MASTECTOMY #

Pre-operative #

Consent #

• Discuss reconstruction options.
• Present alternatives (e.g., Breast-Conserving Surgery).
• Inform about post-operative chemotherapy and radiotherapy.
• Explain potential post-operative complications.

Pre-operative Ward Preparation #

• Mark the surgical site.
• Mark the incision in the supine position and verify in the sitting position.
• Ensure 1 pint of blood is ready.
• Shave the axilla.

In the Theatre #

Preparation #

• WHO safety checklist.
• Position patient
  • supine
  • arm abducted at 90 degrees on an arm board, with a
  • sandbag under the ipsilateral scapula.
• Insert a cannula in the opposite forearm.
• Place mammogram on illuminator and reconfirm the surgical site.
• Administer GA with endotracheal intubation.

Team Positioning #

• Surgeon stands on the side of the lesion.
• 1st assistant at the head end.
• 2nd assistant on the opposite side.

Sterilization and Draping #

• Clean from
  • chin to umbilicus,
  • opposite nipple to posterior axillary fold, and
  • the upper limb (axilla, shoulder, and arm up to the elbow).
• Drape
  • the arm separately.
  • Expose the breast and axilla from the clavicle to 2 cm below the inframammary fold.

Marking the Incision #

• Transverse elliptical skin incision including:
  • Tumor with a 2 cm margin.
  • Biopsy site.
  • Nipple-Areola Complex.
  • Extend from the lateral border of the sternum to the anterior axillary line.
  • Check for approximation.

Tip

• Remark the incision with methylene blue.

Tip for Marking the incision

• Mark the medial and lateral ends.
• Draw the breast firmly downwards and mark a straight line connecting the two points.
• Similarly, mark the lower flap by drawing the breast up.

Upper Flap Dissection #

• Incise the skin with a No. 23 blade.
• Place skin hooks and hold up vertically.
• Apply counter traction on the breast using a gauze towel.
• Dissection plane is between
  • small pale subcutaneous fat and
  • large bright breast fat
  • by dividing Cooper’s ligaments (with a scalpel).
• The raised flap should be about 0.5 - 1 cm thick.
• Dissection limit: Extend up to the top of the breast (2nd rib).
• Achieve hemostasis and place a saline-soaked towel under the flap.

Warning

Avoid buttonholing.

Lower Flap Dissection #

• Position: Surgeon turn towards the lower side of the body.
• Dissect the flap similar to the upper flap
• Dissection limit is up to the lower border of the breast (6th rib).

Dissection of breast off pectoralis #

• Retract
  • superior-medial margin of upper flap using Czerny retractor
  • Retract the breast laterally.
• Incise the pectoral fascia.
• Dissect off the breast from the pectoralis muscle with the pectoralis fascia.
• Ligate the perforator vessels entering the deep surface of the breast.
• Dissection limit using sharp dissection is up to
  • the lateral border of the pectoralis major
  • and anterior border of the latissimus dorsi.
  • serratus anterior, and latissimus dorsi.
• Keep the separated breast supported in a folded towel.
• Place two wet towels underneath each flap.

Danger

If pactoralis major is invaded

• Remove the breast with a cuff of muscle with a 2 cm margin.

Axillary dissection #

Exposing the Axilla #

• Indentify Pectoralis minor by retracting Pectoralis major medially.
• Rotter’s node is excised by blunt dissection.
• Axillary space is exposed by
  • Retracting latissimus dorsi laterally and
  • retracting the pectoralis major superomedially.
• Clavipectoral fascia is divided along the lateral border of the pectoralis minor to enter the axilla.

Identifying Structures: #

• Look for the medial pectoral nerve (curves at the edge of the pectoralis minor).
• Identify the pectoral branch of the thoracoacromial trunk.

Axillary Vein Dissection: #

• Identify the coracoid process.
• Divide the clavipectoral fascia up to the coracoid process (along the border of pectoralis minor).
• Perpendicularly deep to coracoid process lies the axillary vein (the largest, bluish vessel in this region).
• Identify the axillary vein at the apex of the axilla.

Axilla Dissection limit: #

• Superiorly up to the axillary vein.
• Laterally up to the latissimus dorsi.
• Medially up to the serratus fascia of the lateral chest wall.
• Inferiorly up to the angular vein.

Lymph Node and Fat Removal: #

• Strip off lymph nodes and fat from the axillary vein using combined blunt and sharp dissection.
• Apply gentle traction to the breast and,
• Remove axillary fat from the apex of the axilla to the posterior axillary fold.
• Ligate and divide the constant venous tributary from the axillary fat to the axillary vein.

Clearing Level 2 Nodes: #

• Retract pectoralis minor superomedially and
• Bluntly dissect the fat underneath the pectoralis minor using pledgets.
• Clear the level 2 nodes with long curved artery forceps up to the medial border of the pectoralis minor.

If Level 3 Clearance is Needed: #

• Divide the pectoralis minor from the coracoid process
  • No need to suture it back.
• Clear the level 3 nodes up to the costoclavicular ligament.

Preserving Nerves #

• Strip the remaining fat off the lateral chest wall, preserving the serratus fascia
  • long thoracic nerve lies more posteriorly within serratus fascia.
• Preserve the thoracodorsal neurovascular bundle.
• Preserve the intercostobrachial nerve if possible.
  • Divide the axillary fat between the branches;
  • if difficult, clean division with scissors and burn the proximal end in the chest wall.

Specimen marking: #

• Remove the breast and the level I and II nodes en bloc.
• Label with nylon stitches borders of the breast and level I and II lymph nodes separately.

Hemostasis and Drainage #

• Immerse the surgical site with distilled water for 1 minute, then suck out and check for hemostasis.
• Insert a closed suction drain through a separate stab incision into the axilla.
  • Stab incision should be (2 cm) below the lateral half of the incision.
  • Anchor with nylon.

Closure #

• Subcutaneous tissue with polygalactin interrupted 2/0 (vicryl).
• Skin subcuticular 3/0 monocryl.
• Squeeze out blood and air, and activate suction drainage.

Postoperative Care #

Immediate Care #

• Adequate Analgesia: Ensure the patient has adequate pain relief.
• Early Mobilization: Encourage early mobilization of the shoulder with active physiotherapy.
• Flap Inspection on day 2.
• Drain Removal on day 5 or when drainage reduces. Change suction to non-suction within 24-48 hours.

Discharge Advice to Patient #

• Avoid Strenuous Activity: Do not engage in repetitive movements for long hours.
• Limb Care: Avoid accidental injury to the limb.
• Avoid BP Measurements or cannulation on the affected limb.
• Cellulitis: If there is any evidence of cellulitis, seek medical attention immediately to start antibiotics.

Questions #

1. Why Use a Transverse Scar? #

• Better Cosmesis: Aligns with Langer lines in the breast, which are horizontal.
• Functional Outcome: Better functional outcome for the arm.
• Radiotherapy Advantages:
  • Lung damage is limited to a straight transverse area rather than a large oblique area.
  • For patients with cardiac problems who need Trastuzumab or anthracycline, which are cardiotoxic, a transverse scar on the left side minimizes radiotherapy damage to the heart.
• Reconstruction: More favorable during reconstruction procedures.

2. What to Do in Case of Accidental Injury to the Axillary Vein? #

Immediate Actions:

• Pack and apply pressure to the injury site.
• Inform the anesthetist and vascular team.
• Prepare blood for transfusion.

Surgical Preparation:

• Have the
  • sucker,
  • vascular clamps,
  • vascular tapes,
  • vascular needles, and
  • heparin saline ready.
• Extend the incision by cutting the pectoralis minor from the coracoid process.
• Obtain proximal and distal control using a
  • bulldog clamp,
  • Satinsky clamp,
  • vascular tape, or
  • two swabs on holders.

Procedure:

• Start a heparin infusion.
• Repair the defect:
  • Primary Closure: Use 5-0 polypropylene for small defects.
  • Large Defects: Use an interposition graft from the great saphenous vein (GSV).