Melanoma wide local excision + SLNB

# OPERATION NOTE — Melanoma wide local excision + SLNB

Date: 19/05/2026Elective
Surgeon: Mateusz Gładysz, Consultant Plastic and Hand Surgeon
Assistant: [Registrar Dr ____]
Anaesthetist: [Dr ____]    Anaesthetic: GA
WHO Surgical Safety Checklist: Sign-in / Time-out / Sign-out — completed.

## Diagnosis / Indication

- Biopsy-proven cutaneous melanoma of [SITE].
- Histology: Breslow [___] mm, non-ulcerated, mitotic rate [___]/mm², Clark level [___], margins [___].
- Stage (AJCC 8): pT1; clinically N0, M0.
- Plan: Wide local excision with 10 mm clinical margin (per Australian and New Zealand Melanoma Guidelines, Sladden et al., MJA 2018 / SCNZ 4th Edition); sentinel lymph node biopsy (SLNB) as Breslow ≥0.8 mm with high-risk features.

### Configurable WLE margin (Breslow-based)

- Melanoma in situ: 5–10 mm
- pT1 (≤1.0 mm): 10 mm
- pT2 (1.01–2.0 mm): 10–20 mm
- pT3 (2.01–4.0 mm): 10–20 mm
- pT4 (>4.0 mm): 20 mm

Margin selected for this patient: 10 mm. Rationale: per guideline.

## Consent

Risks: bleeding, haematoma, infection, scar, recurrence, incomplete excision, lymphoedema (regional), seroma, sensory loss, anaphylaxis to patent blue, transient blue staining of skin and urine, false-negative SLNB, need for completion lymphadenectomy if SLN positive (current practice is observation per MSLT-II / DeCOG-SLT — discussed).

## Preoperative

- Lymphoscintigraphy performed [date, time]: Tc-99m antimony sulphide colloid injected intradermally peri-lesionally; SLN basin identified: axilla. Number of hot nodes on SPECT-CT: [___]. Skin marked.

## Position / Prep / Drape

Supine; [arm abducted / leg externally rotated / head turned] for axilla access. Prep 0.5% chlorhexidine-alcohol. Wide drape.

## Anaesthesia / Antibiotics

GA. Cefazolin 2 g IV at induction. Tourniquet not used (interferes with dye dynamics).

## Procedure — SLNB first, then WLE

1. Blue dye: 1.0 mL of patent blue V injected intradermally around the biopsy scar; gentle massage.
2. Gamma probe used to localise transcutaneous hot spot; skin incision marked in skin crease over peak count.
3. Incision through skin and subcutis; blunt dissection along blue lymphatics.
4. Hot/blue sentinel node identified, mobilised, vascular pedicle clipped, node excised.
5. Ex vivo counts: SLN1 [___] counts; background bed [___] counts. SLN considered "hot" if ≥10% of hottest node or ≥10× background.
6. Field rechecked for residual hot nodes; additional SLNs harvested until residual basin count <10% of hottest node.
7. Nodes labelled SLN1, SLN2, … sent for serial sectioning + S100 / SOX10 / HMB45 immunohistochemistry.
8. Wound irrigated, haemostasis; closure deep dermal 3-0 Monocryl, subcuticular 4-0 Monocryl.
9. WLE: margin marked at 10 mm radial clinical clearance from the scar / visible pigment, extended down to deep fascia (not including fascia unless tumour-involved). Elliptical excision along long axis of limb / RSTL. Orientation sutures: short = superior, long = lateral. Closure: direct primary (undermining wide).

## Findings

- SLN basin: [___] nodes harvested.
- WLE bed: no macroscopic residual tumour.

## Specimens

- "SLN1 — axilla — short = lateral"; "SLN2 …"; "WLE [SITE] — short = superior, long = lateral".

## Estimated blood loss

[___] mL.

## Complications

Nil intra-operative.

## Count

Swabs / needles / instruments — confirmed correct.

## Post-op plan

- Mobilise as comfort. Elevate limb (if relevant).
- Analgesia: regular paracetamol + ibuprofen ± oxycodone PRN.
- Drain (if present) out when <30 mL/24 h.
- Warn re. transient blue urine and skin 24–48 h.
- Histology MDM referral.
- Clinic follow-up at 2 weeks for review and discussion of nodal histology; subsequent surveillance per SCNZ 4th Edition.

## Signature

Mateusz Gładysz, Consultant Plastic and Hand Surgeon — 19/05/2026