Videos of Surgical Procedures in Dermatology
Axillary Sentinel Lymph Node Biopsy: Video of the Surgical Procedure
Biopsia selectiva del ganglio centinela de localización axilar. Video quirúrgico
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Moreno-Ramírez, L. Ferrándiz, T. Ojeda-Vila, F.M.I. Mendonça, P. de la Riva" "autores" => array:5 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Moreno-Ramírez" "email" => array:1 [ 0 => "dmoreno@e-derma.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Ferrándiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "T." "apellidos" => "Ojeda-Vila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F.M.I." 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Video quirúrgico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Selective sentinel lymph node biopsy (SLNB) is the gold-standard technique for lymph node staging in patients with primary cutaneous melanoma. However, over the last 2 decades, the debate about SLNB has focused on the absence of any direct benefit on patient survival.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> SLNB was developed as an alternative technique for lymph node staging with a lower surgical morbidity than prophylactic lymphadenectomy, which was performed on all patients with primary melanoma up to the 1990s. SLNB is now a surgical technique that, thanks to marking using nuclear medicine, can be highly selective. Marking also enables targeted dissection to be performed; this is associated with a lower surgical morbidity.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The video is a step-by-step presentation of the standard surgical technique for axillary SLNB. We show the whole procedure in a 48-year-old man with an ulcerated primary melanoma in the left scapular region with a Breslow thickness of 1.60<span class="elsevierStyleHsp" style=""></span>mm (stage T2b), with scintigraphic identification of 3 sentinel lymph nodes (SLN) in the left axillary region.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Description of the Technique</span><p id="par0015" class="elsevierStylePara elsevierViewall">The day before the operation, in the nuclear medicine department, the patient receives intradermal injections of 2<span class="elsevierStyleHsp" style=""></span>mCi of Nanocoll divided between 4 points around the scar of the primary melanoma. Dynamic study (60 images/20<span class="elsevierStyleHsp" style=""></span>s) is performed immediately, and static images (300<span class="elsevierStyleHsp" style=""></span>s) and multimodality single-photon emission computed tomography associated with x-ray computed tomography images are also obtained. The area of projection of the SLN is marked on the skin with permanent ink. The day of the operation, 20 to 30<span class="elsevierStyleHsp" style=""></span>min before anesthetic induction, Linfazurin patent blue dye, 2<span class="elsevierStyleHsp" style=""></span>ml, is injected (0.5<span class="elsevierStyleHsp" style=""></span>ml at each of 4 points around the scar of the primary tumor).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Under general anesthesia, in the supine position and with abduction of the ipsilateral upper limb to 90° to 100°, the site of the SLN is determined percutaneously by portable gamma camera (Sentinella Oncovision). Using a gadolinium probe, the exact site of the surgical field is marked at the point of maximum uptake, and an incision of 4 to 6<span class="elsevierStyleHsp" style=""></span>cm is made. Subcutaneous dissection is continued until the clavipectoral fascia is identified. The manual probe is used as often as necessary to guide dissection until blue-green stained structures, corresponding to the SLNs to be excised, are identified in deeper planes. After excision, uptake by the SLN is checked ex vivo using the manual probe in association with the portable gamma camera; this must be performed away from the surgical field to avoid detecting the uptake in the area of the primary tumor<span class="elsevierStyleItalic">.</span> Similarly, uptake in the surgical field is checked using the portable gamma camera directly over the surgical wound; this must be done to exclude persistent foci of uptake corresponding to additional SLNs. If a positive reading is obtained, the identified structures must be excised. After confirming an absence of uptake in the surgical field, hemostasis is checked and the wound is closed by tissue planes. The SLNs are sent to the pathology department in containers with formol, and histopathology is performed with hematoxylin and eosin and immunohistochemistry with HMB-45, S-100, and Melan-A stains.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, in the same operation, after excision of the SLNs, the surgical margins are enlarged. When enlarging the margins, the radioactivity emitted by the area of the primary tumor may be found to overlap that from the lymph node region, as occurred in the case presented. In this situation, the gamma camera allows us to perform anteroposterior, lateral, and oblique projections and, together with the use of lead plates over the area of the primary tumor, this helps to differentiate the 2 zones.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The video presented was recorded using a GoPro<span class="elsevierStyleSup">®</span> Hero4 (GoPro Inc, USA) handheld camera fixed to a headset worn by the surgeon, with a resolution of 720<span class="elsevierStyleHsp" style=""></span>p, 60<span class="elsevierStyleHsp" style=""></span>fps and narrow field.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Indications/Contraindications</span><p id="par0030" class="elsevierStylePara elsevierViewall">SLNB is indicated in patients with primary cutaneous melanoma with tumor stage T1b or higher (Breslow thickness<span class="elsevierStyleHsp" style=""></span>≥1<span class="elsevierStyleHsp" style=""></span>mm or with ulceration and/or a mitotic index<span class="elsevierStyleHsp" style=""></span>≥1<span class="elsevierStyleHsp" style=""></span>mitoses/mm<span class="elsevierStyleSup">2</span>). In those cases of primary melanoma with Breslow thickness less than 1<span class="elsevierStyleHsp" style=""></span>mm, and with mitoses, SLNB can be considered with a Breslow thickness above 0.75<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The contraindications of SLNB are determined by the general state of health of the patient, severe comorbid conditions, and anesthetic risk established using scales such as the Karnofsky and American Society of Anesthesiologists indices.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Complications</span><p id="par0040" class="elsevierStylePara elsevierViewall">The complication rate of SLNB is less than 5%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In a series by the Melanoma Unit of Hospital Universitario Virgen Macarena, the only complication observed was localized seroma, which developed in 3.64% of patients who underwent the operation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> However, possible complications of the procedure include seroma-lymphorrhea, hemorrhage, hematoma, infection, wound dehiscence, and complications associated with general anesthesia or spinal anesthesia (in the case of inguinal SLNB).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Instruments now available for the intraoperative identification and mapping of SLNs have changed SLNB into a technique with a low morbidity. For the surgical dermatologist, accustomed to complex reconstructions, the technique may be considered of intermediate complexity. However, as with all surgical techniques, SLNB requires appropriate training (><span class="elsevierStyleHsp" style=""></span>20 cases), and routine practice with a minimum monthly number of operations (><span class="elsevierStyleHsp" style=""></span>3 cases/month),<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> in order to perform the operation with greatest safety and the lowest possible rate of error.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> In those centers in which these conditions are satisfied, knowledge of the natural history of melanoma and the surgical ability of the dermatologist will possibly make this specialist the most appropriate professional to indicate and perform SLNB.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Description of the Technique" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Indications/Contraindications" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Complications" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Moreno-Ramírez D. Biopsia selectiva del ganglio centinela de localización axilar. Video quirúrgico. Actas Dermosifiliogr. 2016;107:425–426.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0060" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 98660503 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estado actual del ganglio centinela en el melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. 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Peltz" 5 => "M.D. Ebert" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Surg" "fecha" => "2001" "volumen" => "193" "paginaInicial" => "593" "paginaFinal" => "600" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11768674" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The learning curve and sentinel node biopsy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. Tafra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "2001" "volumen" => "182" "paginaInicial" => "347" "paginaFinal" => "350" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11720668" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000005/v2_201703310310/S1578219016300245/v2_201703310310/en/main.assets" "Apartado" => array:4 [ "identificador" => "6209" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Videos of Surgical Procedures in Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000005/v2_201703310310/S1578219016300245/v2_201703310310/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016300245?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 9 | 16 |
| 2024 October | 89 | 43 | 132 |
| 2024 September | 97 | 28 | 125 |
| 2024 August | 105 | 49 | 154 |
| 2024 July | 119 | 32 | 151 |
| 2024 June | 103 | 38 | 141 |
| 2024 May | 102 | 26 | 128 |
| 2024 April | 94 | 21 | 115 |
| 2024 March | 99 | 40 | 139 |
| 2024 February | 72 | 36 | 108 |
| 2024 January | 67 | 32 | 99 |
| 2023 December | 82 | 17 | 99 |
| 2023 November | 92 | 33 | 125 |
| 2023 October | 100 | 28 | 128 |
| 2023 September | 69 | 28 | 97 |
| 2023 August | 69 | 15 | 84 |
| 2023 July | 94 | 35 | 129 |
| 2023 June | 53 | 24 | 77 |
| 2023 May | 70 | 20 | 90 |
| 2023 April | 33 | 13 | 46 |
| 2023 March | 47 | 23 | 70 |
| 2023 February | 63 | 24 | 87 |
| 2023 January | 46 | 17 | 63 |
| 2022 December | 56 | 31 | 87 |
| 2022 November | 50 | 25 | 75 |
| 2022 October | 29 | 20 | 49 |
| 2022 September | 36 | 36 | 72 |
| 2022 August | 28 | 26 | 54 |
| 2022 July | 29 | 37 | 66 |
| 2022 June | 27 | 20 | 47 |
| 2022 May | 50 | 33 | 83 |
| 2022 April | 52 | 32 | 84 |
| 2022 March | 36 | 42 | 78 |
| 2022 February | 31 | 27 | 58 |
| 2022 January | 52 | 31 | 83 |
| 2021 December | 39 | 32 | 71 |
| 2021 November | 38 | 41 | 79 |
| 2021 October | 38 | 39 | 77 |
| 2021 September | 27 | 39 | 66 |
| 2021 August | 38 | 31 | 69 |
| 2021 July | 22 | 22 | 44 |
| 2021 June | 33 | 30 | 63 |
| 2021 May | 34 | 28 | 62 |
| 2021 April | 67 | 52 | 119 |
| 2021 March | 56 | 20 | 76 |
| 2021 February | 53 | 33 | 86 |
| 2021 January | 33 | 14 | 47 |
| 2020 December | 25 | 15 | 40 |
| 2020 November | 22 | 20 | 42 |
| 2020 October | 26 | 12 | 38 |
| 2020 September | 24 | 8 | 32 |
| 2020 August | 21 | 16 | 37 |
| 2020 July | 33 | 16 | 49 |
| 2020 June | 36 | 20 | 56 |
| 2020 May | 30 | 22 | 52 |
| 2020 April | 30 | 18 | 48 |
| 2020 March | 32 | 16 | 48 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 6 | 0 | 6 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 6 | 0 | 6 |
| 2019 April | 2 | 1 | 3 |
| 2019 March | 4 | 6 | 10 |
| 2019 February | 4 | 0 | 4 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 5 | 0 | 5 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 7 | 0 | 7 |
| 2018 May | 1 | 1 | 2 |
| 2018 February | 21 | 4 | 25 |
| 2018 January | 38 | 8 | 46 |
| 2017 December | 60 | 8 | 68 |
| 2017 November | 32 | 10 | 42 |
| 2017 October | 27 | 8 | 35 |
| 2017 September | 44 | 5 | 49 |
| 2017 August | 32 | 7 | 39 |
| 2017 July | 21 | 7 | 28 |
| 2017 June | 33 | 7 | 40 |
| 2017 May | 18 | 7 | 25 |
| 2017 April | 24 | 4 | 28 |
| 2017 March | 14 | 5 | 19 |
| 2017 February | 15 | 13 | 28 |
| 2017 January | 12 | 6 | 18 |
| 2016 December | 31 | 12 | 43 |
| 2016 November | 31 | 10 | 41 |
| 2016 October | 23 | 25 | 48 |
| 2016 May | 0 | 4 | 4 |
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