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To the Editor:
Assessment of regional lymph node basins is important in many diseases, most notably in breast cancer and melanoma. The sentinel node procedure has largely replaced axillary dissection as the primary procedure to assess lymph node in these two malignancies because it has a more focused histological examination and decreased morbidity.1 Long thoracic nerve injury is a feared, albeit rare, complication of axillary surgery. The debility, known as "winged scapula," that occurs with this injury severely impacts even simple activities of daily living. As a result of lack of reporting, its exact incidence is unknown. A PubMed search of "long thoracic nerve injury" identifies 64 documents in English. Of these, only one reports on a case of transection after an axillary dissection.2 An older study found that 12 of 40 patients (30%) had a serratus anterior palsy but no reported transections.3 The rest of the reported data related primarily to trauma, thoracotomy, or cardiac operations. We present our technique for immediate repair of a long thoracic nerve transection identified in the operating room.
A 50-year-old white woman presented with a palpable mass in the left breast adjacent to the nippleareola complex. Core needle biopsy revealed infiltrating ductal carcinoma. The patient underwent primary chemotherapy and then presented for her definitive cancer operation. After discussion of her options, the patient decided on mastectomy with a sentinel lymph node biopsy.
The sentinel lymph node biopsy was performed and the nodes were sent for intraoperative evaluation. While waiting for the results, the mastectomy was performed. The pathologist reported that one of the sentinel nodes revealed evidence of carcinoma. Therefore, the decision was made to continue with a Level 1 and 2 axillary dissection.
Dissection was initiated with locating the axillary vein. Once identified, the procedure continued laterally and the thoracodorsal bundle was identified at its origin along the axillary vein. The nodal tissue lateral to the bundle and inferior to the axillary vein was dissected. The thoracodorsal bundle was further exposed inferiorly to its insertion in the latissimus dorsi...