Lymph nodes dissected without axillary incision.(Gynecology)

NEW YORK -- A new endoscopy-supported operative technique in which lymph nodes are dissected without axillary incision is feasible, safe, and appears to result in both fewer lymph seromas and dramatically improved arm mobility for breast cancer surgery patients.

The concept of Axillary Dissection with Access Minimized (ADAM) is fairly simple. Unlike the standard procedure, in which the breast tumor is removed via one incision and the lymph nodes dissected through another, ADAM accomplishes both procedures through a single incision, using standard laparoscopic equipment.

"We often think of ways we can use equipment that we already have in our [operating room] for new procedures.... This was one idea that has turned into reality," Volker R. Jacobs, M.D., said at an international congress of the Society for Laparoendoscopic Surgeons, which named his report the "Best Gynecology Paper by a Resident or Fellow."

In ADAM, an incision is made above the breast tumor as usual--in any quadrant--and the tumor is removed. Next, the surgeon digitally dilates the retromammary space between the mammary tissue and the pectoral muscle toward the axilla, and, under visual control, makes a sharp opening of the axillary fascia. The lymph nodes--or just the sentinel lymph node--are then removed via endoscope.

Breast tissue plastic is used for covering larger tumor defects, and if necessary, drainage is allowed for one day before suturing, said Dr. Jacobs of the Technical University of Munich.

Standard laparoscopic equipment includes long instruments (hook, grasper, and scissor), a hook with attached light cable, a rigid endoscope (5-10 mm), and a standard endoscopic tower (camera, light source, and monitor).

Dr. Jacobs and his associate, Stefan Paepke, M.D., who initially developed ADAM, perform the procedure with reusable instruments because of cost considerations. Lipolysis is not done, ...