Single-port Non-liposuction Endoscopic Axillary Lymph Node Dissection in Breast Cancer Surgery

Summary

This study describes a standardized surgical procedure for single-port endoscopic axillary lymph node dissection without liposuction in breast cancer. Indicated for patients with biopsy-confirmed nodal metastasis or positive sentinel lymph nodes, the technique emphasizes preservation of critical structures, particularly the intercostobrachial nerve, to reduce postoperative morbidity and optimize functional recovery.

Abstract

Breast cancer is the most common malignant tumor among women worldwide. For patients with a high axillary lymph node burden, axillary lymph node dissection (ALND) remains an essential component of surgical management; however, its associated complications may adversely affect long-term quality of life. With advances in endoscopic technology, ALND has progressively evolved toward minimally invasive and anatomically precise approaches. This study systematically describes the surgical steps and key technical considerations of single-port endoscopic ALND performed without liposuction.

Indications included breast cancer patients with pathologically confirmed axillary lymph node metastasis preoperatively or positive sentinel lymph nodes identified intraoperatively. A total of 15 patients were enrolled. The mean number of retrieved lymph nodes was 16.8 per patient. The mean intraoperative blood loss was 8.46 mL, and the mean total postoperative drainage volume was 241 mL. No severe intraoperative or postoperative complications were observed during the study period. This study presents a standardized surgical protocol intended to support the reproducible clinical implementation of single-port endoscopic ALND.

Introduction

Since the 2000s, the incidence of female breast cancer has increased gradually by approximately 0.6% annually. It now ranks as the second most common cancer globally and is a leading cause of cancer-related deaths among women, posing a significant challenge to women's health worldwide^1,2. The management of axillary lymph nodes plays a pivotal role in the diagnosis and treatment of breast cancer. In 1757, French scholars first proposed that axillary lymph nodes are an indispensable component of breast cancer surgery. Subsequently, William Halsted established the principle that breast cancer surgery should include removal of the breast together with regional lymph nodes and introduced radical mastectomy, a procedure involving en bloc resection of axillary lymph nodes³.

However, with the accumulation of clinical experience and continuous advancements in surgical techniques, the feasibility of more precise and minimally invasive procedures has been gradually recognized through long-term exploration. In the 1990s, pivotal trials on sentinel lymph node biopsy (SLNB), such as the INT 09/98 and IBCSG 10-93 trials⁴, demonstrated that ALND provided no survival benefit in patients with clinically node-negative breast cancer. Consequently, the concept of SLNB was established, fundamentally reshaping the surgical management of the axillary region⁵. Even so, ALND remains a crucial therapeutic procedure for patients with a high axillary tumor burden. Current standard indications for ALND include:(1) Clinical stage cT1-2 disease with ≥3 positive sentinel lymph nodes; (2) Clinical stage cT3-4 disease with lymph node metastasis confirmed by preoperative needle biopsy or intraoperative frozen section; (3) Clinical N1 disease before neoadjuvant therapy, with sentinel lymph node metastasis diagnosed intraoperatively; (4) Clinical N2-3 disease before neoadjuvant therapy^6,7. Furthermore, the status of axillary lymph nodes plays a pivotal role in breast cancer staging, prognostic evaluation, and guiding adjuvant therapy decisions.

Although ALND is indispensable in breast cancer management, its associated complications inevitably affect patients' quality of life, including lymphedema, seroma, and impaired arm function and sensation. Against this backdrop, reducing the incidence of ALND-related complications has become a key clinical focus, and the refinement of surgical techniques has represented a critical breakthrough.

Over recent decades, endoscope-assisted surgery has become mainstream across various surgical disciplines. The application of endoscopy for axillary lymph node dissection (ALND) in breast cancer dates back to the 1990s. Due to the abundance of axillary fat, which can obscure the surgical field, early endoscopic ALND often involved liposuction for fat dissolution and aspiration prior to lymph node dissection⁸, aiming to achieve better visualization and working space. However, the liposuction process carries risks such as vascular or nerve injury and incomplete lymph node dissection. This study's technique differs from previous single-port endoscopic ALND techniques in two key aspects: First, it omits the liposuction step commonly used in early endoscopic ALND (for removing axillary fat), thereby avoiding liposuction-related vascular and nerve injury as well as incomplete lymph node clearance; Second, it relies on direct endoscopic visualization of native anatomical landmarks (rather than liposuction-assisted exposure), ensuring precise dissection and significantly reducing procedural variability compared with prior single-port ALND.

With technological advancements and the pursuit of more precise dissection and functional preservation, subsequent clinical studies have explored alternative approaches. It has been demonstrated that key anatomical structures-vessels, nerves, and lymph nodes-can be accurately identified without the liposuction step, achieving satisfactory surgical outcomes⁹. Numerous studies have confirmed the feasibility and oncological safety of endoscope-assisted breast surgery^10,11,12. Furthermore, the endoscopic approach minimizes trauma to nerves and blood vessels, leading to reduced complications, lower postoperative pain, better shoulder joint mobility, and shorter drainage duration¹³. Consequently, endoscope-assisted ALND holds significant clinical value. However, its widespread adoption has been limited by a steeper learning curve compared with traditional surgery and the technical challenges of manipulating instruments in a confined space¹⁴.

This article uses video and a case report to systematically demonstrate the entire procedure of single-port endoscopic non-liposuction ALND for breast cancer. We aim to contribute to the standardization of this technique, potentially shortening the learning curve and allowing more patients to benefit. We report a representative case from this study: a 45-year-old female patient. Preoperative core needle biopsy confirmed invasive carcinoma of the left breast, and axillary lymph node biopsy revealed metastatic involvement. Preoperative imaging showed no invasion of the intermuscular lymph nodes between the pectoralis major and minor muscles. Intraoperatively, 15 axillary lymph nodes were retrieved, 5 of which were positive for metastasis. The postoperative drainage tube was maintained for 8 days, and the total length of hospital stay was 11 days.

Protocol

This study was approved by the Ethics Review Committee of The Sixth Affiliated Hospital of Sun Yat-sen University (Approval No. 2024ZSLYEC-253). Photographs and videos were used with the patient's formal written consent. The accompanying video is intended for educational purposes only. The equipment utilized in this study is listed in the Table of Materials.

1. Patient preparation

1. Patient selection
   1. Include patients with pathologically confirmed breast cancer and preoperatively or intraoperatively confirmed positive sentinel lymph nodes.
   2. Confirm that the patient has good performance status and is able to tolerate general anesthesia and surgery.
   3. Obtain informed consent for single-port endoscopic axillary lymph node dissection.
   4. Exclude patients with fixed or matted axillary lymph nodes suggesting adhesion to major nerves or vessels, distant metastasis, and a previous history of axillary surgery.
2. Anesthesia and surgical positioning
   1. Induce general anesthesia and perform endotracheal intubation.
   2. Position the patient supine with the affected side near the edge of the operating table.
   3. Disinfect the surgical field with povidone-iodine solution and drape the affected limb with sterile sheets.

2. Surgical procedures

1. Injection of carbon nanoparticle suspension for lymph node mapping
   1. Prepare a carbon nanoparticle suspension diluted 1:1 with normal saline to a total volume of 1 mL.
   2. Draw the suspension into a 1 mL syringe. Inject 0.3 mL of the tracer at three sites within the parenchyma of the upper outer quadrant of the breast.
   3. Massage the injection area for 5 min. Wait 5 min before proceeding.
2. Air cavity building
   1. Make a 3-5 cm longitudinal incision on the lateral chest wall. Dissect the subcutaneous tissue for approximately 3 cm.
   2. Insert a wound protector through the incision.
   3. Place a multi-channel single-port trocar through the wound protector.
   4. Connect the 12 mm port to a constant-pressure insufflator.
   5. Establish CO₂ insufflation at 8 mmHg with a gas flow rate of 40 L/min.
   6. Insert a laparoscopic grasping forceps through the left 5 mm port.
   7. Insert an electrocoagulation hook through the right 5 mm port.
   8. Insert a 10 mm 30° endoscopic camera through the inferior 10 mm port.
   9. Flex the forearm to 90° and secure it above the head with a curved clamp (Figure 1).
3. Anatomical boundaries of axillae
   1. Define the walls of the axilla as follows: 1) Anterior wall: pectoralis major, pectoralis minor, subclavius, and clavipectoral fascia; 2) Posterior wall: latissimus dorsi, teres major, subscapularis, and scapula; 3) Medial wall: serratus anterior, ribs, and intercostal muscles; 4) Lateral wall: coracobrachialis, long and short heads of biceps brachii, and humeral tuberosity; 5) Apex: mid-clavicle, lateral border of the first rib, and superior border of the scapula; 6) Floor: skin, superficial fascia, and axillary fascia (including the cribriform fascia; 7) The axillary floor consists of superficial and deep layers, extending laterally into the brachial fascia, medially into the clavipectoral fascia, anteriorly into the thoracic fascia, and posteriorly into the fascia of the latissimus dorsi.

3. Axillary lymph node dissection

1. Dissection of the floor and posterior wall
   NOTE: Axillary lymph node dissection was performed in a stepwise sequence in this study: inferior and posterior walls → lateral axillary wall → anterior axillary wall → medial axillary wall. (Figure 2).
   1. Incise the cribriform fascia using an electrocoagulation hook (coagulation mode: 40 W; cutting mode: 25 W).
   2. Dissect along the avascular plane between the cribriform fascia and the serratus anterior fascia to expose the pectoralis minor muscle.
   3. Continue the dissection laterally along the surface of the pectoralis minor muscle, with careful dissection of the posterior axillary wall.
   4. Identify and preserve the lowest intercostobrachial nerve (ICBN) (Figure 3A) and the lateral thoracic vessels.
   5. Proceed with dissection from lateral to medial relative to the ICBN to ensure continuous visualization and complete neural protection.
2. Dissection of the lateral axillary wall
   1. Using the medial border of the latissimus dorsi muscle as a starting point, dissect medially along the lateral aspect of the intercostobrachial nerve (ICBN) toward the thoracodorsal artery. Continue the dissection superiorly until the axillary vein is exposed (Figure 2D).
   2. Mobilize the lymph nodes and surrounding fibrofatty tissue in this region (lateral triangle) en bloc, then resect them as a single specimen to complete the dissection of the lateral triangle.
   3. If the ICBN obscures the surgical field or is at risk of compression or traction during dissection, use a nerve suspension technique for protection. First, confirm the course of the ICBN; then, gently pass a soft silicone strip beneath the nerve.
   4. Fix both ends of the silicone strip using a Hem-o-Lock clip with a suture attached. Perform percutaneous puncture above the superficial projection of the ICBN using a suture passer, and connect the suture to the suture passer.
   5. Gently lift and stabilize the ICBN away from the main surgical field with controlled, minimal traction; carefully monitor the traction force throughout the procedure to avoid excessive tension, compression, or injury to the nerve, ensuring the integrity of the ICBN is preserved (Figure 3B).
3. Dissection of the anterior axillary wall
   1. The anterior axillary wall lies anterior to the axillary vein; dissect along the lateral wall of the axillary vein from lateral to medial using an electrosurgical hook (Figure 2C).
   2. During dissection, carefully coagulate the branches of the axillary vein: gently coagulate with the electrosurgical hook, avoiding excessive cautery that may damage the axillary vein trunk.
4. Dissection of the medial axillary wall
   1. Using the main trunk of the thoracodorsal vessels as the lateral reference, dissect along the plane between the serratus anterior fascia and the axillary adipose tissue (Figure 2E).
   2. Continue dissection superiorly toward the axillary apex (axillary venous angle, formed by the junction of the axillary vein and subclavian vein, as well as the confluence of the thoracodorsal vessels), advancing toward the main trunk of the thoracodorsal vessels.
   3. Determining the medial boundary of Level II without exposing the medial border of the pectoralis minor muscle
      1. Even without fully dissecting the medial border of the pectoralis minor muscle, identify the medial boundary of Level II lymph nodes accurately using two constant anatomical landmarks: the axillary vein as the superior border, and the chest wall (serratus anterior fascia) as the medial border. Dissect from lateral to medial along the inferior border of the axillary vein.
      2. After entering the retro-pectoralis minor space, remove all lymphatic and fibrofatty tissue between the axillary vein and the chest wall completely.
      3. After completely mobilizing the lymph nodes and surrounding fibrofatty tissue in this region (medial triangle and Level II), resect the specimen en bloc to complete dissection of the medial triangle and Level II lymph nodes.
5. Specimen retrieval, pathological processing, and oncological adequacy
   1. Remove the dissected specimen intact and en bloc directly through the incision without an endoscopic retrieval bag.
   2. Immediately fix the intact specimen in 10% neutral buffered formalin and send for standard pathological examination, including lymph node harvest, histopathological evaluation, and metastatic assessment.
   3. Perform axillary lymph node dissection using en bloc resection of Levels I and II lymph nodes with surrounding fibrofatty tissue, in accordance with oncologic principles.
   4. Identify a single isolated lymph node at the axillary venous angle. To ensure complete dissection and avoid tumor retention, selectively remove this single node as a complementary excision after en bloc resection.
6. Irrigation and closure
   1. Irrigate the surgical cavity with 2,000 mL of warm sterile distilled water.
   2. Place a drainage tube in the axilla and connect it to a negative-pressure suction device.
   3. Close the subcutaneous tissue and skin in layers (Figure 4).

4. Intraoperative technical considerations

1. Identify and preserve the intercostobrachial nerve throughout all stages of dissection.
   NOTE: Avoid traction or compression of the nerve when passing instruments across it.
2. Use a nerve suspension technique when necessary to achieve adequate neural protection and expand the working space.
3. Preemptively seal blood vessels using electrocoagulation or ultrasonic shears to maintain a clear surgical field.

5. Postoperative management

1. Routine care and drain management
   1. Apply a compression dressing to the axilla.
   2. Monitor the daily volume and color of drainage.
   3. Remove the drain when the daily drainage volume remains below 20 mL for 3 consecutive days.
   4. Initiate the use of a compression sleeve on postoperative day 1 to promote lymphatic drainage.
2. Postoperative mobilization protocol
   1. Days 1-3：Restrict abduction and elevation of the affected shoulder strictly. Permit gentle, non-weight-bearing exercises of the hand, wrist, and elbow (i.e., fist clenching, finger extension, wrist flexion and extension, elbow flexion and extension) below shoulder level.
   2. Day 4 until drain removal: In the absence of bleeding, hematoma, or excessive drainage (>50 mL/day), initiate passive or assisted shoulder pendulum exercises, limited to a 30° range. Active abduction and forward flexion are prohibited.
   3. After drain removal (postoperative days 8-10): Perform assisted shoulder forward flexion and abduction using the contralateral hand, limited to 60°. Continue pendulum exercises with increased amplitude. Avoid resistance training, heavy lifting, and shoulder elevation beyond 90°.
   4. One week after drain removal: Gradually introduce active range-of-motion exercises (i.e., wall climbing) based on patient recovery, as tolerated without pain.

Results

From October 2023 to July 2024, a total of 15 patients were enrolled in this study. The mean patient age was 51.2 years, and the mean BMI was 23.5 kg/m². The mean duration of ALND was 51.06 min (range: 36-62 min), and the mean intraoperative blood loss was 8.46 mL (range: 3-16 mL). The mean postoperative drainage volume was 241 mL (range: 37-790 mL). The mean drain indwelling time was 8.13 days (range: 4-14 days). The mean hospital stay was 10 days (range: 5-16 days). The mean number of harvested axillary lymph nodes was...

Discussion

This video provides a detailed demonstration of the entire procedure for single-port endoscopic-assisted axillary lymph node dissection. The key technical points of this approach include the precise identification of anatomical boundaries and standardized preservation of the intercostobrachial nerve (ICBN). The dissection plane is guided by anatomical landmarks, including the medial border of the latissimus dorsi muscle, the lateral border of the serratus anterior muscle, the axillary vein, the thoracodorsal vessels, and...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
1 mL syringe (0.45 × 16RWLB)	WEGO	20163141593
2-0 silk suture	SUYAO	201520211225
5 mm 35 cm 30° rigid endoscope	Karl Stoz	26046BA
Carbon nanoparticles suspension injection	LUMMY	H20041829
Drainage Tube	CHANGJIANG	H20041829
Electrosurgical Hook	TNKJ	20222010212
Hem-o-Lock	Weidu	WD-JZ 2S
Laparoscopic grasping forceps	YOUSHI	P20200108013
Single port	SURGAID	5012151092
suture passer	YOUSHI	P20210227004