Of balloon axilloscopy and avoidance of iatrogenic injury to the long thoracic nerve

Background: Laparoscopic removal of axillary lymph nodes is possible and affords an excellent view of all structures, allowing preservation of vessels and nerves. The technique uses pediatric trocars and a lifting device to maintain the newly created axillary space. Objective: To prove that a newly developed technique of balloon axilloscopy can be performed using only one 10-mm and two 5-mm standard trocars and constant carbon dioxide flow to preserve the axillary space and that preservation of all nerves and vessels is possible with this approach. Design: Prospective study on 4 fresh-frozen human cadavers and 7 live porcine models. Setting: A hospital department of minimal surgery access and a university department of anatomy. Results: The balloon dissection consistently revealed and preserved the nerves and vessels, and exposure and dissection of the first rib could similarly be accomplished. An alternative route to the apex of the axilla has been developed-between the pectoralis minor and pectoralis major muscles-after their careful separation. The axillary content of surgical interest (lymph nodes) is easily separated from the other anatomical elements and is simply dissected under complete visualization and preservation of all vital axillary structures. Conclusions: Balloon axilloscopy was easy to perform, provided the surgeon with constant visualization of vital anatomical structures, and allowed easy separation and dissection of the axillary lymph nodes and the first rib. As a technical aid prior to a conventional axillary dissection, or as part of a pure endoscopic procedure in the axilla, balloon axilloscopy is 100% reliable in identifying the long thoracic nerve and moving it out of the way, separating the lymph nodes from it and from the intercostobrachial nerve and axillary vein and artery, rendering the whole dissection process safer for both the surgeon and the patient.