Surgical anatomy of the axilla

DR DUNCAN WAWERU
UROLOGY
MODERATOR DR.P.ODULA
objectives

• Surgical approach and incisions of the axilla

• Important anatomical structures and landmarks in the axilla
• Axillary masses
• Detail the common conditions arising from injury to contents of the
axilla
Definition of the axilla

Gateway to the upper limb

An area of transition between the neck and the arm.

Pyramidal in shape with its apex directed towards the root of the
neck
Its boundaries
Anterior: pectoralis major,pectoralis minor and subclavius muscle
Posterior: suscapularis,lattismus dorsi and teres major
Medial: upper four intercostal spaces of thoracic wall
Lateral: shaft of humerus with coracobrachialis and short head of
the biceps brachii muscle
landmarks
• It is important to make use of a relatively constant landmark, namely
the medial pectoral pedicle, present within the axilla.
landmarks
 surgical access to the axilla

After patient placed supine to operating table arm is

elevated 45 degrees and patient’s arm abducted 130 degrees or
preparing free skin flap. For of the axillary vessels a mid axillary
incision is done. The incision slightly ventrally forms axilla
downward along the outerside of the pectoralis major muscle and
flap’s anterior border incison follows a line slopping inferiorly and
obliqually.

exposure
orientation
• At the inlet of the axilla. The orientation is as follows
• Anterior to Posterior
• Axillary vein- axillary artery--trunks of brachial plexus
• Axillary artery Can be divided into 3 parts relative to Pectoralis Minor
• 6 branches of axillary artery
• 1 branch (1st part)
• superior thoracic artery
• 2 branches (2nd part)
• thoraco-acromial artery & lateral thoracic artery
• 3 branches (3nd part)
• subscapular artery, anterior circumflex humeral artery, posterior circumflex humeral
artery
Axillary mass
• Breast cancer
• Skin cancer
• Bacterial infection
• Benign cyst (see Cysts)
• Haematoma
• Syphilis
• Hodgkin's disease
• Lymphoma
• Chronic lymphocytic leukaemia
Axillary dissection
• Axillary dissection can be carried out from incision of mastectomy but
the preference for a skin incision below the hairline extending from
the posterior edge of the pectoral fold to the posterior axillary line
• Dissection is through medial retraction of pec major and this reveals
pec minor and clavipectoral fascia and lateral pectoral nerve
identified and preserved.
• Dissection carried out superiorly along edge of pec minor and the
inferior aspect of axillary vein.is is followed to its apex and this is
where the vein crosses the first rib
• The axillary contents separated from thoracic wall and the long
thoracic nerve is exposed and should be preserved carefully
The vessel relations of the breast lymph nodes

• Humeral: associated. with distal (3rd part of axillary v.

• Lateral(brachial):axillary veins medial and posterior portions
• Central :associated. with middle (2nd part of axillary v.
• Apical( subclavicular): associated. with proximal (1st part of
axillary v.
• Posterior(subscapular)
Relevance of axillary nodes
• Breast cancer initially develops as a lump in the breast, but often
spreads to the axillary lymph nodes, which allows it to access the
lymphatic system and travel to other areas of the body. During
surgical procedures to remove breast cancer, including lumpectomies
and partial, modified radical, radical, or total mastectomies, surgeons
often remove some of the axillary lymph nodes to determine whether
the breast cancer has spread, and also to determine cancer staging.
Staging of breast cancer
To determine the advancement of breast cancer, lymph nodes in the
armpit are removed. An incision is made (A), and lymph nodes are
removed and tested (B), leaving a small scar
The clinical examination of axillary lymph nodes is unreliable and the
most accurate procedure that aids in the determination of the
prognosis is axillary node assessment
• In breast cancer, the sentinel node is usually located in the axillary
nodes, under the arm. In a small percentage of cases, the sentinel
node is found somewhere else in the lymphatic system of the breast.
If the sentinel node is positive, there may be other positive lymph
nodes upstream. If it is negative, it is highly likely that all of the
upstream nodes are negative.
Sentinel node procedure
• in breast cancer, a sentinel node biopsy pinpoints the first few lymph nodes into
which a tumor drains (called the "sentinel" node). This helps doctors remove only
those nodes of the lymphatic system most likely to contain cancer cells. The
sentinel nodes are the first place that cancer is likely to spread.

• How is a Sentinel Node Biopsy Performed?

• To locate the sentinel nodes, a labeling substance, either a radioactive tracer, blue
dye, or both, is injected into the area around the tumor before a mastectomy or
lumpectomy is performed. The tracer travels the same path to the lymph nodes
that the cancer cells would take, making it possible for the surgeon to determine
the one or two nodes most likely to test positive for cancer by either visualizing
the color or using a handheld Geiger counter. This method varies in how it is
performed among hospitals.
Clinical Notes on Axillary
Lymph Node Dissection
• 3 Levels of surgical dissections relative to pec. minor• (i.e.,
• opposite
• arrangement of 3 parts of axillary vessels)
• Level I
• below (lateral to) pec. minor
• Level II
• deep to pec. minor
• Level III
• above (medial to) pec. Minor
• Normally most axillary node dissection is at level ll
Clinical significance of lymphatic drainage to
the axilla
• Cancer cells tend to spread along lymph passages
• • Typical spread is supr./laterally to axillary lymph nodes
• • More than 75% of drainage via axillary lymph nodes
• • Most remaining drainage is medially to parasternal nodes
• • Unilateral lymphatic blockage may occur
Lattismus dorsi mobilisation
• latissimus dorsi myocutaneous flap (LDMF) is one of the most reliable
and versatile flaps used in reconstructive surgery

• Large volume of tissue is available for reconstruction.

• Long vascular pedicle offers excellent range for pedicled flaps.
• The flaps are mostly used for breast reconstruction after radical
mastectomy.
• he most encountered variation on the axillary region is
localization anomaly of axillary arch. For instance, as a variant,
the arch may originate from lateral margin of the latissimus
dorsi, lying across the axilla, and inserting into tendon of the
pectoralis major muscle nearby its humeral insertion point.
• This variances are to be noted by the surgeon as they reduce the
likelihood of injury to the brachial plexus
• The major risk of unwitting injury to the BP and axillary vein may
also cause an incomplete removing of nodes
• The axilla includes many neurovasculature and important
structures of the region. The axillary artery which is begin as a
continuation of the subclavian artery, when it pass under the first
rib’s outer margin, ending point is nominally at the inferior
border of the teres major where it is called as the brachial artery . It
placed on deep to infraclavicular part of the BP. During dissection,
the axillary vein takes place approximately 1 cm cranial direction
from the lateral margin of the latissimus dorsi muscle. The
inferolateral part of the clavipectoral fascia at the upper extent of the
area is readily represented. When it is removed and the underlying fat
gently send away, the blue hue of the axillary vein can be seen easily.
• Mostly, two axillary veins are identified (
Variations of brachial plexus
• The first group is abnormal location of the cords. The second group
is absence of the posterior cord. The third group is abnormal
formation and course of the median nerve.
• Iatrogenic BP damages have been shown during infraclavicular
and transaxillary biopsy, general anesthesia and resection of
tumours in axillary region. An ulnar nerve pressure palsy which
is the most frequent positioning damage under general
anaesthesia, may occur because of malpositioning of the patient.
• Intercostobrachial nerve observed and large trunks to be preserved
• Ligation of small vessels and tributaries of axillary vein allows access
to the posterior structures namely thesubscapular vessels and the
thoracodorsal nerve.
• the area between the long thoracic and subscapular vessels is
dissected carefully and the enblock removal of lymphatic tissue
occurs
• Axilla has abundant axillary hairs , therefore infections of hair follicles
may occur giving rise to boils. The moisture content is also high and
may predispose individual to bacterial infections post operatively
• Axilla may have an abscess originating from the cervical vertebrae and
tracking along the neurovascular bundle
Surgical approach

• Axilla surgery present with axillary lymph node dissection in breast

surgery
• below approach used for anterior shoulder reconstructions
• incision is on the major axillary skin fold with the arm adducted;
• depending on patient's size, the incision will pass up toward coracoid
process;
• skin incision begins in the axilla and is centered over pectoralis major
tendon;
• identify the coracoid which serves as a landmark for brachial plexus
(lying medially) and the cephalic vein (lying inferiorly);
• Delto-Pectoral Interval:
• skin and the subcutaneous tissue are undermined up to the level of the
coracoid process;
• cephalic vein: marks the location of the deltopectoral interval;
• cephalic vein proceeds superiorly over the coracoid on its way to the
subclavian vein;
• if the cephalic vein is not visible, look for a fat strip which may overlie the
vein;
• in most cases, the vein is retracted laterally (along w/ the deltoid) because
it is usually more adherent to the deltoid (preserving the deltoid's venous
drainage)
• generally the deltopectoral groove is opened distally until the
insertion of the pectoralis is reached;
• deltoid muscle: anterior 1/3 of the deltoid insertion may be elevated
for further posterolateral exposure;
• on occasion, a small portion of the deltoid can be dissected off the
clavicle, allowing flap of muscle to be reflected more laterally;
• pectoralis muscle: incise the cephalad 1-3 cm of the pectoralis major
tendon in order to achieve better exposure of the inferior portion of
the subscapularis tendon(and better protection of the axillary nerve);
• detaching the upper 1-2 cm of the pectoralis will also better visualize
the inferior capsule & axillary nerve, which passes just inferior to the
capsule;

• note that the remaining internal rotators are intact (latissimus, teres
major, and subscapularis);
• use the long head of the biceps to help locate the insertion of the
pectoralis (placing arm in abduction and internal rotation may also
help with exposure);
• long head of the biceps emerges from the bicipital groove at a point
just above the insertion of the pectoralis, and can be injured when
the pectoralis insertion is partially incised;
• once the deltopectoral interval has been fully developed, the
clavipectoral fascia is exposed (which is most prominent lateral to
coracoid muscles);
• clavipectoral fascia is differentiated from the deeper tissues, because
it will not move with internal and external rotation;
• tip of the coracoid and the conjoined tendon (short head of biceps
and the coraco-brachialis) is identified;
• clavipectoral fascia is then divided vertically just lateral to the
conjoined tendon, up to coracoacromial ligament, exposing
subscapularis tendon & lesser tuberosity.
• proximally, the fascia is divided at a point just lateral to the coracoid;
• the incision is carried distally to the level of the anterior circumflex;
• these vessels mark the level of the subscapularis tendon;
Long thoracic Nerve
• Above nerve supplies the serratus anterior and is significant due to
its proximity to the axilla
• The nerve can be injured in mastectomy and this leads to the
phenomenon of the winged scapula
• The long thoracic nerve should be visible and retracted as dissection
leads to the apex of the axilla.
Musculocutaneous nerve
• identification of musculocutaneous:
• musculocutaneous nerve can usually be palpated on deep surface of
coracobrachialis;
• nerve enters posterior of coracobrachialis about 5 cm distal to
coracoid tip but can be as close as 1 to 2 cm;
• Above nerve is easily injured during anterior shoulder reconstruction
and fractures at the head of humerus .
• Discussion:
• - it is essential to locate axillary nerve when performing
reconstruction;
• - to facilitate nerve identification, place arm in adduction & in
neutral rotation;
• - pass a finger along lower aspect of subscapularis, inorder to
palpate nerve as it passes medially along subscapularis to palpate
axillary nerve coursing inferolaterally;
• - volar aspect of the index finger palpates the nerve proximal to the
quadrangular space.
• - note that external rotation and adduction of the arm moves the
nerve away from subscapularis tendon and offers further protection;
• - anterior circumflex humeral vessels mark inferior border of
subscapularis;
• - incise upper 2 cm of pectoralis tendon to better palpate and
visualize nerve;
• - proximally the nerve courses back to the brachial plexus;
• - distally the nerve course to the quadrangular space
Injuries to brachial plexus
• Among distal lesions a distinction must be made between
• (a) injuries of nerves located close to effectors i.e axillary,
suprascapular, musculocutaneous, or radial nerves where good
recovery can be expected in 70% to 80% of grafted patients
• (b) injuries involving nerves far from effectors involving lateral or
medial cords or the median or ulnar nerves, where results are less
satisfactory
• The overall prognosis of infra- or retroclavicular plexus injuries is
nevertheless better than that of supraclavicular lesions.
Applied aspects

• Erbs paralysis
• Common injury at birth or during motorcycle injuries and gymnast
injuries due to forcible lateral extension of the head and neck.
therefore all muscles supplied by c5 and c6 are injured
• Klumpkes paralysis
• Occurs due to injuries to the lower aspect of the brachial plexus
namely c8 and t1.this results in paralysis of the intrinsic muscles of
the hand and long flexors of the hand
• Axillary nerve injury due to fracture of the surgical neck of the
humerus
Injuries to the axillary artery and vein

• This injuries may complicate axillary surgery due to the bleeding

potential and the proximity of the neural bundle of the hand.
• The vein due to its non pulsatile nature and thin vascular wall is more
prone to injury and can lead to profuse bleeding intraoperatively

• Detailed knowledge on variations of axillary architecture can

prevent damage on the branches of the axillary artery during
elevating serratus anterior flaps. It is also important to understand
anatomic characteristics on neigbourhood area of axillary region
Complications of axillary surgery
• There are several direct risks associated with axillary surgery.
• 10% develop carpal tunnel syndrome.
• In females who have had a previous breast surgery before the axillary
surgery, recurrent wound infections and progression of lymphedema
can occur.
• persons may also feel tightness and heaviness in the arm as a result
of lymphedema.
• A recent study indicated that approximately 31% of persons may
have numbness and tingling of the hand
• The complications of axillary lymphedema could be mitigated by use
of pneumatic compression pumps post operatively and skin incisions
should be as sterile as possible due to the risk of infections in this
area
• Plastic surgery: brachioplasty especially after weight loss
• Endoscopic thyroid surgery robotic thyroidectomy eliminates the neck
scar by accessing the thyroid gland through an incision under the
arm. This is called an axillary approach. That incision is 5-7cm long,
but it's hidden—not front and center, like neck scars from open or
even most endoscopic thyroidectomies. There's another very small
incision—5mm—in the chest.
• Anaesthesia
• Use of a brachial plexus block in operations distal to the shoulder
There is hope