Tumescent Local Anesthesia for Wide-awake Sentinel Lymph Node Biopsy

INTRODUCTION Sentinel lymph node biopsy (SLNB) is an important component of skin cancer management.1 Plastic surgeons and other surgical oncologists are faced with an increasing burden of care to provide SLNB services in a timely, affordable manner for proper care of patients. SLNB surgery is noted by some to be a costly endeavor with significant risks to some patients.2,3 The near-ubiquitous reliance on the main operating room (OR) and general anesthesia (GA) for SLNB is regarded as a principal driver in elevating these costs. Alternatively, tumescent local anesthesia (TLA) in a minor procedure room has been reported as a safe, clinically reliable, and cost-effective means of performing these cases.2–4 Despite these benefits, the technique is poorly adopted, partly because many surgeons are not aware of the utility and technique of TLA for SLNB. The goal of this article is to present a detailed description and video examples of how to successfully perform wide-awake axillary or superficial inguinal SLNB in any minor procedure room. OUR EXPERIENCE WITH GA AND WIDE-AWAKE SLNB The first author (J.S.D.) did all his SLNB in the main OR with GA from March 2012 to December 2019 (7.5 y). For the last 5 years, he has done every SLNB procedure with TLA in a minor procedure room. In these last 5 years, he has removed 108 nodes in 83 patients, with 0 cases of conversion to GA, no cases of local anesthetic systemic toxicity (LAST), no hematomas, and no need for admission for observation. All patients received no more than 7 mg/kg of lidocaine with epinephrine. The low seroma and infection rates are unchanged from the GA period. There has been no need to limit cases based on any elevation of body mass index. The main contraindication would be patients who are unwilling or unable to tolerate minimally painful local anesthesia. Despite zero occurrences of LAST using this protocol, the reader is advised to refer to a recent reference source that goes into all the details of LAST, how to avoid it, and how to treat it,5 should inadvertent excess dosing occur. WHY MAKE THE MOVE TO WIDE-AWAKE SLNB IN A MINOR PROCEDURE ROOM? It is better, faster, and cheaper. The near-bloodless field and hydrodissection produced by the epinephrine-containing tumescence improve surgical exposure and structure identification. It offers postoperative pain relief without any side effects of GA, narcotics, or sedatives when performed in a truly wide-awake fashion. Contrary to initial fears, the tumescence has improved rather than impeded ease of surgery. We routinely enjoy shorter operative case times and attribute most of the time savings to the elimination of GA induction and emergence, along with rapid patient repositioning with the assistance of an alert patient. And yet, this intraoperative time savings pales in comparison to the increased turnover efficiency and case completion rate seen when SLNB is moved to the rapid flow of a multiroom minor procedures clinic. Our waiting time from consultation to surgery is shorter because it is easier to book patients into a minor procedure room with TLA than in the main OR with GA. A significant surgical cost reduction has been reported for SLNB under TLA compared with GA, whereas safety and efficacy remained equal.2,3 The scarcity of main OR resources is one of the most pressing concerns of many surgical services. Seizing this TLA wide-awake opportunity allows increased OR capacity to complete the next best alternative case that requires the specialized OR setting. The value of this approach should garner the attention of surgeons and health system administrators alike. The following are the surgical technique and steps to success. (See Video 1 [online], which demonstrates injection of local anesthesia and surgery for a right axillary SLNB, with melanoma resection and skin grafting.) (See Video 2 [online], which demonstrates injection of local anesthesia and surgery for a left inguinal SLNB, with melanoma resection and skin grafting.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"demonstrates injection of local anesthesia and surgery for a right axillary SLNB, with melanoma resection and skin grafting.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_99cf8pdu"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"demonstrates injection of local anesthesia and surgery for a left inguinal SLNB, with melanoma resection and skin grafting.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_sc4pyqs6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Establish safe and complete surgical field anesthesia with epinephrine-containing dilute lidocaine TLA solution (Table 1). We confine our total dosage to less than 7 mg/kg. Typically, a prepared 500 mL total volume is sufficient to complete primary tumor resection, reconstruction, and SLNB. Table 1. - TLA Formulation Lidocaine (mg/L) Epinephrine (mg/L) Sodium Bicarbonate (mEq/L) 1000 1 10 3. Minimize injection site pain with an initial 30G needle before using larger needles or cannulas to deliver the TLA. 4. Begin at the primary tumor site and anesthetize it sufficiently for a comfortable injection of blue dye. Then infuse it more broadly in preparation for complete secondary tumor resection if that is required to achieve margins. We have not found TLA to impair dye uptake or delivery to the node. 5. Anesthetize the regional nodal basin(s). Direct fluid deep to the appropriate fascial plane to bathe the nodal tissue and then fill the superficial subcutaneous space to achieve dense field anesthesia for your initial cut and dissection. Fluid directed deep to fascia will appear to expand the area minimally, whereas superficial injections will visibly inflate the site and tent the skin. This sign is often sufficient to confirm fluid placement. We have not yet routinely used ultrasound guidance, but we think this is a good idea. 6. We typically tumesce 150–200 mL of solution in the axilla and 100–150 mL in the inguinal site. Use as much volume as necessary based on the patient’s size or the extent of dissection to establish anesthesia. Secondary nodes or atypical locations can be approached in a similar fashion with good success. Our experience is confined to non–head and neck locations. 7. Surgical technique needs little modification other than habituation to operate within a relatively bloodless, yet wet field. Dry the field as you go. Bipolar electrocautery is less stimulating and is chosen over monopolar when dissecting deeper structures. As with any local operation, if the limits of field anesthesia are reached, stop, inject additional TLA, allow time to take effect, then resume as normal. CONCLUSIONS Wide-awake SLNB in a minor procedure room is a good alternative to GA for efficient and cost-effective care of skin cancer patients. DISCLOSURES Dr. Lalonde receives royalties from Thieme Medical Publishers and serves as a consultant for Accurate Surgical & Scientific Instruments, Corp. The other author has no financial interest to declare in relation to the content of this article.