.1 %. The risk of blue dye during
pregnancy is unknown. Performing a sentinel node biopsy with blue dye on a preg-
nant patient is not recommended. Several studies indicate that the level of radiation
associated with radiocolloid is low enough to be safe for use during pregnancy.
Seroma formation may occur after SNB. It is usually treated with observation or
percutaneous aspiration. It is rarely necessary to place a drain for persistent seroma
after SNB. The risk of radiation exposure due to the technetium sulfur colloid is
extremely low. The blue dye may discolor the skin grey temporarily. Such discolor-
ation may last up to 6 months. Injecting the dye into the breast parenchyma instead
of the skin will reduce the risk of tattooing. The patient’s urine will be blue/green
for the first day or two after surgery. Lymphedema after sentinel node biopsy is less
common than after axillary node dissection. It has been reported to occur in 3 % of
patients. The axillary incision from a sentinel node biopsy may be acutely painful,
but chronic pain is rare. Cosmetic axillary skin dimpling or deformity is not com-
mon. Infection after SNB is rare and can be treated with antibiotics. Hematoma may
rarely occur and the risk of infection increases with hematoma formation. Injury to
the intercostobrachial nerve can occur, causing paresthesia of the posterior upper
inner arm. Discomfort may be considerable on occasions, and the patient should be
warned to avoid heavy activities for 1–2 weeks to reduce risk of infection, bleeding,
and other wound complications.
Major Complications
One of the most serious complications of sentinel node biopsy is a false-negative

sentinel node, which may affect both treatment and prognosis for the patient. The
false-negative rate has been found to decrease with surgeon and pathologist experi-
ence. Failure to identify the SN is an indication for level I/II axillary clearance.
Anaphylaxis to the blue dye can be life-threatening. Lymphedema after SNB is
less common than after axillary node dissection, occurring in about 3 % of patients,
and can rarely be severe. Blue dye tattooing can rarely be permanent. Large hema-
toma infection and abscess formation are relatively rare and may require further
surgery. Seroma formation is rarely a major problem. Permanent paresthesia can
occur from nerve injury. Chronic pain is rare and unpredictable. Occasionally,
dense axillary scarring may increase risks of subsequent axillary dissection.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Blue staining
• Radiation risk
• Further surgery
Inguinal Lymph Node Biopsy (Including Sentinel

Node Biopsy)
Description
General anesthesia is preferable, but inguinal lymph node biopsy can be performed
using local anesthesia, if necessary. The aim is to remove the lymph node(s) with
minimal disturbance of adjacent structures, for diagnosis. Lymphoma staging and
failure of diagnosis on needle or core biopsy are the usual reasons for inguinal
biopsy. Placement of the incision should be such that excision of the scar can be
easily performed if a subsequent radical lymph node dissection of the groin becomes
necessary. Overlying tissues should be gently and carefully separated rather than
divided using scissors, artery forceps, scalpel, or diathermy. Once identified, the
node can be partially lifted into the wound using partly opened artery forceps placed
behind it. Lymphatics entering and leaving the node at either end can then be secured
with other artery forceps and ligated and divided. If the node is not large, and if care
is taken to ligate afferent and efferent lymphatics and to obtain complete hemosta-
sis, wound drainage is rarely required. The deeper tissues are closed with absorb-
able sutures and a continuous skin suture used.
Anatomical Points
The main anatomical variable with inguinal region is found with the venous anat-
omy. The presence of numerous tributaries and varicosities can make the risk of
bleeding and operative difficulty greater. The location of the lymph node, notably its
depth from the skin, and the type of disease process can also dictate the mobility of
the node and ease of dissection. The arterial anatomy is more constant and easier to
predict. Care should be taken to identify larger lymphatics close to the vessels and
preserve these where possible, unless removal is required with the lymph node.
Lymphatics are more easily identified when blue dye is used during sentinel node
tracing. Nerves are rarely seen or are a problem, but small twigs of the femoral
nerve can be identified on occasions, and these may cause troublesome numbness of
the thigh if injured.
Perspective
See Table 5.7. As with axillary node biopsy, lymphoceles can develop and prove
troublesome, but these are more common than with any other region. Areas of sen-
sory loss and very rarely motor problems can result from inadvertent nerve damage.
Lymphedema is rare, but is more likely if multiple nodes are removed, when the
Table 5.7 Inguinal lymph node biopsy (including sentinel node biopsy) estimated frequency of
Infectiona 5–20 %
Neural injurya
Paresthesia (e.g., femoral nerve branch, lateral cutaneous nerve of 1–5 %
thigh)
Motor (e.g., femoral nerve branch) 0.1–1 %
Dehiscence [wound breakdown]a 1–5 %
Leg edemaa 0.1–1 %
Systemic sepsisa <0.1 %
a
main lymphatic channel(s) is ligated during removal of the lymph node, and if the
patient is obese. Infection is more common with inguinal and perineal incisions due
to higher fecal microorganism skin colonization. Risk of wound dehiscence is there-
fore more common also, following infection. If sentinel node tracing is performed
in association with lymph node biopsy, then the risks associated with radiation
exposure and blue dye use also apply. When wider local excision of skin for mela-
noma is performed, these complications and risks need to be included. Discomfort
may be considerable on occasions, and the patient should be warned to avoid heavy
activities for 1–2 weeks to reduce risk of infection, bleeding, and other wound
complications.
Major Complications
Complications are generally few and minor should they occur. However, lympho-
cele and hematoma formation are more common in the inguinal region than else-
where, as is wound infection which can lead to wound dehiscence and lymphatic
leak which can cause significantly delayed recovery and return to work/function,
often requiring dressings. Severe cellulitis may occur, but systemic sepsis is
extremely rare. Neural injury is rarely severe, but can cause significant symptoms
on occasions. Leg edema is rare, but significant lymphedema can occur and on
occasions may be severe; however, these cases are mostly unpredictable. The com-
plications of sentinel node tracing and biopsy need to be included when this is
performed, including blue dye allergic reactions and staining, radiation risks, and
potential risk to a pregnancy.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Blue staining
• Radiation risk
• Further surgery
Pelvic and Retroperitoneal Lymph Node Biopsy

Description
General anesthesia with muscle relaxation is highly desirable. The aim is to selec-
tively dissect a retroperitoneal lymph node via a muscle cutting or splitting incision,
by performing a minilaparotomy, and reflecting the peritoneum away from the
lymph node(s) and iliac vessels. An oblique or vertical incision is made at an appro-
priate site in the low iliac fossa, and the retroperitoneum is exposed, by splitting the
abdominal muscle layers, inserting retractors to enlarge the opening, then retracting
the peritoneum and its contents upwards and medially. The spermatic cord is
avoided in the male. In higher biopsies, the ureter should be retracted with the peri-
toneum, but for safety should always be identified. External iliac and obturator
nodes (including sentinel nodes) can be removed through a small incision low in the
iliac fossa. Common iliac and lower para-aortic nodes require a larger incision,
more superiorly placed. This can be performed as part of a sentinel lymph node trac-
ing and biopsy procedure.
Anatomical Points
The anatomy of the pelvic and retroperitoneal region is relatively constant. If the
incision is made low and too medially, the inferior epigastric vessels may be encoun-
tered and cause troublesome bleeding. Suture ligation may be needed to prevent or
control this. Access to obturator nodes may be impeded by accessory (abnormal)
obturator vessels; these may require formal ligation. Lymphatic tracing may show
channels travelling directly to iliac sentinel lymph nodes.
Perspective
See Table 5.8. Although some muscle discomfort from cutting the abdominal wall
is inevitably associated with these procedures, they are usually straightforward, and
complications are uncommon. Bleeding, hematoma formation, and infection are
potential serious complications, but are relatively rare. Risk of pelvic organ injury
is very low. Lymphatic fluid leaks and collections may arise and require needle
aspiration, but rarely cause clinical problems. Discomfort may be considerable on
occasions, and the patient should be warned to avoid heavy activities for 1–2 weeks
to reduce risk of infection, bleeding, and other wound complications. If sentinel
node tracing and biopsy is performed, then the risks of these procedures need to be
included.
Major Complications
Bleeding and hematoma formation can be serious particularly when a small inci-
sion with limited exposure is used. Enlargement of the incision may be required
for improved safety of access, if bleeding occurs. This may increase risk of compli-
cations, including abdominal wall nerve injury, infection, and subsequent inci-
sional hernia formation. Injury to the spermatic cord, while possible, is extremely
rare and may produce ischemia and testicular atrophy. Major motor or sensory
nerve injury is possible although very unlikely. If sentinel node tracing and biopsy
is performed, allergic reactions, blue staining, radiation risk, and in females, risk
to a pregnancy are potential problems.
Table 5.8 Pelvic and retroperitoneal lymph node biopsy (including sentinel node biopsy)
Infection (wound, cellulitis, abscess, intraperitoneal/systemic) 1–5 %
Bleeding/hematoma formationa 0.1–1 %
Leg edema swellinga
Major/debilitating <0.1 %
Moderate/minor 0.1–1 %
Seroma formation/lymphocele formation 5–20 %
Lymphatic fluid leak 1–5 %
Lymphatic sinus [longer term] 0.1–1 %
Vascular injury (iliac artery/vein)a 0.1–1 %
Spermatic cord/vas deferens injury (male) 0.1–1 %
Neural injurya
Sensory
Lateral cutaneous nerve thigh 0.1–1 %
Inguinal branch of ilioinguinal nerve 0.1–1 %
Motor
Femoral nerve <0.1 %
Paralytic ileus <0.1 %
Perineal edema (scrotal/penile/labial edema) <0.1 %
Abdominal wound incisional hernia (late) <0.1 %
Skin ulceration 0.1–1 %
Reduced mobility/difficulty weightbearing <0.1 %
Urinary retention (urinary catheter – males)a 0.1–1 %
Wound scarring (deformity/dimpling of wound scar/poor cosmesis) 5–20 %
Blood transfusion <0.1 %
a

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Blue staining
• Radiation risk
• Further surgery
Cervical Lymph Node Dissection
Overview: General Points
Both modified (functional) radical and radical neck dissections are two procedures
that are performed for control of malignancy to the head and neck region and are
performed by a variety of surgeons from different subspecialties (ENT, oral, maxil-
lofacial, plastic, and general) for different malignant conditions. The main indica-
tions for neck lymph node dissections are melanoma, SCC of the skin, SCC of the
throat, and other semi-advanced malignancies of the head and neck region, involv-
ing or potentially involving neck lymph nodes. Significant differences therefore
apply between the management of, for example, SCC of the throat, parotid, or skin
involving the lymph nodes of the neck. The mortality, for instance, is different
between malignancy of the larynx, tongue base, parotid, cutaneous melanoma, and
skin SCC, especially when it involves different age groups, different levels of
advancement of disease, and different comorbidities.
In ear, nose, and throat surgery, bilateral neck dissections and true radical neck
dissections are more common than with melanoma surgery where modified radical
neck dissections are almost always performed, unless disease is bulky and advanced.
Laryngectomy, tongue base surgery, or hemiglossectomy with division of the man-
dible are not uncommonly performed together with neck dissection in ENT proce-
dures, which adds increased risk of a range of complications not so frequently
experienced in unilateral neck dissection for skin cancers. The composite nature of
some ENT, oral, and other surgery makes it virtually impossible to separate the rela-
tive risk of complication(s) due to laryngectomy, for example, from that due to neck
dissection. The level of preoperative malnutrition and immunosuppression found in
those with a partially obstructing tongue malignancy is often significantly different
from that experienced by patients with neck malignancy alone. This, and factors
such as preoperative radiotherapy, can significantly predetermine a range of risks of
complication(s), such as infection, wound dehiscence, fistula formation, sepsis,
multisystem organ failure, the need for ICU care, and mortality, that differs appre-
ciably from neck dissection surgery in other patients.
Another caveat is that for some salvage or advanced ENT surgery involving neck
dissection, the extent of disease dictates more complex dissection and therefore
these procedures carry a higher relative risk of many complications. For example,
where neck dissection is combined with laryngectomy and free flap repair, the risk
of infection, flap necrosis, wound breakdown, and oro-cutaneous fistula is higher,
especially when irradiation is given either preoperatively or after surgery.
The estimated frequencies of complications below require some modification in
situations where other procedures are performed in addition to neck dissection, in
accordance with the condition of the patient and surgery being performed.
Nevertheless, the features that are similar in the descriptions of complications
associated with neck lymph node dissection surgery between the various subspe-
cialties and for the range of different malignancies treated are greater than those
features that are significantly different. Therefore, the characteristics of the compli-
cations associated with neck procedures in general have been considered collec-
tively, with the understanding that some procedures will have complication rates at
the high end of the frequency spectrum, while others will be at the lower end.
Cervical Lymphadenectomy: Functional (Modified Radical

Neck Dissection) Cervical Lymphadenectomy and Functional
Neck Dissection
Description
General anesthesia is used. The aim of the procedure is to remove lymph nodes
from the neck, which may involve either all of some of levels I to V, to achieve
removal of the lymph nodes in the appropriate levels of the neck, while preserving
“functional” aspects by retaining the internal jugular vein, sternomastoid muscle,
and accessory (XI) nerve. The exact type of procedure will depend on the pathol-
ogy; preoperative findings, including imaging; and the surgical approach that has
been decided upon. For throat, oral, parotid, or some skin malignancies, other pro-
cedures will be performed in conjunction with neck dissection, and the effects of
these procedures need to be considered in relation to the surgery and consequent
complications anticipated or experienced. Additionally, bilateral neck dissections
are frequently performed for oral and throat malignancies. Unilateral neck dissec-
tions are more common in relation to skin malignancies involving the neck lymph
nodes. The procedure can be performed using any one of a variety of incisions.
However, it is important to ensure that whatever incision is used, adequate exposure
is provided and flap ischemia is minimized. Flaps are raised in the sub-platysmal
plane. Superiorly, skin incisions should be placed well below the lower border of
the mandible, to minimize the risk of damage to the marginal mandibular branch of
the facial nerve. In the posterior triangle, it is important to identify and preserve the
accessory nerve, which is quite superficially located and therefore vulnerable to
damage. The aim is to achieve removal of the lymph nodes in the appropriate levels
of the neck, with preservation of the sternomastoid muscle, accessory nerve, and
internal jugular vein. Routine wound drainage is considered necessary by most sur-
geons. The skin is closed using absorbable interrupted subcutaneous sutures and a
subcuticular suture or staples.
Anatomical Points
Although relatively constant, the anatomy of the neck may vary with body shape
and size and with muscle development. Individuals with “short” and obese necks
present more difficulty. The presence of tumor or previous surgery (including senti-
nel node biopsy) may scar and distort the neck anatomy significantly. The cervical
plexus branches and those of the facial nerve are highly variable in their precise
location, and this may predispose to injury. A nonrecurrent laryngeal nerve on the
right side is not uncommon and may not be fully anticipated. In the lower neck on
the left side, care must be taken to avoid damage to the thoracic duct. The phrenic
nerve should be identified and preserved as it runs downwards deep to the fascia, on
scalenus anterior muscle. The omohyoid muscle usually excised. The internal jugu-
lar vein can be removed, if required, for better lymph node clearance. The great
auricular nerve is usually divided. The ansa hypoglossi, the vagus nerve, the carotid
artery, and the phrenic nerve should all be identified and preserved.
Perspective
See Table 5.9. The range and frequency of complications are intricately associated
with the underlying pathology and whether any additional surgical procedure is
performed together with the neck dissection, for example, parotidectomy or laryn-
gectomy. Comorbidities such as diabetes, with anticoagulation, cardiovascular dis-
ease, malnutrition, or immunosuppression and factors such as perioperative
radiotherapy are highly significant in determining the risk of many complications.
For neck dissection alone, despite the size of the wound and the major neurovascu-
lar structures that are exposed, serious complications are not common and postop-
erative recovery is usually prompt. Numerous minor complications are usual,
principally from sensory nerve injury. Some numbness of the neck is typical from
cervical plexus injury. Vagus, phrenic, hypoglossal, facial, and accessory nerve
injury are reported, but are fortunately not common. The risk of injury to the VII,
XII, and lingual (V1) nerves is related to the extent of dissection of the upper ante-
rior neck. The risk of XI nerve injury is primarily related to whether the posterior
and upper anterior neck are dissected, or not, and whether pathology directly
Table 5.9 Functional (modified radical neck dissection) cervical lymphadenectomy estimated
Seroma/lymphocele formationa, b 5–20 %
Lymphatic or chylous leak/fistula (thoracic duct/right lymphatic duct 1–5 %
injury)b
Neural injurya
Cervical plexus branches >80 %
Accessory (XI) nervea, c 1–5 %
Facial (VII) nerve (mandibular branch)d 1–5 %
Great auricular nervea >80 %
Hypoglossal (XII) nervea 0.1–1 %
Lingual (V) nervea (esp. if submandibular gland is incl.) 0.1–1 %
Vagus (X) nervea, b 0.1–1 %
Recurrent laryngeal nervea, b 0.1–1 %
Superior laryngeal nervea, b 0.1–1 %
Ansa cervicalis 20–50 %
Vascular injury (carotid artery, internal jugular vein)a, b 0.1–1 %
Flap necrosisa 0.1–1 %
Dehiscence [wound breakdown]a, b 0.1–1 %
Frozen shoulder [chronic immobility] 0.1–1 %
Oro-cutaneous fistulaa, b <0.1 %
Pneumothoraxa <0.1 %
Deatha, b 0.1–1 %
Neuroma 0.1–1 %
Soft tissue deformity of neck/shoulderb 20–50 %
Stiff neck/shoulder (acute, short term) >80 %
Reduced range of neck/shoulder movement (long term)a, b 5–20 %
Wound scarring/dimpling/deformity of the skina, b 5–20 %
Wound drain tube(s)a >80 %
a
b
Higher with some additional combined ENT procedures and preoperative radiotherapy
c
Especially for posterior or high anterior dissections
d
Especially with high cervical dissection
involves the nerve. Injury to the laryngeal nerves may be significant in non-
laryngectomy surgery. Some scarring and minor neck contour deformity is an inevi-
table consequence of the procedure, and permanent areas of skin anesthesia are also
to be expected (often including numbness of the ear due to sacrifice of the great
auricular nerve). However, the functional deficit is not as great as often predicted, if
appropriate physiotherapy is initiated early. Some permanent neck stiffness is usual,
especially after postoperative radiotherapy. Injury to the ansa, laryngeal, or hypo-
glossal nerves is rare in functional dissections, but may produce voice and speech
changes and possibly swallowing problems including dysphagia. Cervical plexus
paresthesias can produce difficulties with shaving or makeup application, and this is
often permanent, although some recovery usually occurs.
Major Complications
During high-neck or combined parotid dissection, facial nerve injury may leave
severe unilateral facial weakness, with drooling of saliva and even inability to close
the eye, which can be permanent, and may require surgical correction. Vagus,
phrenic, hypoglossal, facial, and accessory nerve injury causing hoarseness,
raised hemidiaphragm, tongue weakness and taste loss, and shoulder droop may be
serious, but are fortunately uncommon. Bleeding and hematoma formation rarely
may require reoperation. Neck stiffness may also be severe, especially after adju-
vant radiotherapy. Lymphatic leak or fistula from thoracic/right lymphatic duct
injury can be troublesome for many weeks after surgery and may require reopera-
tion for closure. Infection is rarely severe, but may be associated with major wound
dehiscence, as may flap necrosis, leading to prolonged dressings/hospitalization
and possibly further surgery. Voice changes due to injury to the laryngeal nerves
can occur. Pneumothorax and oro-cutaneous fistulae are very rare, but serious
complications. Numbness can be quite disturbing and may be permanent. Burning
pain is often distressing, but indicates nerve recovery is likely and usually settles
after 1–2 months. Cosmetic deformity is rare, but keloidal scarring can occur.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Flap necrosis
• Lymphocele/leak
• Nerve problems
• Further surgery
Radical Cervical Lymphadenectomy (Radical Neck

Dissection)
Description
General anesthesia is used. The aim of the procedure is to remove lymph nodes
from the neck, which may involve either all or some of levels I to V, to achieve en
bloc removal of the lymph nodes in the appropriate levels of the neck, together with
the sternomastoid muscle and internal jugular vein. The accessory nerve is usually
sacrificed deliberately as part of this procedure. The exact type of procedure will
depend on the pathology; preoperative findings, including imaging; and the surgical
approach that has been decided upon. For throat, oral, or some skin malignancies,
other procedures will be performed in conjunction with neck dissection, and the
effects of these procedures need to be considered in relation to the surgery and con-
sequent complications anticipated or experienced. Additionally, bilateral neck dis-
sections are frequently performed for oral and throat malignancies. One jugular vein
is retained. Unilateral neck dissections are more common in relation to skin malig-
nancies involving the neck lymph nodes. In the lower neck on the left side, care
must be taken to avoid damage to the thoracic duct and, on the right side, the right
lymphatic duct. Routine wound drainage is considered necessary by most surgeons.
The skin is closed using absorbable interrupted subcutaneous sutures and a subcu-
ticular suture or staples.
Anatomical Points
Although relatively constant, the anatomy of the neck may vary with body shape
and size and with muscle development. Individuals with “short” and obese necks
present more difficulty. The presence of tumor or previous surgery (including senti-
nel node biopsy) may distort the neck anatomy significantly. The cervical plexus
branches are excised during surgery and numbness is usual. A nonrecurrent laryngeal
nerve on the right side is not uncommon and may not be fully anticipated.
Perspective
See Table 5.10. The range and frequency of complications is intricately associated
with the underlying pathology and whether any additional surgical procedure is
performed together with the neck dissection. Comorbidities such as diabetes, with
Table 5.10 Radical cervical lymphadenectomy (radical neck dissection) estimated frequency of
Infectiona, b 1–5 %
Seroma/lymphocele formationa, b 5–20 %
Lymphatic/chylous leak/fistula (thoracic duct/right lymphatic duct 1–5 %
injury)b
Neural injurya
Cervical plexus branchesc Removed
Accessory (XI) nervec Removed
Facial (VII) nerve (mandibular branch)d 1–5 %
Great auricular nervea, c >80 %
Hypoglossal (XII) nervea, b 0.1–1 %
Lingual (V) nervea (esp. if submandibular gland is incl.) 0.1–1 %
Recurrent laryngeal nervea, b 0.1–1 %
Superior laryngeal nervea, b 0.1–1 %
Vagus (X) nervea, b 0.1–1 %
Ansa cervicalis 20–50 %
Shoulder droop (due to removal of accessory nerve)c >80 %
Neuroma(s) 1–5 %
Multisystem organ failurea, b 1–5 %
Deatha, b 1–5 %
Vascular injurya (carotid artery) 0.1–1 %
Flap necrosisa, b 0.1–1 %
Carotid rupturea, b 0.1–1 %
Frozen shoulder [chronic immobility]a 0.1–1 %
Dysphagia (direct or neural injury)a, b 0.1–1 %
Oro-cutaneous fistulaa, b <0.1 %
Pneumothoraxa <0.1 %
Soft tissue deformity of neck/neck contoura >80 %
Stiff neck/shoulder (acute, short term)a >80 %
Reduced range of neck/shoulder movement (long term)a, b 20–50 %
a
b
Higher with some additional combined ENT procedures
c
Especially in posterior neck dissection
d
Especially with high cervical dissection
anticoagulation, cardiovascular disease, malnutrition, or immunosuppression and

factors such as perioperative radiotherapy are highly significant in determining the
risk of many complications. The risks arising from radical neck dissection alone is
generally lower than for combined ENT procedures. Numerous minor complica-
tions are usual, principally from sensory nerve injury. Numbness of the neck is typi-
cal from cervical plexus excision. Vagus, phrenic, hypoglossal, facial, and nerve
injury are reported, but are fortunately not common. Injury to the laryngeal nerves
may be significant in non-laryngectomy surgery. Neck deformity resulting from this
procedure is considerable, and sacrifice of the accessory nerve results in atrophy of
the trapezius muscle and drooping of the shoulder. However, the functional deficit
is often not as great as often predicted, if appropriate physiotherapy is initiated
early. Some permanent neck stiffness is usual, especially after postoperative radio-
therapy. Due to the more radical nature, there is a higher risk of major complications
than with functional neck dissection. Injury to the ansa, laryngeal, or hypoglossal
nerves may produce voice and speech changes and possibly swallowing problems
including dysphagia. Cervical plexus paresthesias can produce difficulties with
shaving or makeup application, and this is often permanent, although some recovery
usually occurs.
Major Complications
During high-neck or combined parotid dissection, facial nerve injury may leave
severe unilateral facial weakness, with drooling of saliva and even inability to close
the eye, which can be permanent and require further corrective surgery. Vagus,
phrenic, hypoglossal, facial nerve injury causing hoarseness, raised hemidia-
phragm, tongue weakness, and taste loss may be serious, but are fortunately
uncommon. Shoulder droop is usual from accessory nerve sacrifice causing vari-
able deficit. Neck numbness is usually significant. Bleeding and hematoma for-
mation rarely may require reoperation. Late bleeding from catastrophic rupture of
the carotid artery due to erosion as part of dehiscence can occur. Neck stiffness
may also be severe, especially after adjuvant radiotherapy. Lymphatic leak or
fistula from thoracic/right lymphatic duct injury can be troublesome for many
weeks after surgery and may require reoperation for closure. Risk of this is
increased with low-neck dissection. Infection is rarely severe, but may be associ-
ated with major wound dehiscence, as may flap necrosis, leading to prolonged
dressings/hospitalization, and possibly further surgery. These complications are
overall higher after preoperative radiotherapy. Voice changes due to injury to the
laryngeal nerves can occur. Pneumothorax and oro-cutaneous fistulae are very
rare, but serious complications. Numbness can be quite disturbing and may be
permanent. Burning pain is often distressing, but indicates nerve recovery is likely
and usually settles after 1–2 months. Cosmetic deformity can be appreciable in
some cases.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Flap necrosis
• Lymphocele/leak
• Nerve problems
• Voice changes and dysphagia
• Wound deformity
• Further surgery
Axillary Lymphadenectomy
The axillary lymph nodes are anatomically divided into three anatomical levels.
Level I is bordered by latissimus dorsi (laterally), axillary vein (superiorly), and the
lateral edge of pectoralis minor muscle. Level II nodes are found deep to pectoralis
minor. Level III nodes are between the medial edge of pectoralis minor extending
medially to Halstead’s ligament.
For breast cancer, about 15 % of patients, there will be no metastasis in level I,
but there will be metastasis in level II. In 2–3 % of patients, both levels I and II will
be tumor-free, but metastases will be found in level III nodes. For patients with
invasive breast cancer and a clinically negative axilla, a sentinel node biopsy is the
procedure of choice. If the sentinel node is positive, then a level I and II axillary
dissection is currently indicated. Level III nodes are usually left intact unless they
appear to be involved intraoperatively.
For melanoma, some 20 % of patients with melanomas > 1 mm in Breslow thick-
ness draining to the axillary nodes will have metastases present. It is generally rare to
have level III nodes without level I or II nodal involvement. A formal level III axillary
dissection is usually performed for adequate staging and because of the lack of effec-
tive adjuvant therapies should level III lymph nodes be involved. Surgery remains the
most effective treatment for control of lymph node metastases within the axilla. Level
I and level II lymphadenectomies may occasionally be performed in selected high-
risk, elderly patients with low axillary disease on imaging for disease control.
In order to remove level III nodes, the pectoralis minor muscle usually needs to
be divided, detached from its coracoid insertion, or removed. The pectoralis major
muscle is identified, and the dissection is continued superiorly along its lateral bor-
der to the axillary vein. The tissue along the inferior aspect of the axillary vein is
then dissected, and small venous tributaries are ligated and divided. The axillary
vein should not be aggressively skeletonized, as this may lead to more severe
lymphedema, especially if combined with radiotherapy. The dissection continues
laterally until the latissimus dorsi muscle is identified. The tissue bordered laterally
by the latissimus muscle, superiorly by the axillary vein, and medially by the medial
margin of the pectoralis minor muscle is dissected. Care should be taken to identify
the neurovascular structures including the axillary vein, the thoracodorsal vessels
and nerve, the long thoracic nerve, and the intercostobrachial nerve(s). Although the
intercostobrachial nerve(s) may be transected during surgery, sensory changes
result without any functional motor deficit; however, it may often be preserved
unless surrounded by suspicious lymph nodes. The long thoracic and thoracodorsal
nerves should not usually be transected or injured. After the axillary contents have
been removed and meticulous hemostasis has been achieved, a drain is placed into
the axilla and remains until the output is about < about 50 ml/day. The drain can then
be removed either as an inpatient or outpatient.
Axillary Lymphadenectomy (Dissection and Clearance): Level

I (Limited; Sampling) Axillary Dissection
Description
General anesthesia is usually used. The aim is to remove the axillary lymph nodes
that are in level I. For patients with in situ or very small early invasive breast can-
cers, a level I axillary dissection may be indicated; however, the usual dissection
is levels I and II for invasive cancers. Axillary “sampling” is a lesser procedure
removing only some of the level I lymph nodes and is rarely used in most centers,
being essentially replaced by sentinel (selective) node dissection, but some sur-
geons may choose to use this technique on occasions. A transverse or oblique
incision is made just above the inferior aspect of the hair-bearing region of the
axilla from the lateral border of the pectoralis muscle to the latissimus dorsi mus-
cle. Skin flaps are raised superiorly and inferiorly. The dissection usually incises
the fascia at the lateral edge of pectoralis major, but usually does not visualize the
axillary vein or vessels. The nerves to latissimus dorsi (thoracodorsal n.) and ser-
ratus anterior (long thoracic n.) may be visualized. These structures and the inter-
costobrachial nerve are preserved, except when involved with tumor. Hemostasis
is achieved, and a suction drain is usually placed. Absorbable subcutaneous inter-
rupted sutures and a continuous, absorbable subcuticular skin suture are often
used.
Table 5.11 Level I (limited; sampling) axillary dissection estimated frequency of complications,
Infection 0.1–1 %
Bleeding/hematoma formationa
Small 1–5 %
Large 0.1–1 %
Seroma formation/large lymphocele 1–5 %
Aspiration (postoperative) 1–5 %
Nerve injurya
Injury to nerve to latissimus dorsi/nerve to serratus 0.1–1 %
anterior muscle
Edema arm/hand 0.1–1 %
Wound scarring (deformity of the skin, poor cosmesis)a 1–5 %
Axillary fibrous band adhesions 1–5 %
a
Anatomical Points
Although the anatomy of the axilla is relatively constant, care should be taken to
identify the important vascular and neural structures where appropriate. The venous
anatomy is often subtly different between individuals and occasionally between
sides. Occasionally a duplicated axillary vein is present. An unnamed vein of vari-
able size usually exists in the central axilla extending parallel with the chest wall
and anterior to the vessels supplying latissimus dorsi muscle. “Islands” of breast
tissue may be present in the axilla, separate from the axillary tail. Aberrant slips of
muscle that span the axilla may be low-lying deltoid fibers or more commonly a slip
of latissimus extending anterior to the axillary vein.
Perspective
See Table 5.11. The major debility resulting from a level I axillary lymph node dis-
section is the development of lymphedema. The incidence of lymphedema varies
widely in the literature. Lymphedema can be temporary or permanent, but is
generally less than for levels II and III dissections. The risk of infection is low. An
axillary drain may be used for several days. Neurovascular injury is rarely major,
but may occur. Axillary fibrous bands can present as palpable cords in the axilla,
upper arm, or antecubital fossa, limiting shoulder motion. Bleeding and hematoma
formation is uncommon, as is seroma or lymphocele development. These collec-
tions usually resolve without treatment.
Major Complications
One of the most serious complications of axillary lymph node dissection is severe
lymphedema. This is unpredictable, even after limited axillary node surgery, some-
times leading to marked disability. The risk of infection after an axillary lymph node
infection is low. Nerve injury may be increased by scarring after previous surgery.
Intercostobrachial nerve injury is more common, while the thoracodorsal nerve
and long thoracic nerve injury is uncommon with level I dissections. Dysesthesia
may be severe, but usually resolves. Axillary vessel injury and brachial plexus
injury can occur, but dissection is usually away from these. Shoulder joint stiff-
ness and ulnar nerve injury may result from operating table positioning.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Lymphedema
• Nerve problems
• Further surgery
Axillary Lymphadenectomy: Level I and II Axillary Dissection
Description
General anesthesia is usually used. The aim is to remove the axillary lymph nodes
that are in levels I and II. For patients with invasive breast cancer and a clinically
negative axilla, a sentinel node biopsy often precedes a formal dissection. If the
sentinel node is positive, then a level I and II axillary dissection is currently indi-
cated. A transverse or oblique incision is made just above the inferior aspect of the
hair-bearing region of the axilla from the lateral border of the pectoralis muscle to
the latissimus dorsi muscle. Skin flaps are raised superiorly and inferiorly. The dis-
section usually incises the fascia at the lateral edge of pectoralis major, then defines
the axillary vein, nerve to latissimus dorsi (thoracodorsal nerve), nerve to serratus
anterior (long thoracic nerve) progressively as the axillary contents are dissected
laterally. These structures and usually the intercostobrachial nerve are preserved,
except when involved with tumor. Hemostasis is achieved, and a suction drain is
usually placed. Absorbable subcutaneous interrupted sutures and a continuous,
absorbable subcuticular skin suture are often used.
Anatomical Points
Although the anatomy of the axilla is relatively constant, care should be taken to
identify the important vascular and neural structures. The venous anatomy is often
subtly different between individuals and occasionally between sides. Occasionally
a duplicated axillary vein is present. An unnamed vein of variable size may exist in
the central axilla extending parallel with the chest wall and anterior to the vessels
supplying latissimus dorsi muscle. The nerves are relatively constant, except for the
intercostobrachial nerve, which may branch or be dual. The long thoracic nerve is
posterior in the axilla, behind the fascia that overlies serratus anterior muscle, and
the thoracodorsal nerve lies with the vessels to latissimus dorsi travelling medially
to laterally in the axilla. The lateral cutaneous nerve of forearm may arch surpris-
ingly low into the axilla and be at risk of injury. “Islands” of breast tissue may be
present in the axilla separate from the axillary tail. Aberrant slips of muscle that
span the axilla may be low-lying deltoid fibers or more commonly a slip of latissi-
mus extending anterior to the axillary vein.
Perspective
See Table 5.12. The major debility resulting from a level I and II axillary lymph
node dissection is the development of lymphedema. The incidence of lymphedema
varies widely in the literature from 3 % to 80 %. Lymphedema can be temporary or
permanent (Fig. 5.2). The incidence, as well as the severity, increases with the num-
ber of lymph nodes removed. Patients should be educated about strategies to reduce
the risk. If lymphedema is recognized early and treated promptly, the development
of chronic, severe lymphedema may be prevented. Early treatment involves good
skin care, nighttime elevation, fitted compression garments, avoiding arm injury,
and manual lymph evacuation. The risk of infection after an axillary lymph node
dissection is low. Prophylactic antibiotics are often used to reduce the risk of
Table 5.12 Level I and II axillary dissection estimated frequency of complications, risks, and
consequences
Infection (wound, cellulitis, abscess)a 1–5 %
Aspiration (postoperative) 1–5 %
Nerve injurya
Injury to nerve to latissimus dorsi/nerve to serratus anterior 0.1–1 %
Lymphatic fluid leak/sinus <0.1 %
Edema arm/hand 0.1–1 %
a
infection. An axillary drain usually remains in place until the output is < 50 ml/day,
which may take 4–10 days. Neurovascular injury is a complication that can be
reduced with adequate exposure and careful dissection, but brachial plexus injury
and dysfunction of the thoracodorsal and long thoracic nerves may occur. Axillary
fibrous bands can present as palpable cords in the axilla, upper arm, or antecubital
fossa, causing discomfort and limiting shoulder motion (Figs. 5.3 and 5.4). Early
mobilization and physical therapy can stretch, disperse, and resolve these bands and
improve shoulder motion. Bleeding and hematoma formation can be avoided with
careful hemostasis. A seroma or lymphocele may develop after the drain is removed.
A large seroma or lymphocele requires percutaneous aspiration or drain replace-
ment. Small fluid collections usually resolve without treatment.
Major Complications
lymphedema, resulting in swelling of the arm and/or hand, which, if untreated, can
lead to a marked increase in arm circumference and, sometimes, marked disability.
The risk of lymphedema increases with a greater number of lymph nodes removed
and higher body mass index (BMI). After an axillary lymph node dissection, good
skin care of the affected arm is important. Skin cuts should be treated with antibiotic
ointment to avoid infection which increases the incidence and severity of lymph-
edema. The risk of wound infection after an axillary lymph node dissection is low.
Perioperative IV antibiotics and postoperative oral antibiotics can help reduce the
risk of infection. Some surgeons continue antibiotics until the drain has been
removed. Wound dehiscence can follow hematoma, lymphocele, or wound infec-
tion. Systemic infection is relatively rare but can lead to multisystem organ failure.
Nerve injury may be increased by scarring after sentinel node surgery.
Thoracodorsal nerve injury leads to paralysis of the latissimus dorsi muscle. The
motor deficits include slight weakness in arm adduction and internal rotation of the
shoulder. It is not usually a very disabling injury and many patients adapt to it well
without changes in lifestyle. Long thoracic nerve injury leads to paralysis of the
serratus anterior muscle, resulting in “winging” of the scapula and shoulder pain.
Axillary vessel injury should be repaired immediately using standard vascular sur-
gical techniques. Narrowing of the vein by > 50 % may need an autologous vein
patch. Brachial plexus injury due to stretching and positioning during axillary
dissection may be reduced by less prolonged arm retraction overhead and avoiding
dissection above the axillary vein. Direct injury may need acute microsurgical nerve
repair. Injury to the intercostobrachial nerve is common and presents as sensory
changes to the upper inner arm and axilla. Patients complain of numbness and tin-
gling as well as changes in sweating. The affected area usually decreases in size
over time, but never fully resolves. Dysthesia may be severe, but usually resolves.
Shoulder stiffness is usually avoidable with early mobilization, but can be a signifi-
cant disability.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Blue staining
• Radiation risk
• Further surgery
Complete (Levels I to III) Radical Axillary Dissection
Description
General anesthesia is generally required. The aim is to completely clear all lymph
nodes in levels I, II, and III of the axilla. A generous incision is made transversely
across the base of the axilla, just below the hair-bearing area, and extended onto the
chest for a variable distance depending on the body shape, pathology, surgeon prefer-
ence, and type of surgery being performed. If required, further exposure can be achieved
by extending the anterior part of the skin incision forward and/or posteriorly backward
in the line of the anterior border of latissimus dorsi. Flaps are raised in the subcutane-
ous plane, exposing pectoralis major and serratus anterior muscles anteriorly and the
anterior border of latissimus dorsi posteriorly. Dissection of the axillary contents is
commenced superiorly, retracting pectoralis major forward to obtain full access. It is
usually necessary to sacrifice the medial pectoral nerve, since it passes through pecto-
ralis minor, but care should be taken to preserve the lateral pectoral nerve, as well as the
adjacent thoracoacromial vessels. Pectoralis minor is detached as close as possible to
the coracoid process (or divided or removed), taking care to avoid damage to the under-
lying brachial plexus. The anterior and inferior aspects of the axilla around the axillary
vein and artery are cleared, commencing at the levels of the subclavius tendon superi-
orly. The intercostobrachial nerve is sacrificed, but the nerve to serratus anterior, lying
on the chest wall medially, and the nerve to latissimus dorsi, running with the sub-
scapular vessels more laterally, should be identified and preserved. If a large tumor
mass involves either nerve, however, it will need to be sacrificed. The subscapular
vessels are also preserved, unless this is judged likely to compromise the completeness
of node clearance. Routine suction drainage of the wound is recommended.
Anatomical Points
Although the anatomy of the axilla is relatively constant, care should be taken to identify
the important vascular and neural structures. The venous anatomy is often subtly different
between individuals and occasionally between sides. Occasionally a duplicated axillary
vein is present. Division is required of an unnamed vein of variable size which usually
exists in the central axilla extending parallel with the chest wall and anterior to the vessels
supplying latissimus dorsi muscle. The nerves are relatively constant, except for the inter-
costobrachial nerve, which may branch or be dual. The long thoracic nerve is posterior in
the axilla, behind the fascia that overlies serratus anterior muscle, and the thoracodorsal
nerve lies with the vessels to latissimus dorsi travelling medially to laterally in the axilla.
The lateral cutaneous nerve of forearm may arch surprisingly low into the axilla and be at
risk of injury. “Islands” of breast tissue may be present in the axilla separate from the
axillary tail. Aberrant slips of muscle that span the axilla may be low-lying deltoid fibers
or more commonly a slip of latissimus extending anterior to the axillary vein.
Table 5.13 Complete (levels I to III) radical axillary dissection estimated frequency of
Detectable lymphedema head/arm/breast/nipple areolar edemab 20–50 %
Severe lymphedemab 1–5 %
Seroma formation/large lymphocele 5–20 %
Repeated aspiration (postoperative)a 5–20 %
Neural injurya
Sensory
Arm/chest wall paresthesia (intercostobrachial nerve injury) >80 %
Lateral cutaneous nerve of arm or forearm 1–5 %
Motor
Injury to nerve to latissimus dorsi/nerve to serratus anterior 0.1–1 %
Lateral pectoral nerve 0.1–1 %
Reduced range of movement of shoulder/arm 5–20 %
Frozen shoulder 1–5 %
Traction injuries 1–5 %
Skin flap necrosis/ulceration 0.1–1 %
Axillary venous thrombosisa 0.1–1 %
Twitching 0.1–1 %
a
b
These rates will be much higher if postoperative radiotherapy is given
Perspective
See Table 5.13. Overall, complications are considerably higher with complete or
radical lymphadenectomy than lesser procedures. The major debility resulting from
a level I to II (radical) axillary lymph node dissection is the development of lymph-
edema. The incidence of lymphedema varies widely in the literature from 3 % to
80 %. Lymphedema can be temporary or permanent. The incidence, as well as the
severity, increases with the number of lymph nodes removed. Patients should be
educated about strategies to reduce the risk. If lymphedema is recognized early and
treated promptly, the development of chronic, severe lymphedema may be reduced.
Early treatment involves good skin care, nighttime elevation, fitted compression
garments, avoiding arm injury, and manual lymph evacuation. The risk of wound
infection after a radical axillary lymph node dissection is increased by prolonged
use of tube wound drainage, lymphocele re-accumulation and repeated aspirations,
hematoma formation, repeat surgery, and lymphedema. Prophylactic antibiotics are
often used to reduce the risk of infection. An axillary drain usually remains in place
until the output is < 50 ml/day, which may take 4–10 days. Neurovascular injury is a
complication that can be reduced with adequate exposure and careful dissection, but
brachial plexus injury and dysfunction of the thoracodorsal and long thoracic nerves
may occur. Nerves may be involved with tumor and require resection. Numbness
and paresthesia of the medial aspect of the arm and lateral chest wall are to be
expected due to denervation. Axillary fibrous bands can present as palpable cords in
the axilla, upper arm, or antecubital fossa, causing discomfort and limiting shoulder
motion (Figure**). Early mobilization and physical therapy can stretch, disperse,
and resolve these bands and improve shoulder motion. Bleeding and hematoma
formation can be avoided with careful hemostasis. A seroma or lymphocele may
develop after the drain is removed. A large seroma or lymphocele requires percuta-
neous aspiration or drain replacement. Small fluid collections usually resolve with-
out treatment.
Major Complications
lymphedema, resulting in swelling of the arm and/or hand, which, if untreated, can
lead to a marked increase in arm circumference and, sometimes, marked disability.
The risk of lymphedema increases with a greater number of lymph nodes removed,
a higher body mass index (BMI), and after postoperative radiotherapy. After an axil-
lary lymph node dissection, good skin care of the affected arm is important, and skin
cuts should be treated with antibiotic ointment to avoid infection, which increases
the incidence and severity of lymphedema. The risk of wound infection after a radi-
cal axillary lymph node dissection is not uncommon. Perioperative IV antibiotics
and postoperative oral antibiotics can help reduce the risk of infection. Some sur-
geons continue antibiotics until the drain has been removed. Wound dehiscence
can follow hematoma, lymphocele, or wound infection. Systemic infection is rela-
tively rare, but can lead to multisystem organ failure. Nerve injury may be increased
by scarring after sentinel node surgery. Thoracodorsal nerve injury leads to paral-
ysis of the latissimus dorsi muscle. The motor deficits include slight weakness in
arm adduction and internal rotation of the shoulder. It is not usually a very disabling
injury and many patients adapt to it well without changes in lifestyle. Long tho-
racic nerve injury leads to paralysis of the serratus anterior muscle, resulting in
“winging” of the scapula and shoulder pain. Axillary vessel injury should be
repaired immediately using standard vascular surgical techniques. Narrowing of the
vein by > 50 % may need an autologous vein patch. Brachial plexus injury due to
stretching and positioning during axillary dissection may be reduced by less pro-
longed arm retraction overhead and avoiding dissection above the axillary vein.
Direct injury may need acute microsurgical nerve repair. Injury to the intercosto-
brachial nerve is common and presents as sensory changes to the upper inner arm
and axilla. Patients commonly complain of numbness and tingling as well as
changes in sweating. The affected area usually decreases in size over time, but never
fully resolves. Dysthesia may be severe with burning pain as the nerve is recover-
ing, but this usually resolves. Shoulder stiffness is usually avoidable with early
mobilization and physiotherapy, but can be a significant disability. Frozen shoulder
is more common in the elderly and after prolonged immobilization.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphocele
• Nerve problems
• Blue staining
• Radiation risk
• Further surgery
Inguinal, Pelvic, and Para-aortic Lymph Node Dissections
Inguinal dissection is relatively superficial, whereas pelvic and para-aortic lymph-

adenectomies are retroperitoneal dissections and much deeper procedures. The
main complications arise immediately from bleeding from vascular injury and
potential injury to nerves and adjacent organs (chiefly bladder, ureter, and bowel),
while the principal longer-term complications are lymphatic collections, fistulae,
infection, and wound breakdown.
Inguinal and pelvic surgery is not uncommonly associated with significant com-
plications due to the increased risk of infection due to enteric organisms typically
colonizing the skin in the groin and perineal regions. Wound breakdown is increased
by ischemia of the wound edges from tension, diathermy burns, suture material
reactions, thinned flaps, or lymphatic collection, and these may collectively act to
produce wound dehiscence, especially when infection is present. Comorbidities
such as diabetes, malnutrition, immunosuppression, obesity, and the use of radio-

therapy increase the risk of wound infection and wound breakdown.
Drain tubes are usually used by most surgeons, but the timing of their removal is
largely open to personal preference. Most drains usually show reduced drainage
of < 50 ml per 24 h after 4–7 days and at this time can be removed. Recurrent lym-
phatic collections may occur and often require repeated needle aspirations for ade-
quate drainage, which can be quite demanding on the patient and staff, sometimes
for prolonged periods. These almost always settle and very rarely require surgical
re-exploration and ligation of lymphatic vessels. Re-exploration is typically unre-
warding, as no vessel may be found to ligate.
The main indication for an inguinal lymphadenectomy is a cutaneous malignancy,
most commonly melanoma or SCC of the skin, over the trunk, lower limb, penis,
vulva, or anus. In general, the removal of lymph node tissue should usually be a level
above the level that is involved with tumor. The combination of an inguinal with a
pelvic lymphadenectomy is often chosen when the risk of tumor is present in the
pelvic nodes, such as with palpable or otherwise determined melanoma or SCC
nodal deposits in the groin or high in the thigh. In these situations, the risk of recur-
rence within the pelvis is appreciable and often unpredictable. Recent studies of lym-
phatic drainage using sentinel node tracing show direct drainage to a pelvic lymph
node in some cases, even from a lower limb melanoma site, and this may explain
episodes of pelvic tumor “recurrence” after inguinal lymphadenectomy alone.
Retroperitoneal nodal dissection is used for testicular or germinal carcinomas, for
selected cases of melanoma and lymphomas, and for diagnosis where no other method
has succeeded. Complications are increased where the peritoneum has been entered,
and this may be required, but a retroperitoneal approach is usually associated with less
bowel disturbance and reduced risk of organ injury, with quicker recovery.
Pelvic and retroperitoneal lymphadenectomy are performed by a variety of sur-
geons, including urological, gynecological, general, and vascular surgeons, and the
relative risks and complications are also inherently related to what additional sur-
gery is performed concurrently. The risks and complications associated with any
combined surgery to the prostate, bladder, or uterus, for example, would need to be
included with the lymphadenectomy risks when considering the risks associated
with a composite procedure.
Inguinal (Groin) Lymph Node Dissection

(Subinguinal Groin Dissection)
Description
General anesthesia is usually employed, although a spinal anesthetic is satisfactory.

The aim is to achieve en bloc removal of all lymph nodes in the femoral triangle,
from its apex distally to the level of the inguinal ligament proximally, including the
node of Cloquet in the femoral canal. An oblique elliptical incision centered over
the upper part of the femoral triangle, extending from a point medial to the anterior
superior iliac spine to another point on the mid-medial thigh, is most satisfactory.
Flaps are raised, allowing full access to the groin contents. Care to avoid later ten-
sion in the skin closure greatly reduces the risk of wound edge necrosis. This can be
achieved through judicious excision of an adequate ellipse of skin from the central
part of the femoral triangle overlying any enlarged nodes or previous biopsy scar,
but with avoidance of taking too much skin initially. Skin edges can be trimmed at
the end of the operation, if viability is of concern, or a sartorius muscle transposition
may be desirable to cover the femoral vessels if there is concern of wound break-
down. Some surgeons use a sartorius muscle flap almost routinely, as wound break-
down can be unpredictable and idiosyncratic. Tissue anterior and medial to the
femoral vessels is removed, but the fascia overlying the femoral nerve is left intact
unless its removal is necessary to ensure tumor clearance. The upper part of the long
saphenous vein is routinely removed as part of the operative specimen. The saphe-
nofemoral junction is usually flush suture ligated. It is usually necessary to repair
the femoral hernia that is produced by removing lymphatic tissue from the femoral
canal. This can readily be done from below, by obliterating the space between ingui-
nal ligament and pectineal ligament and/or fascia, with a nylon or Prolene darn, or
using single sutures. Care should be taken to avoid constricting the femoral vein by
the closure, to permit adequate venous expansion (the tip of the little finger should
be easily passed medially to the femoral vein at completion of closure of the femo-
ral canal defect). Suction drainage is used, and the skin is closed using soluble inter-
rupted subcutaneous and continuous subcuticular sutures or staples.
Anatomical Points
The femoral triangle anatomy is relatively constant with little variation, apart from
the venous anatomy, which particularly varies with regard to the tributaries and
varicosities associated with the great saphenous vein. The femoral artery and vein
lie deep within the femoral triangle, but can rarely be mistaken for the more super-
ficial great saphenous vein, which itself can lie surprisingly deep within the subcu-
taneous fat of the upper thigh, especially in obese individuals. The lateral cutaneous
nerve of thigh and femoral nerve lie laterally to the femoral artery, usually superfi-
cially and deeper, respectively. Exposure of all main vessels ensures the correct
anatomy is identified.
Perspective
See Table 5.14. Despite the nature of the surgery, most complications are minor.
Considerable lymph drainage from the wound is normal for 48–72 h, and strict
Table 5.14 Inguinal (groin) lymph node dissection (subinguinal groin dissection) estimated
Leg edema swellingb
Moderate/minor 20–50 %
Major/debilitating 1–5 %
Skin flap necrosis/ulcerationa 1–5 %
Wound dehiscence 1–5 %
Neural injury
Sensory
Femoral nerve 50–80 %
Lateral cutaneous nerve thigh 5–20 %
Inguinal branch of ilioinguinal nerve 1–5 %
Femoral branch of genitofemoral nerve 1–5 %
Obturator nerve 0.1–1 %
Saphenous nerve paresthesia/anesthesia <0.1 %
Motor
Obturator nerve <0.1 %
Chronic dressings or vacuum dressingsa 0.1–1 %
Vascular injury (femoral artery or vein)a 0.1–1 %
Muscle weakness 0.1–1 %
Lymphatic sinus [long term] 0.1–1 %
Femoral (or prevascular or inguinal) hernia (late) 0.1–1 %
Erosion of femoral artery (late delayed major bleeding)c <0.1 %
Systemic infection/multisystem organ failurea <0.1 %
Deatha <0.1 %
Stiffness/reduced range of movement (short term) 5–20 %
Reduced mobility/difficulty weightbearing 0.1–1 %
Urinary retention (urinary catheter) 5–20 %
Wound scarring (deformity/dimpling of wound scar/poor cosmesis)a 5–20 %
Wound drain(s)a All
a
b
Depending on the sensitivity of measurement of degree of leg edema or swelling
c
Muscle transposition flap may reduce risk of hemorrhage
bed rest with elevation of the foot of the bed during this period is helpful. The
wound drain tubes are often required for 4–7 days. The procedure normally
causes little discomfort because sensory nerves supplying the upper, anterior
thigh are often necessarily divided. Seroma/lymphocele is a relatively common
complication after drain removal, and repeated percutaneous aspiration may be
necessary. Rarely, formal exploration and ligation of a lymphatic or obliteration
of the lymphocele cavity is required. Permanent limb edema is a common sequel,
but in most cases is minor or mild and easily controlled with a surgical stocking.
However, occasional patients develop major lymphedema causing serious life-
long disability. The risk of severe lymphedema is greatly increased if pre- or
postoperative radiotherapy is given to the groin or pelvis. Bleeding during sur-
gery is usually controlled at the time, but late hematoma may occur and neces-
sitate return to theater for evacuation. Infection is more common with surgery in
the groin region, and infection of lymphoceles or hematomas may occur. This
can lead to wound dehiscence and the need for chronic or vacuum dressings.
Discomfort may be considerable on occasions, and the patient should be warned
to avoid heavy activities for 1–2 weeks to reduce risk of infection, bleeding, and
other wound complications.
Major Complications
At surgery bleeding is the most common complication, while in the postoperative

period lymphocele collection, hematoma formation, and wound infection are
the most common. Sterile technique is required to prevent infection during
repeated aspirations of lymphoceles. Cellulitis is more common due to lym-
phatic obstruction after lymphadenectomy, both as a short- and long-term compli-
cation. Abscess formation is rare, but may necessitate operative drainage.
Systemic infection is relatively rare and may lead to multisystem organ failure,
which is the main cause of mortality when it occurs, usually related to comor-
bidities, immunosuppression, or old age. Skin flap necrosis can be related to thin
flaps or inadvertent diathermy burns and is usually adequately managed with
dressings for 1–4 weeks. Reactions to soluble suture material, although uncom-
mon, can be significant and cause wound edge necrosis and skin ulceration.
Wound dehiscence is not uncommon if infection occurs and may be significant,
requiring prolonged dressings or vacuum wound care. Lymphedema is related
to the degree of removal of the main lymphatic channels and is usually minor or
moderate in nature, exacerbated by hot weather or fluid retention, but usually
controlled with a graduated support stocking. Major lymphedema can occur,
either early or later after surgery, and is largely unpredictable, but can be debilitat-
ing and difficult to alleviate. Lymphatic leakage can occur, but usually resolves
spontaneously with continued dressings.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphedema
• Lymphocele
• Lymphatic leak
• Chronic dressings
• Nerve problems
• Further surgery
Radical Inguino-pelvic (Ilioinguinal) Lymph Node Dissection
Description
General anesthesia is required, with muscle relaxation; however, spinal anesthesia

can also be used. A bladder catheter should always be inserted, to decompress the
bladder for better exposure and reduced risk of damage. The aim is to clear all
lymph nodes in the distal common iliac, external iliac, and obturator groups, as well
as removal of all lymph nodes in the femoral triangle, from its apex distally to the
level of the inguinal ligament proximally, including the node of Cloquet in the fem-
oral canal. An oblique incision is made from the lower abdomen at about the rectus
edge to the thigh at the femoral triangle inferior apex. Anterior abdominal wall fat
is removed, and the thigh flaps are raised, allowing full access to the groin contents.
Care to avoid later tension in the skin closure greatly reduces the risk of wound edge
necrosis. This can be achieved through judicious excision of an adequate ellipse of
skin of the central part of the femoral triangle overlying any enlarged nodes or pre-
vious biopsy scar, but with avoidance of taking too much skin initially. If there is
concern about the viability of the edges of the flaps, they can be trimmed at the
operation completion. Extraperitoneal exposure of the pelvic nodes is obtained
either through an oblique incision through the lower abdominal musculature or by
dividing the inguinal ligament and extending the incision upwards through the
lower abdominal musculature. It is usually necessary to ligate and divide the infe-
rior epigastric vessels to obtain access to the distal external iliac and obturator
nodes. Damage to the testicular vessels and vas deferens should be avoided in the
male. In females, the round ligament can be ligated and divided to improve access.
The extraperitoneal space is best entered laterally by cautiously dividing the trans-
versalis fascia, keeping the peritoneum intact. Scarring from previous surgery or
pathology may make this difficult. Any peritoneal defect should be repaired imme-
diately. Deep retraction of peritoneum and contents upwards and medially, together
with the ureter, provides excellent and safe exposure of the iliac and obturator
regions. Within the pelvis, care must be taken not to damage the obturator nerve as
nodal tissue is swept downwards and anteriorly from the pelvic side wall. The pel-
vic dissection can be continued downwards below the inguinal ligament, and the
node specimen can be passed beneath the inguinal ligament into the groin or
removed as a separate specimen. An alternative approach is to commence with the
inguinal dissection and then proceed to the pelvic dissection. If skin breakdown is
of concern, a sartorius muscle transposition flap is desirable to cover the femoral
vessels. Some surgeons use a sartorius muscle flap almost routinely, as wound
breakdown can be unpredictable and idiosyncratic. Tissue anterior and medial to the
femoral vessels is removed, but the fascia overlying the femoral nerve is left intact
unless its removal is necessary to ensure tumor clearance. The upper part of the long
saphenous vein is routinely removed as part of the operative specimen. The saphe-
nofemoral junction is usually flush suture ligated. It is usually necessary to repair
the femoral hernia that is produced by removing lymphatic tissue from the femoral
canal. This can readily be done from below, by obliterating the space between ingui-
nal ligament and pectineal ligament and/or fascia with a nylon or Prolene darn or
using single sutures. Care should be taken to avoid constricting the femoral vein by
the closure, to permit adequate venous expansion (the tip of the little finger should
be easily passed medially to the femoral vein at completion of closure of the femo-
ral canal defect). Suction drainage is used to the pelvis and thigh, and the skin is
closed using soluble interrupted subcutaneous and continuous subcuticular sutures.
Anatomical Points
The femoral triangle anatomy is relatively constant with little variation, apart from
the venous anatomy, which particularly varies with regard to the tributaries and
varicosities associated with the great saphenous vein. The femoral artery and vein
lie deep within the femoral triangle, but can rarely be mistaken for the more super-
ficial great saphenous vein, which itself can lie surprisingly deep within the subcu-
taneous fat of the upper thigh, especially in obese individuals. The lateral cutaneous
nerve of the thigh and femoral nerve lie laterally to the femoral artery, usually
superficially and deeper, respectively. Exposure of all main vessels ensures the cor-
rect anatomy is identified. The iliac vessels are relative constant anatomically. An
abnormal obturator artery arising from the inferior epigastric artery is present in
30 % of individuals and travels adjacent to the femoral canal where it may be
injured. The shape of the pelvis and degree of superficial subcutaneous fat can alter
the anatomy and relative access. Generally the posterior peritoneum can be bluntly
dissected away from the lymph nodes overlying the iliac vessels to expose the
retroperitoneum, unless scarring or pathology causes adherence of tissue planes.

The ureter is at risk at the upper aspect of the pelvic dissection where it crosses the
bifurcation of the common iliac artery and should be identified. The obturator nerve
is relatively constant in location and should be visualized low in the pelvis.
Perspective
Sequelae are similar to those for subinguinal (“superficial”) lymph node dissection,
but the risk of lymphedema is a little higher. Some initial gastrointestinal motility
problems can occur, but usually resolve within 24 h. More prolonged ileus can
occur, although it is less of a problem than with intraperitoneal surgery. Considerable
lymph drainage from the wound is normal for 48–72 h, and strict bed rest with
Table 5.15 Radical inguino-pelvic (ilioinguinal) lymph node dissection estimated frequency of
Leg edema swellingb
Seroma/lymphocele formation 5–20 %
Skin ulceration 1–5 %
Neural injury
Sensory
Saphenous nerve paresthesia/anesthesia <0.1 %
Motor
Femoral (or prevascular or inguinal) hernia (late)a 1–5 %
(Particularly if inguinal ligament is divided)
Perineal edema (scrotal/penile/labial edema) 5–20 %

Paralytic ileusa 0.1–1 %
Abdominal wound incisional hernia (late) 0.1–1 %
Small bowel obstruction (if intraperitoneal approach was used) (late)a 0.1–1 %
Sexual dysfunction/impotence (if extensive and/or bilateral) 0.1–1 %
Erosion of femoral artery (late delayed major bleeding)c <0.1 %
Injury to the spermatic cord/testicular ischemiaa <0.1 %
Ureteric injury <0.1 %
Bladder injury <0.1 %
Deatha <0.1 %
Wound drain(s)a All
a
b
c
Muscle transposition flap may reduce risk of hemorrhage
elevation of the foot of the bed during this period is helpful. The wound drain tubes
are often required for 4–7 days. The procedure normally causes little thigh discom-
fort because sensory nerves supplying the upper, anterior thigh are often necessarily
divided. Seroma/lymphocele is a relatively common complication after drain
removal, and repeated percutaneous aspiration may be necessary. Occasionally, for-
mal exploration and ligation of a lymphatic or obliteration of the lymphocele cavity
is required. Permanent limb edema is a common sequel, but in most cases is minor
or mild and easily controlled with a surgical stocking. However, occasional patients
develop major lymphedema causing serious lifelong disability. The risk of severe
permanent lymphedema is moderately increased if pre- or postoperative radiother-
apy is given to the groin, and especially to the pelvis. Bleeding during surgery is
usually controlled at the time, but late hematoma may occur and necessitate return
to theater for evacuation. Infection is more common with surgery in the groin region,
and infection of lymphoceles or hematomas may occur. This can lead to wound
dehiscence and the need for chronic or vacuum dressings. Systemic infection is rare,
which can lead to multisystem organ failure and even mortality when it occurs.
Abdominal discomfort may be considerable on occasions, and the patient should be
warned to avoid heavy activities for 1–2 weeks to reduce risk of infection, bleeding,
and other wound complications.
Major Complications
Most complications are slightly more common with the addition of pelvic lymphad-
enectomy to inguinal lymphadenectomy. At surgery bleeding is the most common
complication, while in the postoperative period, lymphocele collection, hematoma
formation, and wound infection are the most common. Sterile technique is required
to prevent infection during repeated aspirations of lymphoceles. Cellulitis is
more common due to lymphatic obstruction after lymphadenectomy, both as a
short- and long-term complication. Abscess formation is rare, but may necessitate
operative drainage. Systemic infection is relatively rare and may lead to multisys-
tem organ failure, which is the main cause of mortality when it occurs, usually
related to comorbidities, immunosuppression, or old age. Skin flap necrosis and
skin ulceration can be related to thin flaps, reactions to soluble suture material, or
inadvertent diathermy burns and is usually adequately managed with dressings for
1–4 weeks. Wound dehiscence is not uncommon if infection occurs and may be
significant, requiring prolonged dressings or vacuum wound care. Lymphedema
is related to the degree of removal of the main lymphatic channels and is usually
minor or moderate in nature, exacerbated by hot weather, fluid retention, or periop-
erative radiotherapy, but usually controlled with a graduated support stocking.
Major lymphedema can occur, either early or later after surgery, and is largely
unpredictable, but can be debilitating and difficult to alleviate. Lymphatic leakage
can occur, but usually resolves spontaneously with continued dressings. Bladder,
ureteric, spermatic cord, and bowel injury and also sexual dysfunction and par-
alytic ileus are relatively rare, but important, complications that may be avoidable
with careful dissection and retraction.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphedema
• Lymphocele
• Lymphatic leak
• Nerve problems
• Organ injury
• Further surgery
Pelvic Retroperitoneal Lymph Node Dissection
Description
General anesthesia with muscle relaxation is used, but spinal anesthesia may be chosen
in some instances. The aim is to remove the pelvic (the iliac and obturator) lymph nodes,
extending from the inguinal ligament to the level of the common iliac artery. An oblique
muscle cutting/splitting incision is made at an appropriate site in the lower abdomen,
lateral to the rectus edge. The peritoneum is then reflected to gain the retroperitoneum
exposing the iliac lymph nodes overlying the iliac vessels. Care is taken not to open the
peritoneum, avoiding injury to bowel and maintaining access exclusively to the lower
retroperitoneal space, which reduces risk of ileus and aids speed of recovery. The pelvic
nodes are then dissected from the iliac vessels (iliac nodes) and from around the obtura-
tor nerve (obturator nodes). The ureter should be retracted with the peritoneum, but for
safety should always be identified. External iliac, obturator nodes, common iliac, and
even lower para-aortic nodes can be removed through this incision. Although performed
separately as described here, pelvic node dissection is often combined with in-continu-
ity inguinal node dissection. The inguinal ligament can be divided, but many surgeons
avoid this, which also aids recovery and reduces risk of later prevascular herniation.
However, care is taken to clear the lymphatic tissue beneath the inguinal ligament.
Occasionally, a midline incision is required, principally for bilateral or larger matted
nodes, and a transperitoneal approach is used, but risks are higher, especially of ileus and
adhesions. A large vacuum drain tube is inserted into the pelvis. The inguinal ligament
is reconstructed, if divided, and the abdominal wall is closed using a mass closure tech-
nique. The skin is closed using subcutaneous sutures or staples.
Anatomical Points
The pelvic vessels and anatomy are relatively constant with little variation. If the
incision is made low and too far medially, the inferior epigastric vessels may be
encountered and cause troublesome bleeding. Suture ligation may be needed to con-
trol this. Access to obturator nodes may be impeded by accessory obturator vessels;
these may require formal ligation. Enlarged nodes can make access difficult and
adherence to vessels and nerves may increase the risks.
Perspective
See Table 5.16. Although some muscle discomfort is inevitably associated with
these procedures, they are usually straightforward, and complications may be
troublesome, but are usually not major. In general, infection is more common
with surgery extending to the inguinal region than for incisions above the waist.
Bleeding, hematoma formation, and later hernia formation can occur. Numbness
due to injury of abdominal wall, obturator or femoral nerves can occur. Some
Table 5.16 Pelvic retroperitoneal lymph node dissection estimated frequency of complications,
Leg edema swellingb
Seroma/lymphocele formation 5–20 %
Skin ulceration 1–5 %
Neural injury
Sensory
Motor

Femoral (or prevascular or inguinal) hernia (late) 0.1–1 %
(particularly if inguinal ligament is divided)
Small bowel obstruction (if intraperitoneal approach was used) (late) 0.1–1 %
Sexual dysfunction/impotence (if extensive and/or bilateral) 0.1–1 %
Injury to the spermatic cord/testicular ischemiaa <0.1 %
Ureteric injury <0.1 %
Bladder injury <0.1 %
Deatha <0.1 %
Wound drain(s)a All
a
b
initial gastrointestinal motility problems can occur, but usually resolve within
24 h. More prolonged ileus can occur, although is less of a problem than with
intraperitoneal surgery. Considerable lymph drainage from the wound is normal
for 48–72 h, and strict bed rest with elevation of the foot of the bed during this
period is helpful. The wound drain tubes are often required for 4–7 days. Seroma/
lymphocele can occur after drain removal, and repeated percutaneous aspiration
may be necessary. Rarely, formal exploration and ligation of a lymphatic or oblit-
eration of the lymphocele cavity is required. Permanent limb edema is a common
sequel, but in most cases is minor or mild and easily controlled with a surgical
stocking. However, occasional patients develop major lymphedema causing seri-
ous lifelong disability. The risk of severe permanent lymphedema is moderately
increased if pre- or postoperative radiotherapy is given to the groin, and espe-
cially to the pelvis, or after repeat surgery. Bleeding during surgery is usually
controlled at the time, but late hematoma may occur and necessitate return to
theater for evacuation. Infection is more common with surgery in the groin
region, and infection of lymphoceles or hematomas may occur. This can lead to
wound dehiscence and the need for chronic or vacuum dressings. Systemic infec-
tion is rare, which can lead to multisystem organ failure and even mortality when
it occurs. The procedure normally causes little discomfort, but this may be con-
siderable on occasions, and the patient should be warned to avoid heavy activi-
ties for 1–2 weeks to reduce risk of infection, bleeding, and other wound
complications.
Major Complications
Bleeding intraoperatively can be serious, but can typically be controlled at the

time, and rarely blood transfusion is required. Catastrophic bleeding is exceed-
ingly rare. Postoperative bleeding can occur and may be serious as it can be
concealed within the abdomen and not evident until later, unless excessive blood
is noted in the drain tube(s) or vital signs alter to indicate hemorrhage.
Hematoma or seroma formation may lead to infection and, on occasions, leads
to wound dehiscence. Cellulitis of the abdominal wall and thigh is more com-
mon, due to lymphatic obstruction after lymphadenectomy, both as a short- and
long-term complication. Abscess formation is rare, but may necessitate opera-
tive drainage. Systemic infection is relatively rare and may lead to multisystem
organ failure, which is the main cause of mortality when it occurs, usually
related to comorbidities, immunosuppression, or old age. Occasionally, collec-
tions require reoperation for drainage. Deep dehiscence is very rare and usu-
ally requires reoperation. Wound hernia formation can occur as a later
complication. Abdominal wall or medial thigh numbness can occur from nerve
injury, but is not usually of major concern. Ureteric injury is very rare. Skin
edge necrosis and skin ulceration can be related to inadvertent diathermy
burns or reactions to soluble suture material and is usually adequately managed
with dressings for 1–4 weeks. Wound dehiscence is not uncommon if infection
occurs and may be significant, requiring prolonged dressings or vacuum wound
care. Lymphedema is related to the degree of removal of the main lymphatic
channels, especially when postoperative radiotherapy is also used, but is usually
minor or moderate in nature, exacerbated by hot weather or fluid retention, and
usually controlled with a graduated support stocking. Major lymphedema can
occur, either early or later after surgery, and is largely unpredictable, but can be
debilitating and difficult to alleviate. Lymphatic leakage can occur, but usually
resolves spontaneously with continued dressings. Bladder, ureteric, spermatic
cord, and bowel injury and also sexual dysfunction and paralytic ileus are
relatively rare, but important, complications that may be avoidable with careful
dissection and retraction.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphedema
• Lymphocele
• Lymphatic leak
• Nerve problems
• Organ Injury
• Further surgery
Para-aortic Retroperitoneal Lymph Node Dissection
Description
General anesthesia with muscle relaxation is used. The aim is to remove the para-
aortic (high common iliac and aortic) lymph nodes from the retroperitoneal space.
This may be unilateral or bilateral and localized or extend to the level of the renal
arteries. The main indications are testicular malignancy and for definitive diagnosis
of a suspected lymphoma, but melanoma and other malignancies are occasionally
treated using this approach. A midline incision, or an oblique muscle cutting/split-
ting incision at an appropriate site in the mid- to lower abdomen lateral to the rectus
edge, can be used. The peritoneum is then reflected to gain the retroperitoneal space
exposing the para-aortic and iliac lymph nodes overlying the iliac vessels. The para-
aortic nodes are then dissected from the vessels, and the dissection can be continued
lower to remove nodes from around the lower iliac vessels and obturator nerve,
often requiring inferior extension of the wound. Care is taken to avoid opening the
peritoneum, which avoids injury to bowel and maintains access exclusively to the
lower retroperitoneal space, which reduces risk of ileus and aids speed of recovery.
The ureter should be retracted with the peritoneum, but for safety should always be
identified. A transperitoneal approach can be used, but ileus and adhesion rates are
higher. A large vacuum drain tube is inserted into the retroperitoneal space or abdo-
men if the peritoneum is opened. The abdominal wall is closed using a mass closure
technique. The skin is closed using subcutaneous sutures or staples.
Anatomical Points
The main problem arises from previous surgery, or inability to open the retroperito-
neal space due to adherence of tissues, or pathology. If the incision is made low and
too far medially, the inferior epigastric vessels may be encountered and cause trou-
blesome bleeding. Suture ligation may be needed to control this. Although the aorta,
inferior vena cava, and iliac vessels are relatively constant, some variability may
occur with the renal vessels principally of the renal veins and especially of the left
renal vein, which may be anterior to, posterior to, or encircling the aorta. The pathol-
ogy, previous surgery, or use of radiotherapy may distort the anatomy and render
surgery more difficult.
Perspective
Sequelae are similar to those for pelvic lymph node dissection, but the risk of lymph-
edema is a little higher. Some initial gastrointestinal motility problems can occur, but
usually resolve within 24 h. More prolonged ileus can occur, although is less of a
problem than with intraperitoneal surgery. Considerable lymph drainage from the
wound is normal for 48–72 h, and strict bed rest with elevation of the foot of the bed
during this period is helpful. The wound drain tubes are often required for 4–7 days.
Seroma/lymphocele can occur after drain removal and may require percutaneous
drainage. Rarely, formal exploration and ligation of a lymphatic or obliteration of the
lymphocele cavity is required. Permanent bilateral limb edema is a common sequel,
but in most cases is minor or mild and easily controlled with a surgical stocking.
However, occasional patients develop major lymphedema causing serious lifelong
disability. The risk of severe permanent lymphedema is moderately increased if pre-
or postoperative radiotherapy is given to the abdomen or pelvis. Bleeding during
surgery is usually controlled at the time, but late hematoma may occur and necessi-
tate return to theater for evacuation. Infection can occur, and infection of lympho-
celes or hematomas may occur. This can lead to wound dehiscence and the need for
chronic dressings. Systemic infection is rare, which can lead to multisystem organ
failure and even mortality when it occurs. Discomfort may be considerable on occa-
sions, and the patient should be warned to avoid heavy activities for 1–2 weeks to
reduce risk of infection, bleeding, and other wound complications.
Major Complications
Most complications are slightly more common than for pelvic lymphadenectomy.
At surgery bleeding is the most common complication, while in the postoperative
Table 5.17 Para-aortic retroperitoneal lymph node dissection estimated frequency of

Leg edema swellingb
Neural injury
Sensory/motor (Lumbosacral plexus) 1–5 %
Sexual dysfunction/impotence (if extensive and/or bilateral) 1–5 %
Lymphatic sinus [longer term] 0.1–1 %
Ascitesa 0.1–1 %
Vascular injury (artery/vein)a 0.1–1 %
Neural injury
Sensory
Femoral nerve 0.1–1 %
Lateral cutaneous nerve thigh 0.1–1 %
Ilioinguinal/iliohypogastric nerve 0.1–1 %
Motor
Ureteric injury 0.1–1 %
Bladder injury 0.1–1 %
Small bowel obstruction (if intraperitoneal approach was used) (late) 0.1–1 %
Systemic infection/multisystem organ failurea 0.1–1 %
Deatha 0.1–1 %
Urinary retention (urinary catheter – males) 5–20 %
Blood transfusion 1–5 %
Wound drain(s)a All
a
b
period, lymphocele collection, hematoma formation, and wound infection are

the most common. Radiological guidance and sterile technique are required for
drainage of lymphoceles. Catastrophic bleeding is rare, as is blood transfusion.
Cellulitis of the lower limbs is more common due to lymphatic obstruction after
lymphadenectomy, both as a short- and long-term complication. Abscess forma-
tion is rare, but may necessitate operative drainage. Systemic infection is relatively
rare and may lead to multisystem organ failure, which is the main cause of mor-
tality when it occurs, usually related to comorbidities, immunosuppression, or old
age. Skin edge necrosis and skin ulceration can be related to inadvertent dia-
thermy burns or reactions to soluble suture material and is usually adequately man-
aged with dressings for 1–4 weeks. Wound dehiscence is not uncommon if infection
occurs and may be significant, requiring prolonged dressings or vacuum wound
care. Complete abdominal wall dehiscence is very rare. Lymphedema is related
to the degree of removal of the main lymphatic channels and is often minor or mod-
erate in nature, exacerbated by hot weather or fluid retention, but usually controlled
with graduated support stockings. Major lymphedema can occur, either early or
later after surgery, and is largely unpredictable, but can be debilitating and difficult
to alleviate. Lymphatic leakage can occur, but usually resolves spontaneously with
continued dressings. Bladder, ureteric, renal arterial, and bowel injury and also
sexual dysfunction and paralytic ileus are relatively rare, but important, complica-
tions that may be avoidable with careful dissection and retraction.

• Discomfort
• Infection
• Bleeding
• Wound breakdown
• Lymphedema
• Lymphocele
• Lymphatic leak
• Nerve problems
• Organ injury
• Further surgery
Figures 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 5.10, 5.11, 5.12, 5.13, 5.14, 5.15,
5.16, 5.17, 5.18, 5.19, 5.20, 5.21, 5.22 and 5.23 illustrate the various complications
seen in lymphatic surgery.
Fig. 5.1 Fluid collection

after axillary SNG
Fig. 5.2 Arm edema after axillary surgery

Fig. 5.3 Axillary band 1

Fig. 5.6 Blue dye reaction
Fig. 5.7 Blue dye staining in

WLE scar
Fig. 5.8 Blue dye staining

skin
Fig. 5.9 Blue nose SNB

Fig. 5.10 Chylous collection

after neck dissection
Fig. 5.11 Chylous fluid

drained
Fig. 5.12 Flap edema
Fig. 5.13 Grafted after

inguinal-pelvic dissection 2
Fig. 5.14 Grafted after

inguinal-pelvic dissection 3
Fig. 5.15 Hematoma after left radical axillary dissection
Fig. 5.16 Hematoma drained

after left radical axillary
dissection
Fig. 5.17 Infected packed

right inguinal-pelvic LN
dissection
Fig. 5.18 Infected seroma

left axilla
Fig. 5.19 Inguinal-pelvic dissection infection 1
Fig. 5.20 Inguinal-pelvic dissection infection 4

Fig. 5.21 Leg edema post groin SNB surgery
Fig. 5.22 Vacuum dressing

inguinal breakdown
Fig. 5.23 Lymphedema of left arm (note the sparing the hand) from a radical mastectomy and
radical axillary lymph node dissection. Compare this to the right side following a modified radical
mastectomy and level II axillary lymph node dissection performed some 25 years later
Further References, Resources, and Reading
Selective (Sentinel) Lymph Node Biopsy (General)
Albo D, Wayne JD, Hunt KK, Rahlfs TF, Singletary SE, Ames FC, Feig BW, Ross MI, Kuerer
HM. Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast
cancer. Am J Surg. 2001;182:393–8.
Bagaria SP, Faries MB, Morton DL. Sentinel node biopsy in melanoma technical considerations of
the procedure as performed at the John Wayne Cancer Institute. J Surg Oncol. 2010;101(8):669–
76. June 15.
Livingston; 2006.
McMasters KM, Reintgen DS, Ross MI, Wong SL, Gershenwald JE, Krag DN, Noyes D, Viar V,
Cerrito PB, Edwards MJ. Sentinel lymph node biopsy for melanoma: how many radioactive
nodes should be removed? Ann Surg Oncol. 2001;8:192–7.
Morton DL, Cochran AJ, Thompson JF, Elashoff R, Essner R, Glass EC, Mozzillo N, Nieweg OE,
Roses DF, Hoekstra HJ, Karakousis CP, Reintgen DS, Coventry BJ, Wang HJ. Sentinel node
biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international
multicenter trial. Ann Surg. 2005;242:302–11.
Porter GA, Ross MI, Berman RS, Summner WE, Lee JE, Mansfield PF, Gershenwald JE. How
many lymph nodes are enough during sentinel lymphadenectomy for primary melanoma?
Surgery. 2000;128:306–11.
Schrenk P, Rieger R, Shamiyeh A, Wayand W. Morbidity following sentinel lymph node biopsy
versus axillary lymph node dissection for patients with breast cancer. Cancer.
2000;88:608–14.
Temple LK, Baron R, Cody HS, Fey JV, Thaler HT, Borgen PI, Heerdt AS, Montgomery LL,
Petrek JA, Van Zee KJ. Sensory morbidity after sentinel lymph node biopsy and axillary dis-
section: a prospective study of 233 women. Ann Surg Oncol. 2002;9:654–62.
White DC, Schuler FR, Pruitt SK, Culhane DK, Seigler HF, Coleman E, Tyler DS. Timing of
sentinel lymph node (SLN) mapping after lymphoscintigraphy. Surgery. 1999;126:156–61.
Wrightson WR, Wong SL, Edwards MJ, Chao C, Reintgen DS, Ross MI, Noyes RD, Viar V,
Cerrito PB, McMasters KM. Complications associated with sentinel lymph node biopsy for
melanoma. Ann Surg Oncol. 2003;10:676–80.
Cervical Lymph Node Biopsy (Anterior Triangle) (Including

Sentinel Node Biopsy)
Livingston; 2006.
Scalene Node Biopsy (Including Sentinel Node Biopsy)
Livingston; 2006.
Cervical Lymph Node Biopsy (Posterior Triangle) (Including

Livingston; 2006.
Axillary Lymph Node Biopsy
Albo D, Wayne JD, Hunt KK, Rahlfs TF, Singletary SE, Ames FC, Feig BW, Ross MI, Kuerer
HM. Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast
cancer. Am J Surg. 2001;182:393–8.
Livingston; 2006.
Schrenk P, Rieger R, Shamiyeh A, Wayand W. Morbidity following sentinel lymph node biopsy
versus axillary lymph node dissection for patients with breast cancer. Cancer.
2000;88:608–14.
Temple LK, Baron R, Cody HS, Fey JV, Thaler HT, Borgen PI, Heerdt AS, Montgomery LL,
Petrek JA, Van Zee KJ. Sensory morbidity after sentinel lymph node biopsy and axillary dis-
section: a prospective study of 233 women. Ann Surg Oncol. 2002;9:654–62.
Axillary Selective (Sentinel) Lymph Node Biopsy
Burak WE, St H, Zervos EE. Sentinel lymph node biopsy results in less postoperative morbidity
compared with axillary lymph node dissection for breast cancer. Am J Surg.
2002;183(1):23–7.
Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphad-
enectomy for breast cancer. Ann Surg. 1994;220(3):391–401.
Gomez-Rivera F, Santillan A, McMurphey AB, Paraskevopoulos G, Roberts DB, Prieto VG,
Myers JN. Sentinel node biopsy in patients with cutaneous melanoma of the head and neck:
recurrence and survival study. Head Neck. 2008;30(10):1284–94.
Livingston; 2006.
Kim T, Giuliano AE. Lyman GH Lymphatic mapping and sentinel lymph node biopsy in early-
stage breast carcinoma: a meta-analysis. Cancer. 2006;106(1):4–16. Jan 1, Review.
Lyman GH, Giuliano AE, Somerfield MR, Benson 3rd AB, Bodurka DC, Burstein HJ, Cochran AJ,
Cody 3rd HS, Edge SB, Galper S, Hayman JA, Kim TY, Perkins CL, Podoloff DA, Sivasubramaniam
VH, Turner RR, Wahl R, Weaver DL, Wolff AC, Winer EP, American Society of Clinical
Oncology. American Society of Clinical Oncology guideline recommendations for sentinel lymph
node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23(30):7703–20. Oct 20.
Raut CP, Daley MD, Hunt KK, et al. Anaphylactoid reactions to isosulfan blue dye during breast
cancer lymphatic mapping in patients given preoperative prophylaxis. J Clin Oncol.
2004;22(3):567–8.
Sener SF, Winchester DJ, Martz CH. Lymphedema after sentinel lymphadenectomy for breast
carcinoma. Cancer. 2001;92(4):748–52.
Silberman AW, McVay C, Cohen JS, et al. Comparative morbidity of axillary lymph node dissec-
tion and the sentinel node technique: implications for patients with breast cancer. Ann Surg.
2004;240(1):1–6.
Veronesi U, Galimberti V, Mariani L, et al. Sentinel node biopsy in breast cancer: early results in
953 patients with negative sentinel node biopsy and no axillary dissection. Eur J Cancer.
2005;41(2):231–7.
Inguinal Lymph Node Biopsy (Including Sentinel Node Biopsy)
Livingston; 2006.
Pelvic and Retroperitoneal Lymph Node Biopsy (Including

Livingston; 2006.
Functional (Modified Radical Neck Dissection) Cervical

Lymphadenectomy
Ferlito A, Silver CE, Rinaldo A. Neck dissection: present and future? Eur Arch Otorhinolaryngol.
2008;265(6):621–6.
Guggenheim MM, Hug U, Jung FJ, Rousson V, Aust MC, Calcagni M, Künzi W, Giovanoli P.
Morbidity and recurrence after completion lymph node dissection following sentinel lymph
node biopsy in cutaneous malignant melanoma. Ann Surg. 2008;247(4):687–93.
Holmes JD. Neck dissection: nomenclature, classification, and technique. Oral Maxillofac Surg
Clin North Am. 2008;20(3):459–75. Review.
Livingston; 2006.
O’Brien CJ, Shah JP, Balm AJM. Neck dissection and parotidectomy for melanoma. In: Thompson
JF, Morton DL, Kroon BBR, editors. Textbook of melanoma. London: Martin Dunitz; 2004. p.
296–306.
Radical Cervical Lymphadenectomy (Radical Neck Dissection)
Bron LP, O’Brien CJ. Facial nerve function after parotidectomy. Arch Otolaryngol Head Neck
Surg. 1997;123:1091–6.
Ferlito A, Silver CE, Rinaldo A. Neck dissection: present and future? Eur Arch Otorhinolaryngol.
2008;265(6):621–6.
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Morbidity and recurrence after completion lymph node dissection following sentinel lymph
node biopsy in cutaneous malignant melanoma. Ann Surg. 2008;247(4):687–93.
Holmes JD. Neck dissection: nomenclature, classification, and technique. Oral Maxillofac Surg
Clin North Am. 2008;20(3):459–75. Review.
Livingston; 2006.
O’Brien CJ, Coates AS, Petersen-Schaefer K, Shannon K, Thompson JF, Milton GW, McCarthy
WH. Experience with 998 cutaneous melanomas of the head and neck over 30 years. Am J
Surg. 1991;162:310–4.
O’Brien CJ, Petersen-schafer K, Ruark D, Coates AS, Menzies SJ, Harrison RI. Radical, modified,
and selective neck dissection for cutaneous malignant melanoma. Head Neck. 1995;17:232–41.
O’Brien CJ, Shah JP, Balm AJM. Neck dissection and parotidectomy for melanoma. In: Thompson
JF, Morton DL, Kroon BBR, editors. Textbook of melanoma. London: Martin Dunitz; 2004. p.
296–306.
Level I (Limited; Sampling) Axillary Dissection
Livingston; 2006.
Lyman GH, Giuliano AE, Somerfield MR, Benson 3rd AB, Bodurka DC, Burstein HJ, Cochran
AJ, Cody 3rd HS, Edge SB, Galper S, Hayman JA, Kim TY, Perkins CL, Podoloff DA,
Sivasubramaniam VH, Turner RR, Wahl R, Weaver DL, Wolff AC, Winer EP, American
Society of Clinical Oncology. American Society of Clinical Oncology guideline recommenda-
tions for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol.
2005;23(30):7703–20. Oct 20.
Level I and II Axillary Dissection
Livingston; 2006.
Lyman GH, Giuliano AE, Somerfield MR, Benson 3rd AB, Bodurka DC, Burstein HJ, Cochran
AJ, Cody 3rd HS, Edge SB, Galper S, Hayman JA, Kim TY, Perkins CL, Podoloff DA,
Sivasubramaniam VH, Turner RR, Wahl R, Weaver DL, Wolff AC, Winer EP, American
Society of Clinical Oncology. American Society of Clinical Oncology guideline recommenda-
tions for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol.
2005;23(30):7703–20. Oct 20.
Complete (Levels I to III) Radical Axillary Dissection
Livingston; 2006.
Karakousis CP, Bland KI. Surgery of the primary lesions and nodal dissections in malignant mela-
noma. In: Bland KI, Karakousis DP, Copeland EM, editors. Atlas of surgical oncology.
Philadelphia: WB Saunders; 1995. p. 93–128.
Karakousis C, Hena M, Emrich L, Driscoll D. Axillary node dissection in malignant melanoma:
results and complications. Surgery. 1990;108:10–7.
Ollila DW, McCarthy WH, Felger EA. Therapeutic axillary lymph node dissection for metastatic
melanoma. In: Thompson JF, Morton DL, Kroon BBR, editors. Textbook of melanoma.
London: Martin Dunitz; 2004. p. 273–84.
Starritt E, Joseph D, McKinnon JG, Kai Lo S, de Wit JHW, Thompson JF. Lymphedema after
complete axillary node dissection for melanoma: assessment using a new, objective definition.
Ann Surg. 2004;240:866–74.
Inguinal (Groin) Lymph Node Dissection (Subinguinal Groin

Dissection)
Coit DG, Balch CM. Groin and popliteal dissection, technique and complications. In: Balch CM,
Houghton AN, Sober AJ, Soong S-J, editors. Cutaneous melanoma. 4th ed. St Louis: Quality
Medical Publishing; 2003. p. 203.
Hughes TM, Thomas JM. Combined inguinal and pelvic lymph node dissection for stage III mela-
noma. Br J Surg. 1999;86:1493–8.
Livingston; 2006.
Karakousis CP, Thompson JF. Groin and pelvic dissection. In: Thompson JF, Morton DL, Kroon
BBR, editors. Textbook of melanoma. London: Martin Dunitz; 2004. p. 285–95.
Radical Inguino-pelvic (Ilioinguinal) Lymph Node Dissection
noma. Br J Surg. 1999;86:1493–8.
Livingston; 2006.
Pelvic Retroperitoneal Lymph Node Dissection
noma. Br J Surg. 1999;86:1493–8.
Livingston; 2006.
Para-aortic Retroperitoneal Lymph Node Dissection
noma. Br J Surg. 1999;86:1493–8.
Livingston; 2006.
Chapter 6
Splenic Surgery
Brendon J. Coventry and David Watson
The relative risks and complications increase proportionately according to the type
of surgery, site of the splenic lesion, extent of procedure performed, technique, the
complexity of the problem, and lesion size. Extensive or complex surgery usually
carries higher risks of bleeding and infection than smaller procedures, in general
terms. Similarly, risk is relatively higher for recurrent and complex splenic prob-
lems, for associated lymph node dissections, and especially for those or involving
other organs or major vascular structures. Open dissection procedures are typically
associated with a higher frequency and greater range of complications compared to
laparoscopic procedures, in general. This is principally related to the extent of dis-
section and tissue injury.
In general, for many splenic operations the complications are similar in type and
frequency. Laparoscopic approaches carry specific risks of gas embolism and trocar
injury, but open procedures often carry risk of more tissue injury and longer conva-
lescence. Knowledge of the anatomy and the variations commonly seen is helpful
in minimizing nerve, vessel, and organ injury. Surgeons argue the benefits of one
approach over the other, but there is somewhat variable tangible data to demonstrate
differences in terms of the observed or reported complications. Other surgeons will
argue that the use of drains adds to the complication rates, but this needs to be bal-
anced with the extent and risks of bleeding and lymphatic leakage.
B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM (*)

D. Watson, MBBS, MD, FRACS
Department of Surgery, Flinders Medical Centre, Adelaide, Australia
192 B.J. Coventry and D. Watson

quences from splenic surgery might be achieved by:
• Careful planning considering the anatomy, approach, alternatives, and method
Multisystem failure, systemic sepsis, and death are uncommon after splenic
surgery, even with extensive dissection, but are reported and remain a risk. The
underlying reason for the splenectomy, or the presence of high velocity or severe
trauma to other organs in association with the splenic injury, may be strong
determinants of the operative (open) approach, complication risk, and
outcome.
deep venous thrombosis and nerve palsies, especially in prolonged
procedures.
success of complex splenic surgery overall and can significantly reduce risk of com-
plications or aid early detection, prompt intervention, and reduced cost.
Important Note
For diagnostic fine or core needle biopsy complications, see Chap. 2 of Volume
2, lymph node surgery (Chap. 5), or laparotomy (Chap. 2 of Volume 4).
6 Splenic Surgery 193
Laparoscopic Splenectomy
Description
General anesthesia is used. The aim is to remove the spleen, using laparoscopic
techniques, including any small remnant splenunculi (where present), which may be
separate from the main splenic mass. Certain situations and cases are not appropri-
ate for laparoscopic approaches, and open splenectomy should be performed in
these settings (e.g., massive splenomegaly, invasive malignancy, acute trauma
bleeding). The degree of difficulty and relative risk of complications is proportional
to the size of the spleen and the underlying disease process. A range of patient posi-
tions have been used. They usually entail either the supine position or the lateral
position (left side up) – the latter usually provides better exposure. Ports are then
placed and the procedure performed. A small midline, left subcostal or left trans-
verse upper abdominal incision may be used in conjunction for larger or more dif-
ficult spleens. The spleen is mobilized on its pedicle, freeing any adhesions with the
abdominal wall or organs. Occasionally, the splenic flexure of the colon overlies
the spleen and needs to be “taken down” to permit better exposure. In general, the
spleen is freed from its posterior attachments, as well as any attachment to sur-
rounding structures, and it is then lifted toward the midline of the patient to expose
the splenic hilum from behind. A vascular stapling device(s) is then placed across
the splenic pedicle, which ligated and divided, taking care not to injure the pancre-
atic tail. The short gastric vessels are then divided using a stapler to complete divi-
sion of the splenic attachments. Alternatively the vessels entering the spleen can be
individually dissected and divided between clips. The spleen is then placed in a
plastic bag, morcellated (minced), and removed via a laparoscopic port site, or it
can be delivered intact through an abdominal incision. The pedicle and splenic bed
are checked and hemostasis ensured. A drain is usually not used. Accessory splenic
tissue is sought, particularly in idiopathic thrombocytopenic purpura (ITP) cases,
and is removed once identified at any stage during the procedure. All wounds are
then closed.
Anatomical Points
The spleen may be lobulated as a normal variant, as embryologically it forms from

fusion of individual lobules. A fissure may even occur with two or more separate
lobes or separate spleens. Small, usually rounded, deposits of splenic tissue may
exist as splenunculi, often around the splenic hilum, vessels within the lesser sac or
greater omentum. The short gastric vessels may be closely applied to the spleen,
making division difficult and the risk of injury greater. Adhesions to the anterior,
lateral, or posterior abdominal wall, diaphragm, or bowel may occur. The splenic
flexure of the colon may be tethered to the spleen or to the lateral abdominal wall,
reducing access. The tail of pancreas may overlie the splenic hilum where it is at
risk of injury and may also impede access. The splenic vessels may be multiple, and
widely separated, requiring several individual ligations. If a stapler is used, these
variations are less important. The kidney is usually easily separated from the spleen,
but can be adherent on occasions, particularly with malignant involvement or severe
inflammatory processes. An enlarged spleen can migrate toward the right iliac fossa
and render access to the hilum and delivery difficult.
Perspective
See Table 6.1. Splenectomy can range from an elective procedure with a small
spleen for ITP, or for a moderate-sized spleen, or massive spleen for benign or pri-
mary hematological disorders or metastatic malignancy, to an acute procedure for
hemorrhage from splenic trauma in a shocked patient. The degree of difficulty can
vary between these situations markedly, as can the risks and complications. Spill of
splenic blood or tissue (e.g., with rupture) can lead to recurrent ITP or malignancy,
depending on the initial pathology and situation. Infection is more common in
malignant conditions, in immunocompromised individuals, and after multiple
trauma, especially if preexisting or concurrent lung trauma or infection is present,
or in smokers or asthmatics. Infection of a hematoma in the splenic bed may result
in a subphrenic abscess. Inadvertent injury to the bowel or pancreas may result in
infection or a fistula, which can be chronic and debilitating, with slow closure.
Overwhelming post-splenectomy pneumonia or sepsis is very rare, especially after
vaccination against the usual pathogens, pneumococcus and haemophilus, but can
occur (but is rare), and patient education about this and early intervention is very
important. Paralytic ileus is common, but usually resolves spontaneously within a
week. Injury to the adrenal and kidney is very rare. Laparoscopic injury to bowel or
blood vessels is very uncommon, and gas embolism although potentially cata-
strophic is very rare.
Major Complications
Respiratory infection is perhaps the most common complication following open

splenectomy, and it may lead to lobar pneumonia and severe systemic sepsis. It is
uncommon after laparoscopic splenectomy. Bleeding and ongoing oozing can be
significant, especially in patients with coagulopathies; however, hemostasis at sur-
gery usually controls this adequately. Recurrent ITP can be a problem, if ITP was
the reason for splenectomy, and may require intraoperative nuclear scans and fur-
ther surgery. Recurrent malignancy can also occur, if tumor or blood spill occurs
Table 6.1 Laparoscopic splenectomy estimated frequency of complications, risks, and

consequences
Infection
Subcutaneous 1–5 %
Wound 1–5 %
Late – post-splenectomy sepsis (with vaccination) 0.1–1 %
Chest infection 1–5 %
Paralytic ileusa 5–20 %
Conversion to open surgical procedurea 1–5 %
Gas embolus 0.1–1 %
Pancreatic injury/pancreatitis/pancreatic cyst/leakage/pancreatic 0.1–1 %
fistula
Bowel injury (stomach, duodenum, small bowel, colon) 0.1–1 %
Renal/adrenal injury 0.1–1 %
Diaphragmatic injury 0.1–1 %
Small bowel obstruction (early or late) 0.1–1 %
Subphrenic abscess 0.1–1 %
Accessory spleen formationa (mainly ITP; trauma) 0.1–1 %
Splenic conservationb
Prolonged convalescence period 50–80 %
Limitation to activity 50–80 %
Late rupture 0.1–1 %
Multisystem organ failurec 0.1–1 %
Deathd 0.1–1 %
Pain/tenderness
Port-site hernia(s) (avoiding heavy lifting/straining) 0.1–1 %
Drain tube(s)c 5–20 %
a
Incidence may be higher for moderate and massive splenomegaly
b
Splenic preservation may sometimes be possible for splenic traumatic injury
c
Dependent on underlying pathology, surgical technique preferences, and location on the body
d
Mortality is rare from splenectomy, but is closely related to the underlying pathology, co-morbid-
ities and reasons for the splenectomy/ clinical setting
during splenectomy for malignancy. Use of a plastic bag around the spleen during
laparoscopic surgery during delivery of the spleen from the abdomen may reduce
the risk of both forms of recurrence. Wound infection, peritonitis, and intra-
abdominal abscess formation may predispose to wound dehiscence and even
“burst” abdomen. Pancreatic leakage, pseudocyst formation, and fistula forma-
tion are relatively uncommon, but can be very debilitating. Small bowel
obstruction is not uncommon even years after open surgical procedures.

Overwhelming post-splenectomy sepsis is a rare potentially serious later compli-
cation. Bowel injury or vascular injury is uncommon, although greater than for
open splenectomy, and gas embolism although potentially catastrophic is very rare.
Multisystem organ failure and death are rare complications of splenic surgery and
are more commonly associated with systemic sepsis, severe hemorrhage, associated
trauma, and malignancy. Overall, the risk of death is higher for trauma-associated
splenectomy, where open surgical approaches are often used, principally due to
injury to other organs and acute severe hemorrhage†.
Consent AND Risk Reduction

• GA risk
• Pain/discomfort
• Other abdominal organ injury
• Gas embolism
• Possible open operation
Open Splenectomy
Description
General anesthesia and an upper midline or left subcostal abdominal incision are
used. The aim is to remove the spleen, including any small remnant splenunculi
(where present), which may be separate from the main splenic mass. The degree of
difficulty and relative risk of complications is proportional to the size of the spleen
and underlying disease process. A midline, left subcostal or left transverse upper
abdominal incision is usual. The spleen is mobilized on its pedicle, freeing any
adhesions with the abdominal wall or organs. Occasionally, the splenic flexure of
the colon overlies the spleen and needs to be “taken down” to permit better
exposure. In general, the spleen is freed from attachments to surrounding struc-

tures and is then lifted and rotated anteromedially toward the midline, and this
exposes the splenic hilum from behind. A clamp(s) is then placed across the ves-
sels of the splenic pedicle, which are then divided and ligated, while taking care
not to injure the pancreatic tail. The short gastric vessels are then ligated and
divided to complete division of the remaining splenic attachments. The spleen is
then delivered through the abdominal incision and removed. A plastic bag can be
used similarly to laparoscopic surgery to prevent spillage should rupture occur.
The pedicle and splenic bed are checked and hemostasis achieved. A drain may be
used, more for possible pancreatic leakage than bleeding. Accessory splenic tissue
is sought at all stages during the operation, particularly in idiopathic thrombocyto-
penic purpura (ITP) cases, and removed when found. Mass abdominal closure is
usually used.
Anatomical Points
The spleen may be lobulated as a normal variant, as embryologically it forms from

the fusion of individual lobules. A fissure may even occur with two or more separate
lobes or separate spleens. Small, usually rounded, deposits of splenic tissue may
exist as splenunculi, often around the splenic hilum, vessels within the lesser sac or
the greater omentum. The short gastric vessels may be closely applied to the spleen,
making division difficult and the risk of injury greater. Adhesions to the anterior,
lateral, or posterior abdominal wall, diaphragm, or bowel may occur. The splenic
flexure of the colon may be tethered to the spleen or to the lateral abdominal wall,
reducing access. The tail of pancreas may overlie the splenic hilum where it is at
risk of injury and may also impede access. The splenic vessels may be multiple, and
widely separated, requiring several individual ligations. The kidney is usually easily
separated from the spleen, but can be adherent on occasions, particularly with
malignant involvement or severe inflammatory processes. An enlarged spleen can
migrate toward the right iliac fossa and render access to the hilum and delivery
difficult.
Perspective
See Table 6.2. Splenectomy can range from an elective procedure for a small
spleen in ITP, or for a moderate-sized spleen, or massive spleen for benign or
primary hematological or metastatic malignant disorders, to an acute procedure
for hemorrhage from splenic trauma in a shocked patient. The degree of difficulty
can vary between these situations markedly, as can the risks and complications.
Spillage of splenic blood or tissue (e.g., with rupture) can lead to recurrent ITP or
malignancy, depending on the initial pathology and situation. Infection is more
common in malignant conditions, in immunocompromised individuals, and after
Table 6.2 Open splenectomy estimated frequency of complications, risks, and consequences
Infectiona
Wound 1–5 %
Late – post-splenectomy pneumonia/sepsis (with vaccination) 0.1–1 %
Paralytic ileusb 5–20 %
Pancreatic injury/pancreatitis/pancreatic cyst/leakage/pancreatic 1–5 %
fistula
Bowel injury (stomach, duodenum, small bowel, colon)b 0.1–1 %
Renal/adrenal injurya 0.1–1 %
Diaphragmatic injurya 0.1–1 %
Small bowel obstruction (early or late)a 0.1–1 %
Subphrenic abscessa 0.1–1 %
Accessory spleen formationb (mainly ITP; trauma) 0.1–1 %
Deathc 0.1–1 %
Pain/tenderness
Splenic conservationd
Incisional hernia (avoid lifting/straining for 8/52) 0.1–1 %
a
b
Incidence may be higher for moderate and massive splenomegaly
c
Mortality is rare from splenectomy, but is closely related to the underlying pathology, co-morbid-
ities and reasons for the splenectomy/clinical setting
d
multiple trauma, especially if preexisting or concurrent lung trauma or infection

is present, or in smokers or asthmatics. Infection of a hematoma in the splenic bed
may result in a subphrenic abscess. Inadvertent injury to the bowel or pancreas
may result in infection or a fistula, which can be chronic and debilitating, with
slow closure. Overwhelming post-splenectomy pneumonia or sepsis is very rare,
especially after vaccination against the usual pathogens, pneumococcus and hae-
mophilus, but can occur, and patient education about this and early intervention is
very important. Paralytic ileus is common, but usually resolves spontaneously
within a week. Injury to the adrenal and kidney is very rare.
Major Complications
Respiratory infection is perhaps the most common complication and may lead to lobar
pneumonia and severe systemic sepsis. Bleeding and ongoing oozing can be signifi-
cant, especially in patients with coagulopathies; however, hemostasis at surgery usually
controls this adequately. Recurrent ITP can be a problem, if ITP was the reason for
splenectomy, and may require intraoperative nuclear scans and further surgery.
Recurrent malignancy can also occur, if tumor or blood spill occurs during splenec-
tomy for malignancy. Use of a plastic bag around the spleen before splenic ligation may
reduce the risk of both forms of recurrence. Wound infection, peritonitis, and intra-
abdominal abscess formation may predispose to wound dehiscence and even “burst”
abdomen. Pancreatic leakage, pseudocyst formation, and fistula formation are rela-
tively uncommon, but can be very debilitating. Small bowel obstruction is not uncom-
mon even years after surgery. Overwhelming post-splenectomy sepsis is a rare,
potentially serious later complication. Multisystem organ failure and death are rare
complications of splenic surgery and are more commonly associated with systemic sep-
sis, severe hemorrhage, associated trauma, and malignancy. Overall, the risk of death is
higher for trauma-associated splenectomy, where open surgical approaches are often
used, principally due to injury to other organs and acute severe hemorrhage†.

• GA risk
• Pain/discomfort
Laparoscopic Splenectomy
Coventry BJ, Watson DI, Tucker K, Chatterton B, Suppiah R. Intraoperative scintigraphic localiza-
tion and laparoscopic excision of accessory splenic tissue. Surg Endosc. 1998;12(2):159–61.
Kollias J, Watson DI, Coventry BJ, Malycha P. Laparoscopic splenectomy using the lateral posi-
tion: an improved technique. Aust N Z J Surg. 1995;65(10):746–8.
Watson DI, Coventry BJ, Chin T, Gill PG, Malycha P. Laparoscopic versus open splenectomy for
immune thrombocytopenic purpura. Surgery. 1997;121(1):18–22.
Winslow ER, Brunt LM. Perioperative outcomes of laparoscopic versus open splenectomy: a
meta-analysis with an emphasis on complications. Surgery. 2003;134(4):647–53. discussion
654–5.
Winslow ER, Brunt LM, Drebin JA, Soper NJ, Klingensmith ME. Portal vein thrombosis after
splenectomy. Am J Surg. 2002;184(6):631–5. discussion 635–6.
Open Splenectomy
Coventry BJ, Watson DI, Tucker K, Chatterton B, Suppiah R. Intraoperative scintigraphic localiza-
tion and laparoscopic excision of accessory splenic tissue. Surg Endosc. 1998;12(2):159–61.
Watson DI, Coventry BJ, Chin T, Gill PG, Malycha P. Laparoscopic versus open splenectomy for
immune thrombocytopenic purpura. Surgery. 1997;121(1):18–22.
Winslow ER, Brunt LM. Perioperative outcomes of laparoscopic versus open splenectomy: a
meta-analysis with an emphasis on complications. Surgery. 2003;134(4):647–53. discussion
654-5.
Winslow ER, Brunt LM, Drebin JA, Soper NJ, Klingensmith ME. Portal vein thrombosis after
splenectomy. Am J Surg. 2002;184(6):631–5. discussion 635–6.
Chapter 7
Specialized Cancer Procedures and Surgery
John Thompson, Brendon J. Coventry, Douglas Tyler, and Hidde M. Kroon
Isolated Limb Chemotherapy: General Perspective

and Overview
These procedures are used for delivering high-dose regional chemotherapy for
intractable malignant disease confined to a limb, for local disease control, with the
intent of either cure or palliation. Isolated limb perfusion (ILP) is where open surgi-
cal dissection and cannulation of the main limb artery and vein are performed under
general anesthesia, with connection of those vessels to a bypass pump for circula-
tion of chemotherapy to that limb, abrogating or limiting systemic toxic effects.
Isolated limb infusion (ILI) is a technique where open operation is avoided by using
radiological placement of arterial and venous catheters into the main limb vessels
and then under general anesthesia intra-arterial infusion of chemotherapy with cir-
culation using a manual syringe pump, to circulate the chemotherapy to that limb,
abrogating or limiting systemic toxic effects. The risks and complications must be
viewed in terms of what the relative risks are if the procedure was not performed.
J. Thompson, MD (*)
Department of Surgery, Royal Prince Alfred Hospital, Melanoma Institute,
The University of Sydney, Sydney, Australia
L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia
D. Tyler, MD
Chief, Division of Surgical Oncology, Duke University Medical Center, Durham, NC, USA
Vice Chairman, Department of Surgery, Duke University Medical Center, Durham, NC, USA
H.M. Kroon, MD, PhD
Sydney Melanoma Unit, Sydney Cancer Center, Royal Prince Alfred Hospital,
Sydney, New South Wales, Australia

The exact frequency of a particular complication will depend on the type and
extent of disease; the structures already involved by tumor; the individual
patient’s anatomy, comorbidities, and pathology, especially concerning vascular
disease and diabetes; and the type and dose of chemotherapeutic agent
administered.
Repeat infusions or perfusions are typically associated with increased risks of
many of the complications mentioned for the primary procedure.
The frequencies found in some series of ILI or ILP may differ from those men-
tioned in this chapter, and this may be due to selection of different patient groups or
the use of different techniques, agents, inclusion/exclusion criteria, or classification
methods. The frequencies mentioned are estimated to represent the overall expected
and reported relative risks. They may need some modification for specific cases and
situations. The relative risks and complications increase proportionately according
to the site(s) of infusion/perfusion and disease and the vascular supply and condi-
tion of the limb. This is principally related to the surgical accessibility, ability to
correct the problem, blood supply, risk of vascular/tissue/organ injury, hematoma
formation, and technical ease of surgery, including protecting parts of the limb from
damage or injury when desired.
The main serious complications are local and systemic toxicity as a result of the
cytotoxic agents used during the procedure. Normally the toxicity is self-limiting,
but in some cases corticosteroids are needed to reduce the swelling and local inflam-
mation. A fasciotomy of the leg or arm is rarely needed as is the case for amputation
due to local toxicity. Other serious complications are bleeding and infection, which
can be minimized by the adequate exposure, mobilization, reduction of tension, and
ensuring satisfactory blood supply to the distal tissues. Infection is the main sequel
of poor tissue perfusion or hematoma formation and may lead to abscess formation
and systemic sepsis. Multisystem failure and death remain serious potential com-
plications from vascular surgery and systemic infection.
Neural injuries are not infrequent potential problems associated with ILP vas-
cular surgery, because nerves commonly travel with vessels and are at risk of injury
during dissection.
The risk of bowel, bladder, and nerve injury increases with proximity to the
pelvis and is almost exclusively associated with iliac puncture.
deep venous thrombosis and nerve palsies, especially in prolonged procedures.
Limb ischemia, compartment syndrome, and ulnar and common peroneal
nerve palsy are recognized potential complications, which should be checked for,
as the patient’s position may alter during surgery.
This chapter therefore attempts to draw together in one place the estimated over-
all frequencies of the complications associated with ILI and ILP, based on informa-
tion obtained from the literature and experience. Not all patients are at risk of the
full range of listed complications. It must be individualized for each patient and
their disease process, but represents a guide and summary of the attendant risks,
complications, and consequences.
7 Specialized Cancer Procedures and Surgery 203

success of complex ILI/ILP surgery overall and significantly reduces risk of compli-
cations or aids early detection, prompt intervention, and cost.
Important Note
For complications related to other associated/additional surgery that may arise

during ILI or ILP surgery, see the relevant chapter, for example, arterial surgery
(Chap. 3 of Volume 6) or venous surgery (Chap. 4 of Volume 6).
The authors would like to thank Professor Murray Brennan and Dr Mary-Sue Brady,
Memorial Sloan-Kettering Cancer Center, New York, for discussions and comments.
Isolated Limb Infusion Chemotherapy
Description
General anesthesia (GA) is used. The aim is to vascularly “isolate” the limb from
the body and infuse high-dose chemotherapy selectively into the limb. The main
indication is for treatment using chemotherapy of melanoma, soft tissue sarcomas,
and other tumors of the limb not amenable to surgery or other forms of local treat-
ment. This is achieved by preoperatively inserting arterial and venous catheters
under radiological guidance into the femoral artery and vein with the catheter tips
located at about the popliteal fossa. Under GA, the procedure is then performed
using an isolating high-pressure cuff (pneumatic tourniquet) placed proximally on
the limb, and chemotherapeutic agent(s) is infused via the arterial catheter, then
aspirating the limb fluid from the venous catheter and circulating this through a
warming coil set at 42 °C for reinfusion back into the arterial catheter and limb. The
limb and patient are further heated throughout using hot air blankets, and sometimes
a radiant heater is placed over the isolated limb or the operating theater is warmed.
Multiple cycles of this are performed to exclusively expose the limb tissues to the
chemotherapy agent(s). The agent is then washed out with saline, before release of
the cuff to restore the normal vascular flow. The chemotherapy affects all limb tis-
sues, but the aim is for a great toxic effect on the tumor tissues, while limiting the
toxicity to the healthy tissues. The procedure can be used for either lower or upper
limbs and can usually be repeated several times in a similar fashion to the first treat-
ment because there is virtually no scar tissue formed due to its minimally invasive
character. The foot or hand is usually excluded from the effects of chemotherapy
infusion using a compressive Esmarch-type bandage, unless there is tumor involve-
ment of the foot or hand. When chemotherapy is administered to the foot or hand,
normal tissues are also exposed and are at risk of toxic reactions to the chemothera-
peutic agent(s), including desquamation and soft tissue necrosis.
Anatomical Points
Suitable patency of the iliac and femoral vessels is essential for adequate catheter-
ization and infusion. Satisfactory outflow of the arterial tree is also preferable.
Stenoses of the main arterial vessels can sometimes be dilated before catheteriza-
tion. Unusual arterial or venous anomalies can create pooling of concentrated che-
motherapy and result in increased local toxicity.
Perspective
See Table 7.1. Isolated limb infusion (ILI) chemotherapy is associated with many
risks and complications; however, these should be balanced against the risks of
uncontrolled growth of the limb tumor(s) from nontreatment or other treatments.
ILI most commonly has complications that are restricted to the extremity being
treated, but rarely systemic effects related to leakage of the chemotherapeutic agents
from the isolated extremity into the systemic circulation are seen, causing consider-
able systemic toxicity. Common complications are skin desquamation, limb swell-
ing, and muscle stiffness. Skin redness or chemical cellulitis typically indicates the
desired effect of the chemotherapy; however, it may be quite symptomatic and is
therefore listed as a “complication.” Limb swelling may occasionally produce a
threatened or actual compartment compression syndrome, sometimes requiring lon-
gitudinal fasciotomy. Other major, but rare, complications include extensive skin
ulceration, skin necrosis, muscle necrosis, nerve toxicity, bone injury, limb isch-
emia, “trash” limb, limb stiffness, chronic pain, and, very rarely, limb amputation.
Major Complications
Major complications can occur and can require further surgery, which results in
prolonged hospitalization. Skin reaction to the cytotoxic drug used can be exten-
sive leading to extensive skin ulceration, and skin necrosis can be significant lead-
ing to loss of areas of tissue that may need reconstruction using flap repair or skin
grafting. Particularly, the hand, palm, and foot sole are sensitive to high-dose che-
motherapy resulting in troublesome blistering and desquamation (if an Esmarch
bandage is not used). Skin erythema is common and usually develops 4–7 days
after ILI. Muscle necrosis may lead to scarring and muscle stiffness, associated
with loss of mobility and function. Nerve toxicity can lead to loss of sensation or
acute and chronic pain. Bone pain, although very rare, can occur if isolated limb
infusion is performed after radiotherapy. Bleeding and hematoma formation, and
occasionally false aneurysm, can result from the arterial puncture site after removal
of the large (6 Fr) catheter, which may require surgery. Infection can occur either
superficially or rarely of deeper limb tissues. Severe limb swelling may occasion-
ally produce a compartment compression syndrome, sometimes requiring longi-
tudinal fasciotomy. Limb ischemia can result from dislodgement of atheroma or
can be due to “trash” limb after release of the ischemia. This can rarely be irrevers-
ible and seldom results in amputation. Multisystem organ failure and systemic
sepsis are very rare. Mortality is exceedingly rare from ILI and more likely from
tumor spread (see Figs. 7.1 and 7.2).
Table 7.1 Isolated limb infusion chemotherapy estimated frequency of complications, risks, and
consequences
Complications, risks and consequences Estimated frequency
Infection
Groin wounds (catheter sites) 0.1–1 %
Cellulitis 1–5 %
Systemic 0.1–1 %
Bleeding/hematoma formation (at site of vascular catheter insertion) 1–5 %
Tumor recurrence/progressiona 20–50 %
Compartment syndrome (may require fasciotomy) 1–5 %
Leg/arm swelling
Acute >80 %
Chronic 1–5 %
Muscle weaknessa
Acute 50–80 %
Chronic 1–5 %
Muscle stiffnessa
Acute 50–80 %
Chronic 1–5 %
(continued)

Complications, risks and consequences Estimated frequency
Reduced range of movement/mobilitya
Acute >80 %
Chronic 1–5 %
Muscle necrosisa 1–5 %
Numbness and paresthesiaa
Acute 50–80 %
Chronic 1–5 %
Nerve injurya
Motor nerve injurya 1–5 %
Sensory nerve injurya
Acute 5–20 %
Chronic 1–5 %
Femoral (sciatic or obturator) nerve injury (pneumatic cuff) 0.1–1 %
Skin reaction (also chemical cellulitis)a
Acute 50–80 %
Chronic 1–5 %
Skin desquamation (overall)a 20–50 %
Skin ulceration/necrosis (overall)a 1–5 %
Systemic chemotherapy leakage and toxicitya
Bone marrow toxicity 0.1–1 %
Nausea and vomiting 0.1–1 %
Lymphatic fluid leak (catheter or other wounds)a 0.1–1 %
Major iliac, femoral, or popliteal arterial/venous injurya 0.1–1 %
Embolization (thrombus or atheroma) 0.1–1 %
Trash or ischemic leg/foot 0.1–1 %
Amputation of leg (due to toxicity from the procedure)a 0.1–1 %
Deep venous thrombosis 0.1–1 %
False aneurysm 0.1–1 %
Multisystem organ failurea < 0.1 %
Death (<30 day)a <0.1 %
Pain/tenderness [limb pain; wound pain]
Chronic (>12 weeks)a (including muscle pain) 5–20 %
Skin discoloration >80 %
Loss of hair, nails 0.1–1 %
Groin/scrotal/perineal edema 0.1–1 %
Blood transfusiona 0.1–1 %
Wound scarring/deformitya – poor cosmesis 1–5 %
a
Dependent on underlying pathology, anatomy, technique, chemotherapy agent used, surgeon pref-
erences, and comorbidities
Fig. 7.1 Late complete response after ILI for melanoma showing muscle fibrosis and contraction
of the lower leg, which has not overly influenced mobility
Fig. 7.2 Post-ILI early cellulitis changes within weeks of the procedure

• Discomfort
• Bleeding*
• False aneurysm*
• Distal embolization*
• Further surgery
*Dependent on catheter size and site
Hyperthermic Isolated Limb Perfusion Surgery

and Chemotherapy
Description
General anesthesia (GA) is used. Hyperthermic isolated limb perfusion (HILP)

chemotherapy is a surgical procedure for treating advanced malignancies of the
extremities, most commonly utilized in the management of recurrent melanoma,
soft tissue sarcomas, and other tumors of the limb not amenable to surgical resec-
tion. The procedure initially involves dissecting out the major artery and vein of
into the limb. For the lower limb, this is usually the iliac or femoral artery and vein.
For the upper limb, this is usually the infraclavicular axillary artery and vein or the
upper brachial artery and vein. In addition to controlling the major vessels both
proximally and distally, any smaller collateral vessels are either controlled or
ligated. The patient is then systemically heparinized, the vessels clamped, and
large-bore arterial and venous catheters are placed into the artery and vein, respec-
tively. Once the arterial and venous cannulas are in place, a tourniquet is wrapped
tightly around the extremity proximal to the cannulas. At this point, the cannulas
are connected to a pump oxygenator, and the extremity is put on bypass. Through a
combination of warming blankets and heated perfusate, the extremity is heated to
between 38.5 °C and 41 °C. Using technetium-labeled red blood cells injected into
the systemic circulation (small dose) and the isolated extremity (25-fold higher
dose than that injected systemically), the isolated nature of the extremity is not only
confirmed, but a leak rate, if any, can be calculated by the measurement of radioac-
tive levels with a gamma counter placed over the heart. When it is confirmed that
no leak is present, the chemotherapy is injected into the extremity and perfused
continuously for 1 h. The chemotherapy is then washed out with dextran; the
extremity is taken off the bypass, and the normal circulation is restored. The vessels
are repaired and the incision closed. Precise details of the procedure depend on the
site and extremity being perfused. The foot or hand is usually excluded from the
effects of chemotherapy infusion using a compressive Esmarch-type bandage,
unless there is tumor involvement of the foot or hand. When chemotherapy is
administered to the foot or hand, normal tissues are also exposed and are at risk of
toxic reactions to the chemotherapeutic agent(s), including desquamation and soft
tissue necrosis.
Anatomical Points
Anatomical variation depends on the site being perfused. Generally, venous anat-
omy is more variable than arterial anatomy. Passage of cannulas in the arterial sys-
tem is usually easy, unless atherosclerotic plaques are present. Passage of cannulas
in veins may be more difficult due to valves in the vessels. Prior surgery on the
extremity can lead to a higher likelihood of edema. Awareness of the course of the
nerves of the brachial plexus for upper extremity perfusions and the femoral nerve
for lower extremity perfusions is important. Repeat perfusions should generally be
restricted to the brachial and femoral regions. Excessive scarring can make a repeat
operation in the infraclavicular axillary, iliac, and popliteal regions very difficult
especially when dissecting out the venous structures.
Perspective
See Table 7.2. HILP, like isolated limb infusion, is associated with many risks and
complications. These complications, however, should be balanced against the risks
of uncontrolled growth of the limb tumor(s) being treated, should that treatment not
be offered. Consideration might also be given to using ILI, with potentially lower
risk profile, where available and appropriate. Most of the complications are minor
in most cases when they occur. Regional perfusion treatments most commonly have
complications that are restricted to the extremity being treated, but occasionally
systemic effects related to leak of the chemotherapeutic agents from the isolated
extremity into the systemic circulation are seen. In most centers, systemic leak rates
are reported from 2 % to 27 %, when an effort is made to control collateral vessels,
and continuous monitoring for leak is carried out during the procedure. Significant
systemic manifestations of leak are usually related to the toxicities of the type of
chemotherapy used. For melphalan, the most common agent used, the side effects
include nausea and vomiting in the immediate post-perfusion period and neutrope-
nia, which occurs 10–12 days after the procedure. Systemic leak of tumor necrosis
factor alpha (TNF-α) can cause fever, hypotension, and respiratory distress.
Regional toxicities can be minimized by keeping ischemic time to the extremity
during the procedure as short as possible and keeping limb temperatures below
40 °C. In addition, careful monitoring of the limb postoperatively to avoid the sequel
of a compartment syndrome is imperative. Serial measurements of creatinine
Table 7.2 Isolated limb perfusion surgery chemotherapy estimated frequency of complications,
Infection
Groin wounds (catheter sites) 1–5 %
Cellulitis 1–5 %
Systemic 1–5 %
Bleeding/hematoma formation (at site of vascular catheter insertion) 1–5 %
False aneurysm 1–5 %
Tumor recurrence/progressiona 20–50 %
Compartment syndrome (may require fasciotomy) 1–5 %
Numbness and paresthesiaa
Acute 50–80 %
Chronic 1–5 %
Nerve injury
Motor nerve injurya 1–5 %
Sensory nerve injurya
Acute 5–20 %
Chronic 1–5 %
Femoral (sciatic or obturator) nerve injury (pneumatic cuff) 0.1–1 %
Leg/arm swelling
Acute >80 %
Chronic 1–5 %
Muscle weaknessa
Acute 50–80 %
Chronic 1–5 %
Muscle stiffnessa
Acute 50–80 %
Chronic 1–5 %
Reduced range of movement/mobilitya
Acute >80 %
Chronic 1–5 %
Muscle necrosis 1–5 %
Neurological (cerebral) impairment 1–5 %
Lymphatic fluid leak (catheter or other wounds) 1–5 %
(also chemical)
Systemic chemotherapy leakage and toxicitya
Bone marrow toxicity 1–5 %
Nausea and vomiting 5–20 %
Skin reaction (also chemical cellulitis)a
Acute 50–80 %
Chronic 1–5 %
Skin desquamation 50–80 %
Skin ulceration/necrosis (overall) 1–5 %
Major iliac, femoral, or popliteal arterial/venous injurya 0.1–1 %

Embolization (thrombus or atheroma)a 0.1–1 %
Trash leg/foota 0.1–1 %
Amputation of leg (due to toxicity from the procedure)a 0.1–1 %
Deep venous thrombosisa 0.1–1 %
Disseminated intravascular coagulation 0.1–1 %
Death (<30 day)a 0.1–1 %
Pain/tenderness [limb pain; wound pain]
Chronic (>12 weeks)a (including muscle pain) 5–20 %
Numbness and paresthesia 50–80 %
Skin discoloration >80 %
Loss of hair, nails 0.1–1 %
Groin/scrotal/perineal edema 5–20 %
Blood transfusiona 0.1–1 %
Wound scarring/deformitya – poor cosmesis 1–5 %
a
Dependent on underlying pathology, anatomy, surgical technique, and surgeon preferences
phosphokinase (CPK) should be performed every 8 h for the first 2 days and once a
day thereafter for the remainder of the hospitalization. About two-thirds of patients
will develop a rise in CPK, most with an early peak in the first 1–4 days post perfu-
sion. About 10 % of patients will have a CPK peak on or after the fifth post-perfusion
day. Severe limb toxicity is most frequently seen in patients whose CPK rises above
1,000 IU/L and/or have a late peak CPK pattern. In these situations, where neces-
sary, there should be a low threshold for performing fasciotomies if symptoms
develop, to prevent a compartment syndrome from developing. Serial measurement
of compartment pressures may also be helpful.
Major Complications
The major complications from HILP are compartment syndrome and extremity
damage necessitating amputation, which in some series run as high as 15 % and
3 %, respectively. Although amputation usually follows a compartment syndrome
caused by a severe toxic reaction to the chemotherapeutic drugs that was recog-
nized too late, it may also occur as the result of vascular injuries resulting from
the instrumentation of the major limb vessels during the procedure. Even with
aggressive monitoring as described above, muscle damage from melphalan or
other agents can, on rare occasions, be severe enough that amputation is ulti-
mately required despite early fasciotomy. Skin erythema is common and usually
develops 5–10 days after perfusion. Skin reactions and edema usually resolve
4–10 weeks after HILP. Skin ulceration and necrosis may take longer. Limb
swelling can be influenced by whether a lymph node dissection has been done and
is done in conjunction with the perfusion and the site of the perfusion. When
patients do develop limb edema, an ultrasound should be performed to rule out a
deep venous thrombosis which if present would require long-term anticoagula-
tion. Infection is usually minor; however, deep tissue infections can occur.
Bleeding from the arteriotomy site can occur, and a false aneurysm rarely devel-
ops; however, further surgery may be required. Repeat perfusions are at greater
risk of arterial injury and bleeding due to the invasive nature of the procedure and
the formation of scar tissue. Many patients develop muscle stiffness and
decreased mobility of the extremity that may persist in up to 25 % of patients
with long-term follow-up. Physical therapy can be important in helping to maxi-
mize extremity motion in the postoperative period. Multisystem organ failure
and systemic sepsis may rarely occur and are the most common causes of mortal-
ity when it rarely occurs.

• Discomfort
• Bleeding*
• False aneurysm*
• Distal embolization*
• Further surgery
*Dependent on catheter size and site
Retroperitoneal Surgery: Retroperitoneal Tumor

Surgery +/− Biopsy
Description
General anesthesia is used. The main tumors presenting as masses arising from the
retroperitoneal tissues are sarcomas and lymphomas. Occasionally, carcinomas
arising from the retroperitoneal portions of the ascending or descending colon or
duodenum or metastatic tumor masses (notably testicular carcinoma or melanoma)
can present in the same manner. Tumors are not always malignant. Other rare pri-
mary and metastatic tumors constitute the remainder. Bowel obstruction may be a
feature of all of these tumor types. Surgery is determined by the location and extent
of disease, but resection of the abdominal mass is typical, with surrounding lymph
nodes and involved organs, if appropriate. Adjuvant radiotherapy may be used. The
extent of resection and consequent complications is largely determined by the loca-
tion and extent of disease. Relatively large incisions are often required depending
on tumor size and required access. Midline and inverted Y incisions are relatively
popular.
Anatomical Points
The anatomical origin and extent of the tumor and the displacement or involvement
of adjacent organs largely determine the surgery required, and this may be reason-
ably planned preoperatively using CT, MRI, ultrasound, PET, and other scans.
Angiography may be helpful.
Perspective
See Table 7.3. Extensive surgery is associated with a higher rate of complica-
tions and notably major complications. Severe bleeding and injury to adjacent
structures are the most immediately devastating issues that can lead to further
major complications, such as infection, particularly peritonitis and abscess for-
mation. Injury to the pancreas may invoke pancreatitis or pancreatic leakage,
leading to a pancreatic collection, which may become infected and sometimes
form an external fistula. These can be chronic and debilitating. Seromas or lym-
phatic collections are not uncommon, but may not be symptomatic, unless large,
compressing other structures, or infected. Small bowel obstruction due to adhe-
sions from the extensive dissection and radiotherapy can be recurrent and may
require surgery. Colostomy or ileostomy may be required for bowel
involvement.
Major Complications
Bleeding and infection can be major issues leading to systemic sepsis and even
multisystem organ failure, which is a significant cause of early mortality. Later
mortality is due to tumor recurrence or persistence. Peritonitis, and sometimes
abscess formation, can also be significant complications. Pancreatic leak, collec-
tion, and fistula can also be debilitating. Bowel injury (or involvement) may require
stoma formation (colostomy and/or ileostomy) to reduce infective risk. Significant
lymphatic leakage may occur from thoracic duct injury, leading to lymphatic
ascites or collection. Renal or ureteric injury may be significant and precipitate
urinary infections or further, later surgery. Use of ureteric stents inserted preopera-
tively may be helpful in reducing ureteric injury. Small bowel obstruction may be
Table 7.3 Retroperitoneal tumor surgery +/− biopsy estimated frequency of complications, risks,
and consequences
Infectiona
Wound 1–5 %
Intra-abdominal 1–5 %
Late – post splenectomy pneumonia/sepsis (with vaccination) <1 %
Pancreatic injury/pancreatitis/pancreatic cyst/leakage/pancreatic fistulaa 1–5 %
Bowel injury (stomach, duodenum, small bowel, colon)b 1–5 %
Radiation-induced enteritisa 5–20 %
Seroma, lymphocele formation/lymph ascites/fistula 1–5 %
Small bowel obstruction (early or late)a 1–5 %
Renal/adrenal injury (including contralateral)a 0.1–1 %
Bladder injurya 0.1–1 %
Diaphragmatic injurya 0.1–1 %
Subphrenic abscessa 0.1–1 %
Stoma formationa 0.1–1 %
Death (<30 days)e 0.1–1 %
Paralytic ileusb 20–50 %
Nerve injury (lumbar plexus or branches, sympathetic chain)a 0.1–1 %
Incisional hernia (avoiding lifting/straining for 8 weeks) 0.1–1 %
Splenic conservation after injuryc, d
a
b
Incidence may be higher for large masses
c
Dependent on splenic involvement and relative risk of injury, i.e., site of surgery
d
e
Mortality is rare, but is closely related to the underlying pathology, adjacent organ involvement,
co-morbidities and clinical setting
a recurrent major issue, often treated well conservatively, but surgery may be
required. Further surgery may also be required for recurrence or metastasis of
tumor. Long-term survival results can be obtained, sometimes surprisingly, despite
apparent extensive tumor involvement.

• GA risk
• Pain/discomfort/neuralgia
• Possible stoma
• Renal impairment
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Index
A Arm lymphedema, modified radical

Abscess formation mastectomy
modified radical mastectomy female, 33
female, 21 male, 22
male, 33 Axillary lymphadenectomy
pelvic retroperitoneal lymph node for breast cancer, 147
dissection, 170 complete radical axillary dissection,
radical inguino-pelvic lymph node 154–157
dissection, 166 level I axillary dissection
retroperitoneal surgery, 213 anatomic variance, 149
Accessory XI nerve injury, in cervical complications, 150
lymph node biopsy, 126 description, 148
Addisonian crisis, 108, 111–112 and level II dissection, 150–153
Adrenalectomy. See Adrenal gland surgery perspective, 149–150
Adrenal gland surgery for melanoma, 147
laparoscopic adrenalectomy Axillary lymph node biopsy
anatomical points, 105–106 anatomical considerations, 128–129
complications, 108–109 complications, 130
description, 105 description, 128
medical considerations, 106–108 perspective, 129–130
perspective, 106 Axillary lymph node dissection procedures,
open adrenalectomy 4, 131, 150–153, 156
anatomical points, 109–110 Axillary vein thrombosis, modified radical
complications, 110–112 mastectomy, 22, 34
description, 109 Axillary vessel injury
medical considerations, 106–108 axillary lymph node dissection, 150, 153, 156
perspective, 110 male breast surgery, 33
Adrenal surgery, 1
Adverse capsular contracture (ACC), 40, 44
Amputation B
HILP, 211 Biopsy
ILP, 205 Cervical lymph node (see Cervical lymph
Anaphylactic reaction, sentinel lymph node biopsy)
node biopsy, 120 excisional breast biopsy, 5–7
Angiosarcoma, of upper extremity, 22, 34 incisional, 5

DOI 10.1007/978-1-4471-5421-1, © Springer-Verlag London 2014
220 Index
Biopsy (cont.) description, 26

inguinal lymph node (see Inguinal perspective, 26
lymph node biopsy) Breast cancer
mammographically detected lesions, axillary lymphadenectomy, 147
localization axillary sentinel lymph node biopsy
anatomical points, 9 anatomic variance, 131
complications, 9–10 description, 131
description, 8–9 perspective, 131–133
perspective, 9 Breast implants
nipple (see Nipple) anatomical points, 37
sentinel node, 11 complications, 38–40
SLN biopsy, 116–117 description, 37
anatomical variation, 118 displacement, 38
complications, 120 perspective, 38
description, 118 Breast surgery, 1
perspective, 119–120 deep venous thrombosis and nerve palsies, 4
Bleeding female
cervical lymph node biopsy, 126 breast abscess drainage, 26–28
chemotherapy ILP, 205 duct and nipple surgery, 23–25
functional cervical lymphadenectomy, 143 excisional breast biopsy, 5–7
HILP, 212 mammographically detected lesions,
inguinal lymph node dissection, 161 localization biopsy, 8–10
isolated limb perfusion, 202 modified radical mastectomy, 17–22
laparoscopic splenectomy, 194 nipple biopsy, 28–30
minimally invasive parathyroidectomy, 92 partial mastectomy, 14–17
open adrenalectomy, 110 subcutaneous mastectomy, 12–14
open splenectomy, 199 male
para-aortic retroperitoneal lymph node gynecomastia, 34–37
dissection, 172 modified radical mastectomy, 30–34
pelvic and retroperitoneal lymph node patient positioning, 4
biopsy, 137 postoperative care, 4
pelvic retroperitoneal lymph node preoperative assessment, 4
dissection, 170
radical cervical lymphadenectomy, 146
radical inguino-pelvic lymph node C
dissection, 166 Capsule formation, breast implants, 38, 43, 44
retroperitoneal surgery, 213 Carbon-track localization. See Biopsy
sentinel lymph node biopsy, 120 Cellulitis
Blistering, chemotherapy ILP, 205 inguinal lymph node biopsy, 135
Blue dye staining inguinal lymph node dissection, 161
axillary lymph node biopsy, 130 para-aortic retroperitoneal lymph node
cervical lymph node biopsy, 122, 127 dissection, 174
scalene node biopsy, 125 pelvic retroperitoneal lymph node
sentinel lymph node biopsy, 120 dissection, 170
in skin, 178 radical inguino-pelvic lymph node
in WLE scar, 177 dissection, 166
Bone pain, chemotherapy ILP, 205 Central duct excision. See Duct and nipple
Bowel injury, retroperitoneal surgery, 213 surgery
Bowel perforation, adrenalectomy, 108, 111 Cervical lymph node biopsy
Brachial plexus injury anterior triangle, 121–122
axillary lymph node dissection, 150, 153, 156 posterior triangle
modified radical mastectomy, 22, 34 anatomical points, 126
Breast abscess drainage complications, 126–127
anatomical points, 26 description, 125–126
complications, 27–28 perspective, 126, 127
Index 221
Chemotherapy, isolated limb perfusion description, 5–6

anatomical points, 204 perspective, 6
complications, 205–208 Extremity damage, HILP, 211
general anesthesia, 203–204 Extrusion, breast implants, 38
hyperthermic isolated limb perfusion
surgery (see Hyperthermic isolated
limb perfusion (HILP)) F
perspective, 204 Facial nerve injury
Compartment syndrome functional cervical
HILP, 211 lymphadenectomy, 143
isolated limb perfusion, 202 radical cervical
Core biopsy lymphadenectomy, 146
breast hematoma, 11 False-negative sentinel node
of lymph nodes, 115 axillary SLN biopsy,
Cosmetic deformity breast cancer, 133
functional cervical sentinel lymph node biopsy, 120
lymphadenectomy, 143 Fasciotomy, HILP, 211
radical cervical lymphadenectomy, 146 Female breast surgery
breast abscess drainage, 26–28
duct and nipple surgery, 23–25
D excisional breast biopsy, 5–7
Death mammographically detected lesions,
adrenalectomy, 108, 112 localization biopsy, 8–10
breast surgery, 4 modified radical mastectomy, 17–22
isolated limb perfusion, 202 nipple biopsy, 28–30
laparoscopic splenectomy, 196 partial mastectomy, 14–17
open splenectomy, 199 subcutaneous mastectomy, 12–14
sentinel lymph node biopsy, 120 Fine-needle aspiration biopsy,
Deep venous thrombosis of lymph nodes, 115
adrenal gland surgery, 104 Fistula
breast surgery, 4 breast abscess drainage, 26
HILP, 212 cervical lymphadenectomy, 143
splenic surgery, 192 retroperitoneal surgery, 213
Desquamation, chemotherapy ILP, 205 Free transverse rectus abdominis
Discomfort myocutaneous flap reconstruction
axillary lymph node biopsy, 129–130 anatomical points, 50–52
cervical lymph node biopsy, 126 complications, 53–55
scalene node biopsy, 124 description, 50
sentinel lymph node biopsy, 119–120 perspective, 53
Duct and nipple surgery Frozen shoulder, axillary lymph node
anatomic points, 23–24 dissection, 157
complications, 25 Functional cervical lymphadenectomy
description, 22–23 anatomical considerations, 141
perspective, 23–25 complications, 143
Dysthesia, axillary lymph node dissection, description, 140–141
150, 153, 157 perspective, 141–143
E G
Edema Gas embolism, adrenalectomy, 108
flap, 180 Gynecomastia
HILP, 211–212 anatomical points, 35
Excisional breast biopsy complications, 35–37
anatomical points, 6 description, 34–35
complications, 6–7 perspective, 35
222 Index
H I
Hadfields procedure. See Duct Idiopathic thrombocytopenic purpura (ITP)
and nipple surgery laparoscopic splenectomy, 194–195
Hematoma open splenectomy, 199
abdominal wall, 55 ILP. See Isolated limb perfusion (ILP)
after left radical axillary dissection, 181 Incisional hernia, pelvic and retroperitoneal
axillary lymph node biopsy, 130 lymph node biopsy, 137
cervical lymph node biopsy, 127 Incomplete carcinoma excision, 17
chemotherapy ILP, 205 Infection
core biopsy breast, 11 axillary lymph node biopsy, 130
functional cervical breast implants, 38
lymphadenectomy, 143 cervical lymph node biopsy, 127
gynecomastia, 35 gynecomastia, 36
inguinal lymph node biopsy, 135 HILP, 212
inguinal lymph node dissection, 161 isolated limb perfusion, 202
minimally invasive modified radical mastectomy
parathyroidectomy, 92 female, 21
modified radical mastectomy male, 33
female, 21 pelvic and retroperitoneal lymph node
male, 33 biopsy, 137
para-aortic retroperitoneal lymph node radical cervical lymphadenectomy, 146
dissection, 174 retroperitoneal surgery, 213
partial mastectomy, 11 scalene node biopsy, 124–125
pelvic and retroperitoneal lymph node sentinel lymph node biopsy, 120
biopsy, 137 systemic, breast abscess, 27
pelvic retroperitoneal lymph node Inguinal lymph node biopsy
dissection, 170 anatomical points, 134
radical cervical lymphadenectomy, 146 complications, 135–136
radical inguino-pelvic lymph node description, 134
dissection, 166 perspective, 134–135
scalene node biopsy, 124 Inguinal lymph node dissection, 157
segmentectomy, 17 anatomical points, 159
subcutaneous mastectomy, 14 complications, 161
Hemithyroidectomy. See Partial thyroidectomy description, 158–159
Hemorrhage perspective, 159–161
breast implants, 38 Intercostobrachial nerve injury, axillary lymph
cervical lymph node biopsy, 126 node dissection, 150, 153, 157
male breast surgery, 33 Isolated limb perfusion (ILP)
modified radical mastectomy, 21 chemotherapy
scalene node biopsy, 124 anatomical points, 204
HILP. See Hyperthermic isolated limb complications, 205–208
perfusion (HILP) general anesthesia, 203–204
Hookwire/Carbon-track localization. See hyperthermic isolated limb perfusion
Biopsy surgery (see Hyperthermic isolated
Hypercalcemia, minimally invasive limb perfusion (HILP))
parathyroidectomy, 92 perspective, 204
Hyperparathyroidism, minimally invasive complication frequency, 202
parathyroidectomy, 92 high-dose regional chemotherapy, 201
Hyperthermic isolated limb hyperthermic (see Hyperthermic isolated
perfusion (HILP) limb perfusion (HILP))
anatomical points, 209 late complete response after, 207
complications, 211–212 patient positioning, 202
description, 208–209 post-ILI cellulitis, 207
general anesthesia, 208 postoperative care, 203
perspective, 209–211 preoperative assessment, 203
Index 223
L high-quality postoperative care, 117

Laparoscopic adrenalectomy infected seroma left axilla, 182
anatomical points, 105–106 inguinal lymph node
complications, 108–109 biopsy, 134–136
description, 105 dissection, 158–161
left, 108 inguinal-pelvic dissection
medical considerations, 106–108 infection, 183
perspective, 106 inguinal-pelvic dissections, 180
right, 108 leg edema post groin SNB
Laparoscopic splenectomy surgery, 184
anatomical points, 193–194 multidisciplinary input, 117
complications, 194–196 neck lymph node dissections, 139, 140
description, 193 para-aortic retroperitoneal lymph
perspective, 194, 195 node dissection, 171–174
Latissimus dorsi (LD) flap breast pelvic and retroperitoneal lymph node
reconstruction biopsy, 136–138
anatomical points, 41 pelvic retroperitoneal lymph node
complications, 44–46 dissection, 167–170
description, 40–41 preoperative assessment, 117
perspective, 41–45 radical cervical lymphadenectomy,
Limb ischemia, isolated limb 144–146
perfusion, 202 radical inguino-pelvic lymph node
Limb swelling, HILP, 212 dissection, 162–166
Lumpectomy. See Excisional breast biopsy scalene node biopsy, 123–125
Lymphatic ascites/collection, retroperitoneal sentinel lymph node biopsy, 116–117
surgery, 213 anatomical variation, 118
Lymphatic leaks complications, 120
cervical lymph node biopsy, 127 description, 118
functional cervical perspective, 119–120
lymphadenectomy, 143 specialized units, use of, 117
inguinal lymph node biopsy, 135 vacuum dressing inguinal
inguinal lymph node dissection, 161 breakdown, 184
para-aortic retroperitoneal lymph node Lymphedema
dissection, 174 axillary lymph node biopsy, 130
pelvic retroperitoneal lymph node axillary lymph node dissection, 150,
dissection, 170 152–153, 156
radical cervical lymphadenectomy, 146 axillary SLN biopsy,
radical inguino-pelvic lymph node breast cancer, 133
dissection, 166 inguinal lymph node dissection, 161
retroperitoneal surgery, 213 para-aortic retroperitoneal lymph
scalene node biopsy, 124 node dissection, 174
Lymphatic surgery, 1 pelvic retroperitoneal lymph node
arm edema, after axillary surgery, 175 dissection, 170
axillary bands, 176–177 radical inguino-pelvic lymph node
axillary lymphadenectomy (see Axillary dissection, 166
lymphadenectomy) sentinel lymph node biopsy, 120
axillary lymph node biopsy, 128–130 Lymphoceles
axillary SLN biopsy, 131–133 cervical lymph node biopsy, 127
cervical lymph node biopsy, 121–122, inguinal lymph node biopsy, 135
125–127 inguinal lymph node dissection, 161
chylous fluid collection, 179 para-aortic retroperitoneal lymph node
flap edema, 180 dissection, 174
fluid collection, after axillary SNG, 175 radical inguino-pelvic lymph node
functional cervical lymphadenectomy, dissection, 166
140–143 scalene node biopsy, 124
224 Index
M retroperitoneal surgery, 213

Male breast surgery sentinel lymph node biopsy, 120
gynecomastia, 34–37 Muscle damage, HILP, 211
modified radical mastectomy, 30–34 Muscle necrosis, chemotherapy ILP, 205
Mastectomy
complete (see Subcutaneous mastectomy)
modified radical N
female, 17–22 Neck stiffness
male, 30–34 functional cervical lymphadenectomy, 143
partial radical cervical lymphadenectomy, 146
anatomical points, 15 Necrosis
complications/consequences, 17 HILP, 211–212
description, 14–15 nipple, post-implant, 25
perspective, 15–16 segmentectomy, skin, 17
subcutaneous skin, chemotherapy ILP, 205
anatomical points, 12 skin flap, modified radical
complications, 14 mastectomy, 21, 33
description, 12 Nerve injury
perspective, 12–14 axillary lymph node biopsy, 130
Melanoma axillary lymph node dissection,
axillary lymphadenectomy, 147 150, 153, 156
inguinal lymphadenectomy, 158 pelvic and retroperitoneal lymph node
neck lymph node dissections, 139 biopsy, 137
SLN biopsy, 118 sentinel lymph node biopsy, 120
Microdochectomy. See Duct and nipple Nerve toxicity, chemotherapy ILP, 205
surgery Nipple
Minimally invasive parathyroidectomy biopsy
anatomical points, 91 anatomical points, 29
complications, 92–93 complications, 30
description, 90–91 description, 28
perspective, 91–92 perspective, 29–30
Modified radical mastectomy deformity, 29–30
female post-implant necrosis, 25
anatomical points, 18–19 surgery (see Duct and nipple surgery)
complications/consequences, 21–22 Numbness
description, 17–18 axillary lymph node dissection, 157
perspective, 19–21 functional cervical
male, 30–34 lymphadenectomy, 143
anatomical points, 31 radical cervical lymphadenectomy, 146
complications, 33–34
description, 30–31
perspective, 31–33 O
Modified radical neck dissection. See Open adrenalectomy
Functional cervical anatomical points, 109–110
lymphadenectomy complications, 110–112
Mortality description, 109
ILP, 205 left, 111–112
retroperitoneal surgery, 213 medical considerations, 106–108
Multisystem failure perspective, 110
breast surgery, 4 right, 110–111
isolated limb perfusion, 202 Open splenectomy
Multisystem organ failure anatomical points, 197
adrenalectomy, 108, 112 complications, 199
ILP, 205 description, 196–197
laparoscopic splenectomy, 196 perspective, 197–198
open splenectomy, 199 Open surgical lymph node biopsy, 115–116
Index 225
Oro-cutaneous fistula Pelvic and retroperitoneal lymph node biopsy

functional cervical lymphadenectomy, 143 anatomical considerations, 137
radical cervical lymphadenectomy, 146 complications, 137
description, 136–137
perspective, 137, 138
P Pelvic retroperitoneal lymph node dissection
Paget’s disease. See Nipple, biopsy anatomical points, 167–168
Palsy, ulnar and common peroneal complications, 170
nerve, 202 description, 167
Pancreatic leak, retroperitoneal surgery, 213 perspective, 168–170
Para-aortic retroperitoneal lymph node Peritonitis, retroperitoneal surgery, 213
dissection Phrenic nerve injury,
anatomical points, 172 scalene node biopsy, 124
complications, 172, 174 Pneumothorax
description, 171 functional cervical lymphadenectomy, 143
perspective, 172, 173 modified radical mastectomy, 22, 34
Parathyroidectomy. See Parathyroid surgery radical cervical lymphadenectomy, 146
Parathyroid exploration and Prosthesis rupture, of breast implants, 40
parathyroidectomy
anatomical points, 87–88
complications, 89–90 R
description, 86–87 Radical cervical lymphadenectomy
perspective, 88–89 anatomical points, 144
Parathyroid surgery, 1 complications, 146
minimally invasive parathyroidectomy description, 144
anatomical points, 91 perspective, 144–146
complications, 92–93 Radical inguino-pelvic lymph node dissection
description, 90–91 anatomical points, 163–164
perspective, 91–92 complications, 166
parathyroid exploration and description, 162–163
parathyroidectomy perspective, 164–166
anatomical points, 87–88 Radical neck dissection. See Radical cervical
complications, 89–90 lymphadenectomy
description, 86–87 Reconstructive breast surgery
perspective, 88–89 breast implants
risk reduction and management anatomical points, 37
strategies, 85 complications, 38–40
Paresthesias description, 37
axillary lymph node biopsy, 130 perspective, 38
axillary SLN biopsy, breast cancer, 133 free transverse rectus abdominis
Partial mastectomy (PM) myocutaneous flap reconstruction
anatomical points, 15 anatomical points, 50–52
complications/consequences, 17 complications, 53–56
description, 14–15 description, 50
perspective, 15–16 perspective, 53
Partial thyroidectomy latissimus dorsi flap breast reconstruction
complications, 73–74 complications, 44–45
description, 70–71 description, 40–41
Pedicled transverse rectus abdominus pedicled transverse rectus abdominus
myocutaneous flap reconstruction myocutaneous flap reconstruction
complications, 48–50 complications, 48–49
description, 45–46 description, 45–46
226 Index
Renal/ureteric injury, retroperitoneal pelvic retroperitoneal lymph node

surgery, 213 dissection, 170
Respiratory infection scalene node biopsy, 124
laparoscopic splenectomy, 194 Shoulder stiffness, axillary lymph node
open splenectomy, 199 dissection, 150, 153, 157
Retroperitoneal nodal dissection, 158 Skin edge necrosis
Retroperitoneal surgery para-aortic retroperitoneal lymph node
anatomical points, 213 dissection, 174
complicatons, 213–215 pelvic retroperitoneal lymph node
description, 212–213 dissection, 170
perspective, 213 Skin erythema
chemotherapy ILP, 205
HILP, 211
S Skin flap necrosis
Saline-/silicone-filled prosthesis insertion. inguinal lymph node dissection, 161
See Breast implants radical inguino-pelvic lymph node
Scalene node biopsy dissection, 166
anatomical points, 123 Skin reactions, HILP, 211
complications, 124–125 SLN biopsy. See Sentinel lymph node (SLN)
description, 123 biopsy
perspective, 123–124 Splenic surgery, 191
Segmental breast resection. See Partial high-quality postoperative care, 192
mastectomy (PM) laparoscopic splenectomy, 193–196
Segmentectomy. See Partial mastectomy (PM) multidisciplinary input, 192
Selective lymph node biopsy. See Sentinel open splenectomy, 196–199
lymph node (SLN) biopsy operating table positioning, 192
Sentinel lymph node (SLN) biopsy, 116–117. preoperative assessment, 192
See also Scalene node biopsy specialized units, use of, 192
allergic reactions, 122, 125, Stewart-Treves syndrome. See Angiosarcoma,
127, 130, 137 of upper extremity
anaphylactic reaction, 120 Stoma formation, retroperitoneal surgery, 213
anaphylaxis, 122, 125, 127, 130, 133 Stroke, adrenalectomy, 112
anatomical variation, 118 Subcutaneous mastectomy
complications, 120 anatomical points, 12
description, 118 complications, 14
perspective, 119–120 description, 12
radiation risk, 122, 125, 127, perspective, 12–14
130, 136, 137 Subinguinal groin dissection. See Inguinal
risk to pregnancy, 122, 125, lymph node dissection
127, 130, 137 Subtotal thyroidectomy
Sepsis anatomical points, 75
HILP, 212 complications, 77–78
ILP, 205 description, 74–75
isolated limb perfusion, 202 perspective, 75–77
retroperitoneal surgery, 213 Systemic sepsis
Seroma breast surgery, 4
axillary lymph node biopsy, 130 cervical lymph node biopsy, 127
axillary SLN biopsy, breast cancer, 133 retroperitoneal surgery, 213
breast implants, 38 scalene node biopsy, 125
cervical lymph node biopsy, 127 sentinel lymph node biopsy, 120
Index 227
T description, 78–80
Thoracic duct injury, retroperitoneal surgery, perspective, 81–83
213 TRAM flap. See Free transverse rectus
Thoracic nerve injury abdominis myocutaneous flap
axillary lymph node dissection, 156 reconstruction; Pedicled transverse
modified radical mastectomy, 22, 34 rectus abdominus myocutaneous
Thoracodorsal nerve injury, axillary lymph flap reconstruction
node dissection, 153, 156 Tumor recurrence, retroperitoneal surgery, 213
Thyroid lobectomy. See Partial thyroidectomy
Thyroid surgery, 1
partial thyroidectomy U
anatomical points, 71 Ulnar nerve injury, axillary lymph node
complications, 73–74 dissection, 150
description, 70–71 Ulnar nerve paresis, breast surgery, 49, 55
perspective, 72–73
risk reduction and management strategies
acute respiratory distress, 68–69 V
external laryngeal nerve injury, 69–70 Vocal cord paralysis, 92
post-thyroidectomy hemorrhage, 69
subtotal thyroidectomy
anatomical points, 75 W
complications, 77–78 Wound dehiscence
description, 74–75 axillary lymphadenectomy, 153, 156
perspective, 75–77 breast surgery, 49, 55
total thyroidectomy cervical lymphadenectomy, 143, 146
anatomical points, 80–81 inguinal lymph node biopsy, 135
complications, 83–84 sentinel lymph node biopsy, 120
description, 78–80 Wound infection
perspective, 81–83 inguinal lymph node dissection, 161
Tissue necrosis, breast implants, 38 para-aortic retroperitoneal lymph node
Total thyroidectomy dissection, 174
anatomical points, 80–81 radical inguino-pelvic lymph node
complications, 83–84 dissection, 166
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Surgery: Complications, Risks and Consequences

Brendon J. Coventry Editor

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Adelaide, SA, Australia Brendon J. Coventry, BMBS, PhD,

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Hisham Abdullah, MD Putrajaya Hospital, Putrajaya, Malaysia

B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM

B.J. Coventry (ed.), Breast, Endocrine and Surgical Oncology, 1

Individual clinical judgement should always be exercised, of course, when

Richard Rainsbury, Brendon J. Coventry, Armando Giuliano, Robert Mansel,

Armando Giuliano MD, FACS, FRCSEd

B.J. Coventry (ed.), Breast, Endocrine and Surgical Oncology, 3

General Perspective and Overview

The relative risks and complications increase proportionately according to the

For diagnostic fine- or core-needle biopsy complications, see volume 1 or lymph

Female Breast Surgery

Excisional Breast Biopsy (Lumpectomy)

See Table 2.1. Hematoma is an uncommon, but significant, complication. Rarely,

The major risk of excisional biopsy is development of a large postoperative hematoma.

Failure to diagnose due to inadequately sampling a palpable lesion, biopsying

Consent and Risk Reduction

Localization Biopsy of Mammographically Detected Lesions

Fig. 2.1 Scar following

The incision chosen may be peri-areolar, curvilinear, horizontal, or even radial

The major risks are development of a large postoperative hematoma or infection.

Table 2.2 Localization biopsy of mammographically detected lesion—hookwire or carbon,

hematomas may require surgical evacuation, otherwise infection and spontaneous

Fig. 2.3 Breast hematoma

Consent and Risk Reduction

Subcutaneous Mastectomy (Complete Mastectomy)

See Table 2.3. Postoperative hematoma is best avoidable by careful hemostasis.

Table 2.3 Subcutaneous mastectomy estimated frequency of complications, risks, and

Consent and Risk Reduction

Partial Mastectomy (Segmental Breast Resection;

A major consequence of conservative breast surgery is incomplete carcinoma exci-

Consent and Risk Reduction

Modified Radical Mastectomy (Usually Including

Table 2.5 (continued)

in patients undergoing immediate reconstruction. Pneumothorax is a very rare, but

The major complications of modified radical mastectomy include hemorrhage, arm

Consent and Risk Reduction

Duct and Nipple Surgery (Microdochectomy and Central Duct

discharge. Microdochectomy is used for a discharging duct that can be identi-

Fig. 2.5 Partial nipple

Most resolve without further intervention. Prophylactic antibiotics are sometimes

Consent and Risk Reduction

Breast Abscess Drainage

Systemic infection is the most serious complication of breast abscess. Fortunately,

Consent and Risk Reduction