General surgeons, surgical oncologists, or breast surgeons typically perform this procedure. This procedure is done in the operating room, typically with general anesthesia. The usual operating room personnel are required, including anesthesiology, surgical technologist, and circulating nurses. Pathologists will then review the specimen after the procedure is completed. Once pathology is back, surgeons, in combination with radiation and medical oncologists, will decide on the necessary next steps in treatment.

These patients are typically brought to breast tumor board prior to surgery so that a prospective plan is made before taking the patients for surgery. The surgeon then obtains informed consent before the operation. This includes the patients with possible axillary dissection during a sentinel lymph node biopsy procedure, in addition to patients who had a planned axillary lymphadenectomy. Radiotracer and/or lymphazurin/methylene blue are not necessary for this procedure but may have been used if the initial procedure was a sentinel lymph node biopsy that was converted to axillary dissection.[9]

The patient's axilla is prepped and draped in the usual sterile fashion. The patient is supine with the arm of the affected side at 90 to 100 degrees of abduction on an arm board. The landmark used superficially for the axillary incision is the inferior axillary hair line. An oblique incision is made, and electrocautery is typically used to dissect through the subcutaneous tissue to access the axillary fat pad once the clavipectoral fascia is incised. Once this is identified, many surgeons will identify the axillary vein and begin dissection inferior to this. Retraction is used to elevate the pectoralis muscles to dissect out the level two lymph nodes. Typically, most of this dissection can be performed bluntly. The axillary specimen is usually removed en bloc. The cavity is examined, and hemostasis is achieved as necessary, taking care to not injure any of the surrounding nerves or major vessels. A small drain may be left in place, with the exit point at a site other than the incision. The drain is sutured in place. The axillary incision is closed based on surgeon preference. Some sort of compressive dressing can be used postoperatively to provide some support and decrease seroma formation in addition to the drain.[10]

Axillary lymphadenectomy does carry increased morbidity when compared to sentinel lymph node biopsy, which is, in part, why it is performed more selectively in recent years. Typical complications with any surgery include infection and bleeding. Complications specific to this procedure include temporarily decreased range of motion of the shoulder, hematoma, lymphedema, lymphocele, lymphatic fibrosis, lymphangiosarcoma, injury to vasculature, or nerves within the region, or axillary vein thrombosis. Drains are placed commonly after this procedure, and while not a complication in itself, prolonged need for the drain can be a complication. Typically after an axillary lymphadenectomy is performed, there is not a need for additional surgery in the same region, unless there is an axillary recurrence in the future.[11]

Axillary lymphadenectomy is done when there is already positive disease within the axilla. Typically this is done to ascertain the extent of the disease within the axilla, which is extremely important for staging. In turn, the status of the axillary nodes and stage of the patient plays a major part in the subsequent treatment that the patient will be receiving. This can include chemotherapy and radiation therapy. A ten lymph node minimum is considered an adequate axillary dissection, although if less are obtained, surgeons rarely go back to surgery for additional lymph nodes. Of note, once a patient has had an axillary dissection, care is taken to avoid IV or blood pressure recordings in that arm as there is an increased risk of lymphedema compared to sentinel lymph node biopsy. Postoperatively, patients are given arm exercises and can be referred to a lymphedema clinic if this does arise.[12][5]

Breast cancer care requires an interprofessional team approach, including surgeons, medical oncologists, radiation oncologists, radiologists, pathologists, nurse navigators, physical therapists, and more. These teams are crucial in formulating plans during breast tumor boards and in the aftercare of these patients for survivorship planning. Being up to date in all aspects of these specialties provides for the best patient care, improved patient outcomes, and overall enhances the team's performance when taking care of these patients.