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Indication: Commonly for malignant breast lesions.
Preoperative prep investigations completed and consent obtained, and the ipsilateral axilla shaved just before going to the theater or in the theater
Premedications by anesthetists
Anesthesia– General Anesthesia with cuffed-Endotracheal intubation (GA-CTI)
Positioning of patient – Supine slight head up ( for hemostatic effect) and with the arms abducted to 90 degrees
Skin preparation– Using Povidone-Iodine. Area of skin to prepare is vertically on the ipsilateral side from the root of the clavicle to the level of the upper part of the rectus sheath and transversely from the nipple line on the other side to the posterior axillary line on the ipsilateral side. The axillary skin preparation includes the ipsilateral upper limb down to the elbow and including the axilla ( the axilla is prepared last)
Draping– Applied to expose the breast from the level of the clavicle to below the inframammary grove and from the mid clavicle to the midaxillary line
Surgeon’s position – Ipsilateral side
Assistant – The first assistant stays opposite the surgeon. The second assistant stays on the same side to the right of the surgeon.
Scrub Nurse: The scrub nurse to the left of the first assistant
Incision – Elipitical incision the orientation depends on the location of the tumor, but the incisions must be at least 2cm from the gross margin of the lesion and include the tumor, the nipple, and areola complex.
Making the skin flaps
The superiomedial flap – Raised from the upper incision to the clavicle and midsternal line
inferolateral skin flaps- Raised from the inferior incision line to the inframmary fold (superior border of the external oblique) and the midaxillary line. The plane of the flap should be just in the subcutaneous plane not deep into the parenchyma in order to avoid the vascular plane which is associated with significant bleeding
Raising the breast tissue from the retro mammary space: The breast tissue is raised from the retro mammary space, starting medially and working laterally. The axillary tail Is followed into the armpit. The breast tissue cleared should extend from the clavicle down to the eighth costal cartilage and rib and from the lateral edge of the sternum to the midaxillary line.
Blood vessels– In raising the skin flap and the breast tissue, the blood vessels should be secured –medially the perforating branches of the internal mammary vessels at the 2nd to 4th intercostal spaces. Laterally the perforating branches of the intercostal vessels also 2nd to 4th intercostal spaces and towards the axilla, the branches of the lateral thoracic from the second part of the axillary vessels
Axillary dissection– The axillary tail of the breast is followed into the axilla and the axillary tail; the axillary lymphatics and nodes and fat and fascia are cleared en-bloc with the breast.
Structures to preserve–
- the intercostobrachial nerve,
- the long thoracic nerve of bells and
- the subscapular vessels and
- the pectoralis major.
- The pectoralis minor could be excised, divided, or retracted during the procedure to access the level 3 axillary nodes
Closing the wound: Two drains are inserted in the axilla and another below the skin flaps. The subcutaneous tissue and skin are closed. Tight compression bandaging is applied
Postoperative order
- Iv fluids 1 liter every 8 hours
- Pentazocine 60mg every 6 hours
- Allow plain fluids from 6 hrs postop
- Remove drain once less than 100mls in 24 hrs
- Remove stitches 10 days postop
- DVT prophylaxis from second postoperative day.