Axillary Lymph Node Dissection

CPT 38745
Approach Open
Preoperative Diagnosis:

Right/left axillary lymph node metastases / positive sentinel lymph node not meeting Z0011 criteria

Postoperative Diagnosis:

Same

Procedure Performed:

Right/left axillary lymph node dissection (levels I and II)

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old female with [right/left] breast cancer with [positive sentinel lymph nodes / clinically positive axillary nodes / matted axillary adenopathy] not meeting criteria for sentinel node biopsy alone. Axillary lymph node dissection was recommended for [staging/therapeutic] purposes. The risks, benefits, and alternatives were discussed, including risk of lymphedema and numbness, and informed consent was obtained.

Findings:

The axillary contents were [uninvolved / with palpably enlarged/matted lymph nodes]. The long thoracic nerve was identified along the chest wall and preserved. The thoracodorsal nerve and vessels were identified and preserved. The axillary vein formed the superior boundary of dissection. [A Rotter's node between the pectoral muscles was/was not removed.] [___ lymph nodes were identified on pathologic assessment.]

Description of Procedure:

The patient was brought to the operating room and placed supine with the ipsilateral arm abducted on an arm board. General endotracheal anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.

The axilla was prepped and draped in sterile fashion. [A separate axillary incision was made / The mastectomy incision was extended into the axilla.] A transverse or curvilinear incision was made in the axillary hair-bearing skin.

The axillary contents were entered. The axillary vein was identified as the superior limit of dissection. Dissection proceeded inferiorly with careful identification of the long thoracic nerve along the serratus anterior muscle and the thoracodorsal nerve and vessels traversing the axilla posterior to the axillary vein. Both nerves were traced from entry into the axilla to their termination and preserved throughout.

The level I axillary contents (lateral to the pectoralis minor) were dissected en bloc, clearing the fibrofatty lymph node-bearing tissue from the axillary vein superiorly, the serratus muscle medially, the subscapularis posteriorly, and the latissimus dorsi laterally. The level II contents (posterior to the pectoralis minor) were accessed by retracting the pectoralis minor laterally and dissecting the lymph node-bearing tissue in this region.

[For level III dissection: the pectoralis minor was divided at its insertion or the costoclavicular ligament was divided to access the apical nodes.] The specimen was removed en bloc. The intercostobrachial nerve was [identified and preserved / sacrificed given involvement] and the patient was counseled preoperatively regarding potential upper arm numbness.

The axilla was copiously irrigated. Hemostasis was confirmed. A closed suction drain was placed in the axillary cavity and brought out through a separate stab incision. The wound was closed in two layers with [3-0 Vicryl] deep dermal sutures and [4-0 Monocryl] subcuticular skin closure. Sterile dressings were applied.

Complications:

None

Specimens:

Axillary lymph node dissection specimen (levels I and II) sent to pathology

Estimated Blood Loss:

Minimal (less than 30 mL)

Drains:

One closed suction [Jackson-Pratt] drain in the axillary cavity

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** axillary lymph node metastases
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** axillary lymph node dissection, levels I and II
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old female with *** breast cancer with *** axillary nodes. ALND indicated for ***. Lymphedema and numbness risks discussed. Informed consent obtained.

FINDINGS: Axillary vein identified. Long thoracic nerve preserved. Thoracodorsal nerve and vessels preserved. *** palpable nodes.

DESCRIPTION OF PROCEDURE:
Supine, arm abducted. General anesthesia. Surgical timeout per protocol.

Axillary incision. Axillary vein identified as superior limit. Long thoracic nerve traced along serratus and preserved. Thoracodorsal nerve and vessels identified and preserved. Level I and II axillary contents dissected en bloc. Intercostobrachial nerve ***. Specimen removed. JP drain placed.

Wound closed in layers. Skin with 4-0 Monocryl.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Axillary dissection specimen to pathology
COMPLICATIONS: None
DRAINS: JP drain in axillary cavity
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Level III Dissection (Matted/Clinically N2 Disease)

Given clinically evident N2 axillary disease with [matted nodes / involvement of level III on imaging], a level III dissection was added. The pectoralis minor was divided at its coracoid insertion to access the apical level III nodes. The interpectoral (Rotter's) nodes between the pectoralis major and minor were also removed. After node dissection, the pectoralis minor was reapproximated to the coracoid process with [0-Vicryl].

Intercostobrachial Nerve Sacrifice

The intercostobrachial nerve was encased by/closely adherent to nodal disease and was sacrificed to achieve adequate clearance. The patient was counseled preoperatively regarding this possibility and expected upper arm/inner arm numbness.

Charting Tips
  • Document explicit identification and preservation of both the long thoracic nerve and the thoracodorsal nerve. Injury to either causes significant morbidity (winged scapula vs. latissimus flap loss), and their preservation must be in the note.
  • Intercostobrachial nerve status (preserved vs. sacrificed) must be documented. Upper arm numbness is the most common postoperative complaint, and documenting the intraoperative nerve status addresses patient concern and establishes the clinical basis for the symptom.
  • Lymph node count documentation matters. AJCC staging requires the total number of nodes retrieved and the number positive. The operative note should state that the specimen was sent for full lymph node analysis.
Billing Tips
  • Bill 38740 for superficial axillary lymphadenectomy (10.43 wRVU, 90-day global). Use when level I-II nodes are dissected without removal of all axillary contents.
  • Bill 38745 for complete axillary lymphadenectomy (13.52 wRVU, 90-day global). Use when all three levels of axillary nodes are dissected. Document the levels cleared and number of nodes retrieved.
  • When ALND is performed at the same setting as mastectomy or lumpectomy, bill both with modifier -51 on the secondary procedure. Document each as a separate portion of the operative note.
  • Sentinel lymph node biopsy (38900 add-on, 2.44 wRVU) performed immediately before ALND, when SLN is positive on frozen section, can be billed together with 38740/38745. Document the intraoperative frozen section result that prompted conversion to ALND.
  • 90-day global period: drain management, seroma aspiration in the office, and wound checks are bundled. Repeat aspiration of a seroma in the clinic does not generate a separate procedure code within the global period.