Mastectomy/ modified radical mastectomy

Indications:
Tumour size > 4cm

Multicentric tumour

Poorly differentiated tumour

Tumour margin is positive after BCS (2nd time)

Recurrence after BCS

Prior radiotherapy to breast

Scleroderma or association with other collagen disease

Stage1 invasive disease/ stage 2, 3 disease.

Preop and operative preparation

 Preoperative scrub bath is advised
 Cannula should not be placed in affected side arm

Anaesthesia:
 General anaesthesia is used and endotracheal intubation is done.

Position of patient
 Patient lies in supine position with sandbag under same side of thorax
and shoulder.
 Side of chest wall, whole breast area , axilla ,neck and side are cleaned
with chlorhexidine or providone iodine solution and wait for 3 – 4
minute and is coverd with drape.
 Shoulder is kept in abducted and extended position and shoulder should
have free movement as needed during dissection.
Steps
Skin incision

 Different skin incision are used but classical Stewart incision is commonly
used decided by operating surgeon.
 An elliptical skin incision is made from medial aspect of the 2nd and 3rd
intrcostal space enclosing the nipple areola and tumour (1 to 2 cm of
skin margin from tumour) laterally into the axilla along anterior axillary
fold.
 Upper and lower skin flap are raised by using scissor / scalpel /cutting
diathermy along with blunt gauze dissection . It extend medially up to
midline on sternum , laterally to anterior margin of lattismus dorsi
muscle , above up to subclavius muscle or 2nd rib, below 3 cm down the
inframammary fold.( Boundaries of mastectomy)
 Skin and subcutaneous fat is dissected off during flap raising.
 Breast with tumour is raised from medial aspect of pectoralis major
muscle with fascia by making a deep incision close to midline, adjacent
to sternum .
 Dissection is proceeded laterally ligating perforating vessels derived
from lateral thorasic and anterior intercostal arteries.
 Once the dissection reaches axilla, lateral border of pectoralis major
muscle and pectoralis minor muscle is exposed in deeper plane and
medial pectoral nerve is identified and preserved.

Dissection of axilla

Limit of axilla dissection

Above - Lower border of axillary vein

Below- Lattismuss- serratus angle (where LD muscle meets with serratus
ant. Muscle)

Medially - Chest wall (costoclavicular ligament and serratus anterior)

Laterally - Latismuss dorsi

 Lateral mammary crease incision or fish mouth incision are used.

 Axillary fascia and investing layer of deep fascia is divided .
 Fascia in front of axillary vein is dissected to expose the vein and small
tributaries are ligated.
 Pectoralis major is retracted superomedially, finger is swept between to
pectori to clear the rotter’ s node .
 Lateral pectoral nerve is identified and preserved (arise from lateral cord
and is located medially and medial part of pectoralis major.
 Attachment of pectoralis minor tendon is felt with index finger and
hooked around coracoid process and divided from coracoid process to
clear level 2 nodes.(Patey ‘s mastectomy)
 Later from apex of axilla level 3 nodes are cleared .
 Pectoralis minor may or may not removed .
 Axillary vein is cleared medially up to subclavius muscle , posterior and
lateral group lymph node are cleared .
 Subscapularis medially and teres major laterally exposed posteriorly .
Structurs preserved
 Nerve to Serratus anterior
 nerve to Lattismus dorsi with vessels ( thoracodorsal nerve and
vessels)
 intercostobrachial nerve
 axillary vein
 cephalic vein
  Pectoralis major muscle
 Once the specimen is removed it is marked with orientation marker
clip/ suture.
 Wound is washed with saline and check for haemostasis ,two silastic suction
drain are placed one in axilla another in front of pectoralis major muscle
and wound is closed with suction drain.
 Specimen is properly oriented ( long lateral and short superior)
 Specimen is sent in formalin for histopathology.
 Specimen is sent in saline in low temperature for ER/PR/Her 2/Kia 67
study ( histochemistry).

Postoperative care
 Drain output and symptoms and signs of haemorrhage
 Flap viability and wound infection
 Early mobilisation of limb and exercise like over abduction
 Compressive dressing to prevent lymphedema
 Removal of drain in 5 to 7 days when output < 30 ml/ day

Complications
Intraoperative generally no complication seen

 Rarely haemorrhage can occurs but controlled by ligation of

bleeding vessels/ perforators better than diathermy .
 Nerve injury
Early complications

Moderate or severe haemorrhage

In the postoperative period is rare and is best managed by return to the

operating room with early wound exploration for control of haemorrhage and
reestablishment of closed system suction drainage.

Hematoma Formation : if large amount need drainage under general

anaesthesia

Seroma Formation (50%) :

 Avoids metal retraction.

 it should be aspirated repeatedly and supporting with compression
dressing.

Flap necrosis and infection

Lymphoedema (15%)

 The incidence of functionally significant lymphedema after a modified

RM Extended axillary lymph node dissection. adjuvant radiation therapy,
the presence of pathological lymph nodes, and obesity contribute to an
increased incidence.
 Sub optimal treatment no cure so must effort to prevent it
 more commonly found if axillary dissection done above axillary vein.
 Prophylactic antibiotics like benzathine penicilline
 Compressive bandage

 Lymphonodular transfer by silicon lymphatic transfer.

Other complications
  Axillary hyperaesthesia
 Winged scapula due to bell’s neve palsy
 Weakend shoulder adduction due to injury to thoracodorsal nerve.
 Anesthesia over medial aspect of upper arm d/t injury to
intercostobrachial nerve .

Late Complication

 Pain and numbness

 Decrease range of move movement of shoulder
 Atrophy of pectoralis major muscle d/t injury to medial pectoral nerve
 Stewart –treves syndrome is lymphangiosarcoma of upper limb in
patient who develop lymphoedema ( after 5 years ) after mastectomy.

Ashish kumar yadav