Thursday, January 22, 2015

Breast surgery Mastectomy


Mastectomy
In cases of diagnosed carcinoma:
•   Removal of the Breast:
     a.  Partial mastectomy (Lumpectomy): Excision of a breast tumor with appropriate tumor-free margins.
     b.  Simple mastectomy: Removal of entire breast.
     c.  Modified radical mastectomy: Removal of breast and axillary lymph nodes; most frequently performed radical procedure.
   d.  Radical mastectomy: Includes the removal of the entire breast, pectoralis muscles, axillary lymph nodes, fat, fascia and adjacent tissues. A skin graft may be necessary for skin closure. Less frequently employed, unless there is an invasion of deeper structures.
   e.  Extended radical mastectomy: En bloc removal of the breast, axillary contents, pectoralis muscles, and internal mammary lymph nodes. Resection of the ribs and sternum may also be included. A skin graft may be required for closure of the wound; rarely performed today.
Position
The patient is supine with arms extended on arm boards, a folded sheet is under the shoulder on the affected side. Apply electrosurgical dispersive pad.
Anesthesia
General anesthesia.
Procedure
1.  In partial mastectomy, the incision is usually made over the lesion.
2.  The skin is elevated and the breast mass is excised with healthy tissue around. Hemostasis is obtained.
3.  In subcutaneous mastectomy, the incision is generally made in the inframammary fold.
4.  In modified radical mastectomy, usually a transverse or longitudinal incision is used.
5.  Skin flaps are developed and pectoralis fascia is dissected free from underlying structures.
6.  The axillary contents are dissected free from vascular and nervous structures and are removed.
7.  Care is taken to avoid injury to the nerve supply to various muscles.
8.  After hemostasis is achieved, the skin flaps are approximated over the drains or suction catheters (e.g. Hemovac). A skin graft may be required for skin closure.
In radical mastectomy
Additional structures including the pectoralis major and minor muscles and the intervening lymphatic and fatty tissues are excised.
Instruments
General set
•   Additional curved crile clamps and large towel clips hemoclip appliers (small, medium, large) (Fig. 17.25)
•   Rake retractors (4 or 6 prong)
•   Electrosurgical unit
•   Suction tubing
•   Needle magnet or counter
•   Tube (or impervious) stockinette
•   Electrosurgical pencil holder (optional)
•   Dermatome (for skin graft) (e.g., Brown and necessary supplies including mineral oil, saline, tongue blades, and petroleum-impregnated gauze)
•   Drainage unit (e.g. Hemovac)
•   Pressure dressing
•   Marlex mesh, optional

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