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Introduction

This booklet is about the surgery to remove the lymph nodes from your axilla (armpit).  It aims to give you an idea of what is likely to happen and how long you can expect to be in hospital. It is also important that you know about minor problems which are common after this operation, and more serious problems that can occasionally occur. The section “What problems can occur after the operation?” describes these and we would particularly ask you to read this; the headings from this section will also be included in the consent form you will be asked to sign. You can help to reduce certain risks by closely following the advice of your surgeon and his/her team.

What is an axillary node dissection?

It is a surgical procedure performed under a general anaesthetic in which the lymph nodes in the affected axilla are removed.

Why do I need an axillary node dissection?

The doctors have decided that you require an axillary node dissection because on examination of your axilla they found enlarged lymph node/s. The lymph node is part of the lymphatic system that runs alongside the bloodstream.

The lymph system is part of the immune system that protects the body against diseases. The system contains lymph fluid, lymph nodes and lymph ducts. The nodes have an important role in draining and filtering such things as bacteria, viruses and cancer cells. When these reach the lymph nodes the nodes become large and swollen.

The doctor may have taken a sample from the node, or you may have had a CT scan to determine the cause of the enlarged node. With these results the doctor has decided that the lymph nodes need to be removed. Removing these nodes may reduce the chance of cancer cells spreading to different parts of the body (metastases).

What happens before the operation?

On the day of surgery, you will not be able to eat or drink anything immediately before your surgery, because an empty stomach is important for a general anaesthetic. You should have no food, milk or carbonated drinks for 6 hours before the operation, but you may drink clear fluids until 2 hours before. You should have a bath or shower; remove make-up, nail polish, jewellery and piercings (e.g., earrings and body jewellery). The body hair at the surgical site may need to be removed. Wedding rings can stay in place if they are worn on the arm not being operated on. Contact lenses, false teeth etc. can be removed just before you go to the operating theatre.

When you come into hospital you will be asked to wait in the dayroom and later the nurse will admit you to the ward. He or she will go through an individual plan of care with you and answer any questions you may have. You will also be examined by a doctor from the plastic surgery team and be seen by the Anaesthetist who will be giving you a general anaesthetic. We may need to take a blood sample from you and do other tests such as an x-ray or ECG (heart tracing). (See leaflet on Pre-operative Assessment”).

What about the anaesthetic?

A general anaesthetic is usually given by injection into your hand or arm. The general anaesthetic is one of the main concerns for patients; many feel they are handing over control of their life to another person. This worry is understandable, but modern anaesthetics are very safe, and serious complications are uncommon.

What does the procedure involve?

The operation usually takes 1½ to 2 hours. The surgeon will make an incision (cut) under your arm (axilla), above the lymph nodes that are to be removed. The lymph nodes are then removed, also the lymphatic channels and surrounding soft tissue. The tissue removed will be sent off to be analysed. A fine tube is placed within the wound to drain away any excess blood or lymph fluid that may collect. The incision is stitched with either soluble or removable stitches and covered with suture strips (paper tape) and a dressing.

What happens after the operation?

On your return from theatre your arm should be elevated on a pillow to reduce swelling that may occur. You can expect some discomfort and stiffness in your shoulder, our physiotherapists will visit you on the ward and advise you on arm and shoulder movements and activities you should and should not do. For example, lifting too soon may increase swelling and bleeding. You may notice numbness in your arm, this is because some of the nerves have been cut or stretched during surgery.

You will probably feel some pain for the first few days. Suitable pain killing tablets, suppositories or injections will be prescribed. Please tell a nurse if you are in pain. It is important to take painkillers if you need them so that you are able to move around easily, preventing blood clots and chest infections.

You will be able to eat and drink as normal on return to the ward following surgery. Occasionally you may have a ‘drip’ in your arm to replace any fluid that you may need. If so, this can usually be removed on the day of surgery or the day after depending on how well you tolerate drinking fluids. You will be able to have a shallow bath as soon as you feel able, ensuring you keep your wounds and dressings dry. If you need help, please ask the nurse looking after you.

The wound drain will remain in place until there is minimal drainage (normally 5 to 7 days), and then it will be removed. Your wound dressings will also be changed.

Discharge from hospital

You will be discharged 5 to 7 days after your operation, when you are up and about, eating, your drain has been removed and you are comfortable.

Please arrange for someone to collect you and to help out at home for a few days. You will be given medication to take home with you; these will usually be painkillers. Please follow the instructions on the packet.

Occasionally, if it continues to drain, you may be discharged with the drain still in place. The nurse will teach you how to measure and record the drainage in your drain and you will be asked to telephone the ward daily with the amount.

When there is minimal drainage, you will need to return to the dressing clinic or Main outpatients Level 6 to have the drain removed.

We will give you an outpatient appointment at our plastic surgery dressing clinic, Main outpatients Level 6 one week after you have been discharged so we can check your wound and take out any removable stitches you might have. You will also be given a follow-up appointment with your consultant’s team.

What problems can occur after the operation?

Seromas (tissue fluid) and haematomas (blood)

Sometimes blood and tissue fluid can collect within the wound. Treatment is not always necessary, however, if there is too much fluid it may need to be drained with a needle and syringe.

Infection/wound breakdown

Patients may develop a wound infection that requires antibiotics or an area of wound breakdown that requires regular dressings until it heals. Infection will delay the healing process and scars are likely to be worse.

Lost or decreased sensation

Sometimes the nerve supplying sensation to the back of the arm and armpit is cut, stretched or damaged during the surgery. The loss of sensation may be temporary, but for some patients it may persist.

Lymphoedema

It is common to have swelling after surgery in your arm and hand for 2 to 3 months. You can help reduce the swelling in your arm by doing your exercises and elevating (raising) your arm often in the day. However, there is the possibility that this swelling may continue for longer than the usual post-operative period, and this is known as lymphoedema. If this condition persists, there are ways of controlling and treating it.

Winged Scapula

This is a very rare complication that happens when the nerves that hold your shoulder blade flat are damaged, causing your shoulder blade to stick out when you hold your arm out straight. This problem will not normally interfere with your daily activities.

Deep Vein Thrombosis (DVT)

Deep vein thrombosis is a possible problem but is uncommon. If you are at particular risk, then special precautions will be taken to reduce the risk. Moving your legs and feet as soon as you can after the operation and walking about early all help to stop thrombosis occurring.

The risks of a general anaesthetic

General anaesthetics have some risks, which may be increased if you have chronic medical conditions, but in general they are as follows:

Common temporary side effects (risk of 1 in 10 to 1 in 100) include bruising or pain in the area of injections, blurred vision and sickness (these can usually be treated and pass off quickly).

Infrequent complications (risk of 1 in 100 to 1 in 10,000) include temporary breathing difficulties, muscle pains, headaches, damage to teeth, lip or tongue, sore throat and temporary difficulty speaking.

Extremely rare and serious complications (risk of less than 1 in 10,000) include severe allergic reactions and death, brain damage, kidney, heart and liver failure, lung damage, permanent nerve or blood vessel damage, eye injury and damage to the voice box. These are very rare and may depend on whether you have other serious medical conditions.

What should you do if you develop problems?

If you develop any problems, then please contact

Main Outpatients Dept (Level 6) on 01752 438406

Signs of problems to look out for include:

• Severe pain in the axilla (armpit)

• Very high temperature (above 38ºC)

• Redness/heat/excessive swelling of the axilla (armpit)

• A lot of fluid/pus/blood coming from the wound

• Offensive smell from wounds

• Pain/swelling in calves

When will I be back to normal?

Bathing/showering

You may have a shallow bath as soon as you feel able, ensuring you keep your dressings dry. You may have a shower a couple of weeks after surgery if your wound has healed.

Work/general activities

Increase your activities using your arm slowly following the advice of your physiotherapist. Most patients’ wounds have healed within 2-4 weeks, and you should be able to resume a normal lifestyle within 6-8 weeks.

Sport

We advise you not to start any strenuous activity using your arm, such as racquet sports and swimming, for 8-12 weeks after your operation.

Driving

Ideally you should avoid driving for 6-8 weeks after the operation. All wounds should be healed, and you should feel confident in using the steering wheel and performing an emergency stop. If in doubt, seek medical advice or check with your insurance company.

Long term advice following lymph node dissection

The following advice will help reduce the risk of swelling in your arm, and related problems. After the operation the drainage of lymph fluid may be altered, which could make your arm more prone to swelling. This is usually temporary, but some patients may have permanent swelling following the surgery, see section on ‘Lymphoedema’. If you have a break in the skin, you may be more prone to infection.

Exercise / using your arm

Muscle activity will help stimulate the flow of lymph fluid, so it is important that you use your arm for light activities, as you have been doing on the ward. Increase the amount of activity gradually as your physiotherapist has advised. Avoid carrying anything heavier than 10 pounds for long periods on the affected arm.

Skin Care

It is important to ensure your skin is kept intact and avoid any cuts or abrasions to reduce the chances of infection. To reduce your chances of any problems, we recommend you:

• Avoid injections in the affected arm

• Avoid having blood taken from this arm

• Do not have your blood pressure taken on this arm

• Avoid acupuncture treatments on this arm

• Wear thick gloves when gardening or cleaning with wire wool etc.

• Avoid letting your skin become dry and cracked by using moisturisers regularly and wearing rubber gloves for housework

• Use sun block SPF30 to avoid getting sun burnt

• Use nail clippers instead of scissors when cutting nails

• Avoid very hot baths and saunas

• Use an electrical razor or cream for shaving your underarm to avoid nicking the skin

• Avoid constriction from tight bra straps, sleeves, watches, rings and heavy shoulder bags

• Use insect repellent when abroad

• If you cut your affected arm or hand, ensure you clean and cover the area immediately

• Observe the area for redness, swelling and warmth and if this lasts for 24 hours or more you may have an infection and you will need to contact your GP

We would appreciate any comments you have regarding this information and how beneficial it has been for you.

Acknowledgement

The authors would like to thank MARCS Line and the Wessex Cancer Trust for reference materials used in the creation of this document.

Who should you contact for advice?