SENTINEL LYMPH NODE BIOPSY – A PATIENT BOOKLET

BRIEF: To create a patient booklet on Sentinel Lymph Node Biopsy, that includes both written information and illustrations
AUDIENCE: Patients (in particular, breast cancer patients)
SERVICES USED: 2D Illustration, Layout Design
MEDIA: Adobe Illustrator, Photoshop and InDesign
FINAL OUTCOME: Two final versions of a patient booklet on Sentinel Lymph Node Biopsy (the second includes larger images)

The Plastic Surgery Department at Ninewells Hospital and Medical School urgently required a patient information booklet on Sentinel Lymph Node Biopsy to help their patients better understand the procedure.

Sentinel Lymph Node Biopsy (SLNB) is a surgical procedure used to determine whether cancer has spread beyond the primary tumour into the patient’s lymphatic system. It is used most commonly in evaluating breast cancer. Whilst the procedure itself is relatively simple, the Plastic Surgery Department noted that their patients find it difficult to grasp the anatomy and the steps involved in the surgery. They also mentioned that the information they do give patients doesn’t have images. Therefore, in the patient booklet produced, a combination of easy-to-understand, patient-friendly written information and labelled images illustrating the surgical sequence of the SLNB procedure was used.


THE FINAL PATIENT BOOKLETS

SLNB PATIENT BOOKLET VERSION 1

This version contains smaller images. Click cornered square outline in bottom right to view fullscreen.

SLNB PATIENT BOOKLET VERSION 2

This version contains larger images. Click cornered square outline in bottom right to view fullscreen.


PROCESS

IMAGE SEQUENCE

Following observation of multiple SLNB procedures at Ninewells Hospital, as well as in-depth research, an outline of the image sequence order was produced for the illustrations to be made in Adobe Photoshop:

  • IMAGE 1 - Anatomy of the lymphatic system
  • IMAGE 2 - Injection of the blue radio-labelled dye
  • IMAGE 3 - Close up of the blue dye in the lymphatic system
  • IMAGE 4 - Visualisation of the gamma probe in identifying the affected lymph nodes, plus the incision made to access the lymph nodes for removal
  • IMAGE 5 - Removal of lymph nodes
  • IMAGE 6 - Re-inspection of the area using the gamma probe
  • IMAGE 7 - Stitched up incision on the patient
The colour theme of the artwork (especially the anatomy) was carefully selected. Soft tones were used to allow the image to be relatively calm to the patient viewer, with a variety of semi-contrasting colours to allow distinction between the structures.

 
POSITIONING AND BASIS IMAGES
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The patient was depicted in a lying down position, from the point of view of the surgeon. This is because it allows the viewer to orientate where the surgery occurs on the body (with the help of the jaw and neck), whilst allowing all relevant anatomy and the incision placement to be seen.

Firstly, the outline of the body area was drawn. Secondly, the skin and hair were coloured and shaded to give a semi-realistic appearance. Thirdly, the lymphatic system, breast fat and tumour were created to show the relevant anatomy involved in the surgery, and a black square box was used to help the viewer focus on one image at a time. The second and third images were used as a basis for most of the other images in the sequence.

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FIRST, SECOND AND THIRD IMAGES
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With the image showing the skin and anatomy complete, a green dashed line was then made to outline the axillary lymph nodes. This illustration was then used as the first image in the patient booklet to aid learning of the anatomy of the lymphatic system.

The second image was to show the injection of the blue radio-labelled dye. The skin/hair layers were duplicated from the first image and a syringe containing blue radio-labelled dye was drawn, as well as blue discolouration around the injection site. The blue colour was taken from my initial iPad drawings on the surgery day, where the plastic surgeon helped me get the correct colour of the blue dye.

The third image was to show the blue dye draining into the lymphatic system. A close up of the breast was deemed appropriate for the third image, as it allows the viewer to see how the blue dye from the injection site drains into the sentinel lymph nodes. Arrows were used to further define the drainage pathway of the blue dye.

 
 
FOURTH AND FIFTH IMAGES
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For the fourth image, the skin and hair layers were again duplicated from the first image, and the lymphatic system showing the blue dye was duplicated from the third image. A scalpel and gamma probe were then drawn and added to the illustration.

For the fifth image, I didn’t want it to look too realistic and potentially upset viewers, therefore the presence of blood and other tissues not relevant to the surgery were omitted (i.e. only the lymph node and breast fat were shown). Surgical retractors and a tray holding another lymph node were also created.

SIXTH AND SEVENTH IMAGES
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The sixth image was based off layers from the fifth image, with the addition of the probe from the fourth image and stitches. This was to show the wound being reinspected for any additional affected lymph nodes, and consequently being stitched up.

The seventh and final image was relatively simple to produce. The skin/hair layers were duplicated from the first image,an incision line was drawn, and stitches from the sixth image were duplicated and multiplied.

 

WRITTEN CONTENT AND BOOKLET DESIGN

The written content was based off the image sequence, meetings with the client and credible reference sources. The booklet was created in Adobe InDesign, paying close attention to the NHS Scotland Identity Guidelines to ensure the booklet meets NHS requirements.

POST-REVIEW UPDATES

Changes were made to the illustrations and word content following the client's review of the patient booklets. Use the slider below to see how the images changed (left = before, right = after). Can you spot the differences?

(Please note that Image 5 is not shown as there were no changes required)

 

IMAGE 1
Anatomy of the lymphatic system

IMAGE 2
Injection of the blue radio-labelled dye

 
 

IMAGE 3
Close up of the blue dye in the lymphatic system

IMAGE 4
Visualisation of the gamma probe in identifying the affected lymph nodes, plus the scalpel starting the incision

 
 

IMAGE 6
Re-inspection of the area using the gamma probe

IMAGE 7
Stitched up incision on the patient