Axillary lymph node dissection for skin cancer

Introduction

This leaflet provides additional information and guidance for patients who are about to undergo an axillary (armpit) lymph node dissection as part of their treatment for the effects of skin cancer.

What are the lymph nodes?

The lymphatic system is a part of the body's immune system which helps to fight infection. It also helps to remove excess fluid from the body. The lymphatic system consists of vessels similar to veins which carry the lymph around the body. Along its course are groups of nodes or glands. After passing through various nodes, the lymph is finally delivered into the blood stream. The lymph nodes usually lie in groups in the neck, armpit and groin. They are also present inside the chest and abdomen. Each group tends to receive lymph from a specific area of the body.

Sometimes cancer cells can get detached from the main cancer and are carried in the lymph and settle in the lymph nodes. They can grow there causing swelling. The doctor may have previously examined you to assess if the lymph nodes are affected. You may have had to undergo special investigations such as fine needle aspiration (FNA) cytology, biopsy, ultrasound scan or a CT scan.

If the lymph nodes are affected, they are treated with surgery, radiotherapy or both. During surgery the surgeon removes all the nodes from the groin along with some surrounding tissue. These nodes are sent for examination under microscope. The results are usually ready in approximately 4 weeks.

What does the procedure involve?

The operation lasts two to three hours. An incision (cut) is made in the axilla (armpit) and as many lymph nodes as possible are removed from the area. Once the lymph nodes have been removed, one or two drains are placed in the operated area to drain away any excess blood and lymph fluid into a vacuumed bottle, and the skin is secured back in place with stitches or staples. Your surgeon will be able to discuss the exact site and nature of the scar.

You should expect to stay in hospital for at least 24 hours following the surgery.

Before your procedure

When you are seen in clinic, your doctor will explain the operation and why we are offering it to you, including any potential complications and the possible advantages and disadvantages. You will be contacted by our admissions team regarding when and where to go for your operation.

Before surgery you may have a pre-operative appointment for a nurse to assess your general health and arrange for investigations such as blood tests and ECG.

Fasting instruction will be given in the admissions letter.

The surgeon will discuss the surgery with you in detail, also the likely complications and side effects.

On the day of surgery, the surgeon will mark the site for surgery on your skin with a permanent skin marker. Please ask the doctor any questions or discuss any worries you have about the surgery or anaesthesia.

You will also have special stockings to help prevent blood clots in the legs and usually an injection of a drug into the abdominal skin to reduce the risk of blood clots causing deep vein thrombosis (DVT) or pulmonary embolism.

After the procedure

On the evening after your general anaesthetic you may feel rather tired and sleepy and you may not wish for visitors.

You may have a catheter tube for urination. This is removed as soon as you are mobile.

You may also have fluids going into your arm via a tube; this is to ensure you do not become dehydrated. This will be removed when you are able to drink enough fluids on your own. You can eat and drink as normal when you are fully awake following surgery.

The wound drain(s) will remain in place until there is minimal drainage, approximately 30ml in 24 hours. Most patients go home with the drain(s) in place. This is managed by clipping the drain bottle to your waistband, so you can freely move around. Some discomfort is to be expected, and it is usually worse for the first few days after surgery, although it may take a couple of weeks to completely disappear. We will prescribe appropriate pain relief for you to deal with this.

It is necessary to make sure that the wounds heal without any infection and so you will be given antibiotics whilst you are in hospital and will continue the antibiotics until the drain(s) is removed.

Discharge from hospital

The ward nurse will give you some advice on your wound dressing and when you may shower/wash, prior to discharge home. Before you leave the ward you will be given an appointment for the plastics surgery unit; this will be for the week following your discharge.

If you do leave hospital with a drain(s) you will be given information on how to care for this when you leave the ward. You will be taught how to measure and record the contents of your drain(s). Once home you will need to contact the plastic surgery unit and report the amount of fluid in your draining bottle(s). When you drain less than 30ml over a 24 hour period, we will advise you to come in, so we can remove the bottle and drain.

If there are stitches and/or staples in the wound, these will need to be removed after 10-14 days.

Usually you will be given some painkillers and antibiotics to take away on discharge. It is important that you finish the course of antibiotics to help prevent infection.

To start with, you are likely to feel rather tired and you should spend the first week or so taking it easy. After that you will be able to gradually increase your usual activities.

When am I able to resume my usual activities?

Bathing/ showering

When washing, keep the dressing dry by washing around the dressings. The dressings are waterproof, but not for long showers. A dressing is a barrier between the wound and the outside world and if it is wet, it does not work as such and will need changing, it is better that you remove a wet dressing completely, clean the area with water and dry it thoroughly with a clean towel or a hairdryer, before applying a clean dressing.

You may have a shower a few days after surgery. Avoid having a bath until the wounds are fully healed and the stitches or staples are removed.

Work/ general activities/ exercise

You will be able to start work again once you feel up to it but if your job involves a lot of lifting or heavy work this will take longer.

A medical certificate can be provided by the hospital whilst you are an inpatient. Once you are discharged, speak to your GP who will give you a medical certificate to cover the period until you are fit to go back to work.

Straight after your operation it is important to continue moving the arm and the rest of the hand to prevent any of the joints becoming stiff, but please do so gently. Exercise is important and will help to stimulate lymphatic draining and blood circulation.

It is best to start with activities that feel comfortable, gradually building up your strength and stamina. Avoid carrying anything heavy for long periods or repetitive lifting/movements with the affected arm for the first six weeks.

Driving

You will be unable to drive for 48 hours following a general anaesthetic due to insurance. You will be able to start driving once you feel up to it and you are able to perform an emergency stop comfortably. For most people this will take about four to six weeks. Do not drive if you are unwell and unable to take emergency action. It is advisable to check with your insurance company before you start driving again.

Skin Care

It is important to ensure that your skin is kept intact, avoid cuts and abrasions to reduce the risk of infection, such as in the garden, with pets and whilst shaving. Try to keep the skin on your arms and hands clean, soft and well moisturised. Wash with cleansers that won’t dry out the skin and dry thoroughly. Apply moisturising cream/lotion to your arms/hands on a daily basis to keep the skin soft and supple. Avoid highly perfumed creams/lotions and those with lots of additives, if possible, as this may cause skin sensitivity. Avoid shaving as the affected armpit may be numb or have reduced sensation making it more likely for you to cut yourself.

To reduce the chances of any problems we recommend that you avoid injections in the affected arm (including acupuncture) and do not have your blood pressure taken from this arm. Avoid restrictive clothing and tight jewellery that could further impair lymphatic drainage.

Problems that may occur after the operation

There are potential complications with any operation. Fortunately with this type of surgery, complications are rare and may not happen to you. However it is important that you are aware of them and have the opportunity to discuss them with your surgeon / specialist nurse.

Pain

Your surgeon will inject long-lasting local anaesthetic in the wound to diminish your discomfort when you wake up. You will have regular painkillers prescribed and the option of further pain relief, if you need it. Please ask the nurse looking after you for more painkillers if you are in pain.

When discharged it is important to take your painkillers regularly in the first couple of days to minimise the discomfort. Most patients manage with simple painkillers on discharge.

Nerve damage

Sometimes the nerve that supplies sensation to the back of the arm and the armpit is cut, stretched or damaged during the surgery. You might have tingly feelings or shooting pain which can last for six months or longer. The skin of your armpit will feel numb for several months after surgery as a result of bruising to the nerves. For some patients this sensation may never return to normal.

Bleeding

A small amount of bleeding into the dressing after the operation is normal. If this happens the dressing will be changed before your discharge. A bigger bleed will be identified by the nurses and doctors looking after you and may require your return to the operating theatre so that we can stop the bleeding and remove the blood under general anaesthetic. Although very uncommon, if bleeding appears after discharge and the dressing becomes soaked with blood, please return to the A&E department, inform the staff that you are a patient of the plastic surgery team and we will come to help you.

Infection

Any operation can give problems with infection or bleeding. Simple infections will settle with skin treatment others through a course of antibiotics but some infections go on to form an abscess which may need a further operation. If you notice increasing redness of your wound or it is painful, if there is an unpleasant odour or yellow/green fluid coming through the dressing or if you have flu like symptoms and a high temperature, tell your GP or contact us on the details given at the end of this information sheet.

Pets

Please be mindful that if you have pets at home it is advised to minimise contact with them whilst you have a drain in place.

It is important to contact us as soon as possible because infections caught early are easier to treat.

Seroma (tissue fluid)

This is a fluid collection just under the skin at the surgical site. It is caused by fluid normally drained through the lymph glands draining into the skin. This is a normal complication after this surgery. The seroma will need to be drained in clinic with a needle and syringe until it stops re-occurring. This can take a number of weeks to resolve. It is important to contact us promptly if the seroma shows any signs of infection (as described above). Occasionally the seroma will not resolve and surgery may be required to fix the problem.

Haematoma (blood)

This is the name given to a collection of blood that has formed a blood clot around the site of the operation. If it is small it may be left to be reabsorbed by your body’s normal defences. In some cases it may be necessary to return to the operating theatre to find the area it is bleeding from, to seal the area from further bleeding and to remove the clot of blood.

Wound breakdown

The wound can open again after the operation and we may treat this with dressings or, very occasionally, we may need to operate again.

Prolonged drainage

Some people will continue to drain more than 30ml of fluid over a 24-hour period for over six weeks. At this point we may advise you to have another operation, so we can identify the lymphatic leak and deal with it.

Exercises

An exercise sheet will be given to commence when the wounds are fully healed.

Lymphoedema

It is common to have swelling after surgery to your arm and hand. This can last for up to two to three months. You can help to reduce the swelling by ensuring you gradually increase your mobility and raising your arm frequently throughout the day.

However, there is a possibility that the swelling may continue for longer than the usual post-operative period; this is known as lymphoedema. The rates of lymphoedema after this procedure vary between 5 to 25% and you will notice your arm becoming uncomfortable, swollen and feeling tight. Lymphoedema mostly happens within twelve months of melanoma surgery but may occur years later. If you have lymphoedema there are ways of controlling and treating it. The specialist nurse or your consultant will refer you to the specialised lymphoedema clinic within your local area.

Deep vein thrombosis (DVT)

This is an uncommon complication. It occurs when a blood clot develops in your calf or thigh; it may be painful, red and warm in that area. If you are at particular risk, special precautions will be taken to reduce the risk. Moving your legs and feet as soon as you are able after surgery and walking about early, increasing your fluid intake will help to stop thrombosis occurring.

Follow-up after surgery

At the plastic surgery unit appointment (approximately one week after surgery) the nurse will check the skin wound is healing well, change your dressings and will arrange a further appointment to monitor the wound healing and drainage over the following weeks. If you have staples or if the stitches in the skin are the non-dissolving type, these will be removed two weeks after the operation.

Your wound as well as your armpit will be examined for any swelling.

The histopathology (microscopic examination of tissue) results may take four weeks or more to be processed. You will need a follow-up appointment with the consultant team six to eight weeks following surgery. This appointment will be sent to you once the results of your surgery have been reviewed by your consultant.

You may also be offered an appointment with the oncology team to discuss possible further systemic (drug) treatment which the multidisciplinary team may recommend reducing the risk of further skin cancer recurrence.

Contact Telephone numbers:

• Plastic Pre-assessment Clinic: 01223 254296 (Monday to Friday 08.00 to 17.00)
• Plastic Surgery Unit: 01223 348509 (Monday to Friday 08.00 to 18.00)
• M5 Plastic Surgery Ward: 01223 348525 (out of hours/evenings/weekends and bank holidays)
• Skin Cancer Nurse Specialists: 01223 348156 (Monday to Friday 09.00 to 17.00)
• Booking team: 01223 256493

Further information:

Macmillan Cancer Support has information on all aspects of cancer. Lines answered by specialist nurses. Freephone 0808 808 0000, open Monday to Friday, 9:00am - 8:00pm.

• Click here to visit the macmillan website (opens in a new tab).

Melanoma focus – free phone 08088010777

• Click here to visit the melanoma focus website (opens in a new tab).