Download Procedures Basic Format: Modified Radical Mastectomy with Axillary Node Dissection

Procedures
Basic Format:
Modified Radical Mastectomy with
Axillary Node Dissection
Objectives
• Assess the anatomy, physiology, and
pathophysiology of the breast
• Analyze the diagnostic and surgical interventions
for a patient undergoing a Modified Radical
Mastectomy w/Axillary Node Dissection
• Plan the intraoperative course for a patient
undergoing Modified Radical Mastectomy
w/Axillary Node Dissection
• Assemble supplies, equipment, and
instrumentation needed for the procedure.
Objectives
• Choose the appropriate patient position
• Identify the incision used for the procedure
• Analyze the procedural steps for Modified Radical
Mastectomy w/Axillary Node Dissection
• Describe the care of the specimen
• Discuss the postoperative considerations for a
patient undergoing Modified Radical Mastectomy
w/Axillary Node Dissection
Terms and Definitions
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Benign vs Malignant
Biopsy
Frozen Section
Gynecomastia
In situ
Mammography
Mammoplasty
Mastectomy
Xeroradiography
Definition/Purpose of Procedure
• Ablative/Treatment: remove diseased tissue
• Removal of the breast tissue and lymph
nodes under the arm (axillary node
dissection), leaving the chest wall muscles
intact
Modified Radical Mastectomy
Radical Mastectomy
Simple Mastectomy
Segmental Resection
Lumpectomy
Relevant A & P
1. Mammary glands are
between the 3rd and 7th
ribs at ant. Chest wall
2. Areola
3. Nipple
4. Cooper’s Ligaments
5. Tail of Spence
Anatomy of Breast
Breast Incisions
Pathophysiology: Breast CA
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Begins as a single transformed cell
Is hormone dependent
Classified: non-invasive (in situ) vs invasive
Categories: CA of mammary ducts, ca of mammary
lobules, or sarcoma of the breast
• Most: adenocarcinomas
• 70% Infiltrating ductal carcinoma
• Metastasis to other sites
Breast Cancer Location by Quadrant
Pathology: Breast CA Staging
Stage 1
Size
< 1-2 cm
Location
Confined to breast
Stage II
2-5 cm
Stage III
Stage IV
> 5 cm
Large & fully
integrate
w/surrounding
tissue
Breast mass w or Breast mass w
Distant Metastasis
w/o susp
palpable, fixed Ax Extension to skin
ALNodes
&/or subclavicular Lympedema
L Nodes. No D
Metastasis
Surgical Options
Segmental; Breast Total
Conservation Surg Mastectomy
for Stages I & II
Lumpectomy
w/AND & Rad Tx
Modified or
Radical
Mastectomy
Radical or
Extended Rad
Mast
Axillary Lymph Node Dissection
Manifestations of Breast Cancer
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Breast mass or thickening
Unusual lump in underarm or above collarbone
Persistent rash near nipple area
Flaking or eruption near the nipple
Dimpling, pulling, or retraction in an area of the breast
Nipple discharge
Change in nipple position
Burning, stinging, or pricking sensation
Diagnostics
• Exams
– Initial breast exam or mammography
– Chest x-ray
– Bone scanning
• Preoperative Testing
Surgical Intervention:
Special Considerations
• Patient/Family Factors
– High Anxiety/Apprehension due to upcoming
loss/disfigurement: alert to need for therpeutic
communication & alleviation via meds
• Room Set-up: Standard
– Have mammograms in the OR
– Notify pathology if Frozen sections will be required
before case begins—ensure pathologist present
• Universal Protocol
• May use special techniques for Cancer
– May prefer to irrigate with sterile water to crenate
(shrivel or shrink) cancerous cells.
Surgical Intervention: Anesthesia
• Method: General
• Equipment: Typical monitors and machines
Surgical Intervention: Positioning
• Position during procedure
– Supine with operative side close to bed edge
– Arm on operative side is extended to < 90
degrees on a padded armboard
• Supplies and equipment: May place small
sandbag or folded sheet under shoulder of affected
side; may use special arm table or double it
• Special considerations: high risk areas
Surgical Intervention: Skin Prep
• Method of hair removal
• Anatomic perimeters
– Shoulder, upper arm extending down to
the elbow (circumferentially), the axilla, &
chest to table line and to the shoulder
opposite from affected side—access to
underarm for AND and possible extend to
fingertips of operative side
– Arm on operative side should be draped
free using stockinette & drapes that allow
free movement of the arm to facilitate
access to the axilla
• Solution options
– Betadine or Hibiclens
Surgical Intervention: Draping/Incision
• Types of drapes:
• Order of draping
Chest/Breast drape; stockinette
– Anticipated area is outlined with adhesive towels or cloth towels &
clips
– Chest/Breast drape
– Draping of arm includes placement of sheet on armboard and appl
of stockinette over entire arm
• Special considerations: may need 2 set-ups; use of
Sterile water intraop irrigation
• State/Describe incision: usually elliptical for
MRM—see slide
Surgical Intervention: Supplies
• General:
Prep set, basic pack, basin set, chest drapes,
ESU pencil/holder, gloves, Blades # 10 x 3, drsg: 4 x 4’s
& ABDs
• Specific
– Suture: Silk, Dexon, Nylon for drain
– Medications on field (name & purpose)
– Catheters & Drains: Closed wound drainage
system x 2 (Jackson Pratt vs Hemovac)
Surgical Intervention: Instruments
• General: Major tray
• Specific: extra hemostats (Adair breast
clamps/large towel clips or Criles )
• Rake retractors
• If skin graft anticipated: Brown dermatome
w/mineral oil, tongue blades, etc.
Surgical Intervention: Equipment
• General: Suction, ESU with Dispersive
electrode—may need to simultaneously
• Specific: may need additional armboard or
special armrest
Surgical Intervention:
Procedure Steps Overview
• Breast incised elliptically
• Incision deepened to encompass entire
breast
• Breast removed en bloc w/ALNs
• Axillary lymph nodes are removed
• Wound is closed
Surgical Intervention: Procedure Steps
• Surgeon incises skin around the breast elliptically and
deepens w/ESU pencil—lateral extension toward the axilla
thru the subcutaneous tissue. Bleeding is controlled
w/hemostats and ligatures or ESU
• Surgeon dissects the skin from the underlying tissue w/#10
blade on # 3 knife handle and or ESU pencil
– Blades dull easily and will need changing—notify Surgeon each time
– Crv. Metzenbaum scissors are used to isolate large vessels from the
breast tissue when the surgeon extends the incision into the axilla
• Beren’s retractors are used to elevate skin flaps. Allis or
Kocher clamps are placed along breast tissue edges and
retracted up by surgeon or assistant
Elliptical Incision
Surgical Intervention: Procedure Steps
• The margins of skin flaps are covered w/warm moist lap
pads and held away w/retractors.
• The intercostal arteries and veins are clamped and ligated.
• The axillary flap is retracted for complete dissection of the
axilla.
• Careful attention is directed to preventing injury to the
axillary vein & medial and lateral nerves of the pectoralis
major muscle
• The fascia is dissected from the lateral edge of the
pectoralis muscle. Ligation of vessels is performed in the
axilla & adjacent to sternum. The fascia is then dissected
to the serratus anterior muscle. The thoracic &
thoracodorsal nerves are preserved
Surgical Intervention: Procedure
Steps
• Be sure to keep exposed tissue moist with lap
packs for protection
• Surgeon dissects the breast and axillary fascia
away from the latissimus dorsi muscle and
suspensory ligaments—from near the clavicle to
midportion of the sternum. The pectoralis major
muscle is left intact.
• The specimen is passed to STSR
• Wound is inspected for bleeding sites, which are
ligated & electrocoagulated, then irrigated (NS).
Surgical Intervention: Procedure Steps
• Surgeon places closed-wound suction drainage tube(s) thru
stab wounds and secured to skin w/nonabsorbable suture
on a cutting needle
• A few absorbable suture may be used in the subcutaneous
tissue to approximate the skin edges.
• Surgeon closes w/interrupted nonabsorbable sutures or
staple, anchors drains, and connects to closed suction
reservoir.
• The dressing may be one of several: simple gauze, bulky
held in place w/Surgi-Bra, or gauze and elastic wrap.
Counts
• Initial: Sponges, Sharps, Instruments,
Small items
• First closing
• Final closing
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Sponges
Sharps
Instruments
Small Items
Dressing, Casting, Immobilizers, Etc.
• Types & sizes: 4 x 4’s & Abd pads
– May need ACE wraps or Surgical Bra
• Type of tape or method of securing—Silk or
Paper or Foam compression tape
Specimen & Care
• Identified as Breast and axillary lymph
nodes, Left or Right
• Handled: Routine/large container
– Ask : if estrogen or progesterone receptors
studies are to be performed on a specimen, it is
saved in Normal Saline or Dry
Postoperative Care
• Destination
– PACU
• Expected prognosis (Good, Depends on Dx)
– Referral to Reach to Recovery rehabilitative
Program and Physical Therapy possible
Postoperative Care
• Potential complications
– Hemorrhage (vascular breast—watch)
– Infection
– Other: Damage to….
• Surgical wound classification
– Class I
References
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Alexander: pp. 637-655
Berry & Kohn: pp. 637-641
Fuller: pp. 321-322
MAVCC Proc Unit 3 p. 69-70
STST: pp. 457-461
Lemone & Burke: pp. 1582-1594