Introduction

Lymphatic mapping is an exciting undertaking. Anatomy, physiology, imaging, and technical surgical expertise go hand in hand. The routine case in which a single sentinel node is easily identified in the usual location is encountered in perhaps only 25% of patients. Sentinel nodes can be located in strange places, not described in the standard text books. Lymph drainage is much more variable than was previously assumed. Lymph vessels take unexpected turns. These variations in anatomy and physiology are captured in one image by lymphoscintigra-phy. Reviewing the scintigraphy images together with the nuclear medicine physician ensures that the surgeon goes to the operating room well prepared.

Sentinel nodes are sometimes found within 1 minute after making the skin incision, practically falling into the surgeon's hand. Other times, the operation may take more than an hour and require the surgeon to use every trick in this book to find it. Blue dye outlines the drainage patterns that may be different from what the nuclear medicine images suggested. It is therefore important that the surgeon reports his operative findings back to the nuclear medicine physician. We must learn from each other. Lymphatic mapping is still being developed and refined, and a number of questions remain to be solved.

The aim of this chapter is to teach practical lessons. The techniques described have been thought over carefully, but alternative techniques may work as well or perhaps even better. The cases in this chapter have been carefully selected. The most instructive cases are possibly the ones in which the authors confess that mistakes were made. Each case carries a point, often more than one. Anatomical aberrations, variable physiology, pitfalls in the nuclear medicine suite, and technical challenges in the operating room are described.

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