preventing surgical complications of modified radical mastectomy
DESCRIPTION
Lecture prepared by ROJoson for the 2013 Postgraduate Course of the Department of Surgery of the Philippine General Hospital, September 5, 2013TRANSCRIPT
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Back to BasicsPreventing Complications – Improving Outcomes
Preventing Complications of Breast Surgery
Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgSeptember 5, 2013
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Back to BasicsPreventing Complications – Improving Outcomes
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgSeptember 5, 2013
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Preventing Surgical Complications toImprove Outcomes of MRM?
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM Procedure
To remove the whole breast and the ipsilateral axillary lymph nodes that contain or may contain
cancer
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM Procedure
To remove the whole breast and the ipsilateral axillary lymph nodes that contain or may contain
cancer
GOOD-EXCELLENT POSTOPERATIVE OUTCOMES
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM Procedure
To remove the whole breast and the ipsilateral axillary lymph nodes that contain or may contain
cancer
GOOD-EXCELLENT POSTOPERATIVE OUTCOMES?
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM Procedure
To remove the whole breast and the ipsilateral axillary lymph nodes that contain or may contain cancer
GOOD-EXCELLENT POSTOPERATIVE OUTCOMES?
Complete extirpationNO surgical complications and unwanted side-effects
(or lowest acceptable rate)
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrenceNO surgical complications
(dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injury)
NO unwanted side-effects (seroma, dog-ear, ugly scar)
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative OutcomesNO local recurrenceNO surgical complications (dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injuries)NO unwanted side-effects (seroma, dog-ear, ugly scar)
How do we prevent these?
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
For every intraoperative move made, there is a risk for surgical complications and
unwanted side effects!
Intraoperative Risk Management
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative OutcomesNO local recurrenceNO surgical complications (dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injuries)NO unwanted side-effects (seroma, dog-ear, ugly scar)
How do we prevent these?
Intraoperative Risk Management
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative OutcomesNO local recurrenceNO surgical complications (dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injuries)NO unwanted side-effects (seroma, dog-ear, ugly scar)
Intraoperative Risk Management
Good PlanningGood Execution
Good Contingency Adjustment during
Execution
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
AsepsisIncision
Flap CreationTotal MastectomyAxillary Dissection
DrainIncision Repair
Risks
Local recurrence
Surgical complications
Unwanted side-effects
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
AsepsisIncision
Flap CreationTotal MastectomyAxillary Dissection
DrainIncision Repair
Infection
DehiscenceLocal Recurrence
Flap NecrosisHematoma
SeromaMajor Axillary Vascular / Nerve Injury
Avoidance of
Others
Dog-ear Deformity
Ugly Scar
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis Infection
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis Infection
Procedures to eliminate / reduce microorganisms in operative field
Sterilize an operative field with a wide boundary
(at least 3 in)
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Sterilize an operative field with a wide boundary (at least 3 in)
Supraclavicular area Subcostal
area
Upper arm
Contralateral mid-clavicular line
Posterior axillary line
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis Infection
Procedures to eliminate / reduce microorganisms in operative field
Suture drapes along the posterior axillary line
to avoid contamination of the lateral field (close to operating table) and
during axillary dissection
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Suturing of the Drape along the Posterior Axillary Line to Prevent Contamination in the Lateral Field
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis Infection
Procedures to eliminate / reduce microorganisms in operative field
Maintain sterility of the operative field during the entire operation
Avoid contamination of operative fieldby unsterilized instruments, gloves, dirty specimen, etc.
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
IncisionTension-Dehiscence
Local Recurrence
Dog-ear Deformity
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
IncisionTension-Dehiscence
Local Recurrence
Planning and accurate planningBEFORE operation / incision! Dog-ear Deformity
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision Local Recurrence
Adequate marginAt least 2 cm around palpable tumor on the surface
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Planning an Incision to Get an Adequate Margin
Outline the border of the mass
Allot at least 2-cm margin around the palpable border of the mass.
May be more if possible and if needed to have a taut (but no tension) mastectomy flap closure to avoid seroma and unsightly bulges.
Not too large to cause tension and dehiscence though.
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision
Determine the axis/ direction of the elliptical incision that will best promote primary closure without tension.
Tension-Dehiscence
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Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
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Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
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Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
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Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
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Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
45
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Avoid a scar that can be seen when patient wears a bra!
Planning the Incision
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Planning an IncisionAvoid placement of the scar at the upper and mid-sternal
areas (areas known to be keloid prone).
Place at the lower part.
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision
Plan out incision to avoid dog-ear deformities!
Dog-ear Deformity
Frequent, particularly in patients with large body habitus and large breast
Unsightly and source of long-term discomfort!
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Sliding-suturing
(Devalia Technique)
Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin
Surg Oncol. 2007 Dec 17; 4:29.
Planning an Incision to Avoid Lateral Dog-ear Deformity
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D-incision with Triangular Advancement
IC Bennett and MA Biggar . A triangular advancement technique to avoid the dog-ear deformity following mastectomy in large breasted women
Ann R Coll Surg Engl. 2011 October; 93(7): 554–555.
Planning an Incision to Avoid Lateral Dog-ear Deformity
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Tear-drop shaped incision
Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.
Planning an Incision to Avoid Lateral Dog-ear Deformity
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Planning an Incision to Avoid Lateral Dog-ear Deformity
Waisted TeardropRebecca Thomas, Christine Mouat and Burton King. Mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold. ANZ J Surg 82 (2012) 329–333.
Initial drawing of elliptical incision
Retract laterally medial side and redraw to make a teardrop incision
Retract medially lateral side and redraw to make a teardrop incision(broader base)
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Waisted Teardrop
Rebecca Thomas, Christine Mouat and Burton King. Mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold. ANZ J Surg 82 (2012) 329–333.
Planning an Incision to Avoid Lateral Dog-ear Deformity
Resultant waisted” teardrop incision
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Y-incision / Fish-tail Incision
Planning an Incision to Avoid Lateral Dog-ear Deformity
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Techniques to Avoid Lateral Dog-ear DeformityTear-drop / Waisted Teardrop
Y-incision / Fish-tailSliding-suturing
Planning preoperatively (standing, lying down, with arms on the side and extended) and before the incision is the strategy to avoid a dog-
ear deformity!
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision
Plan out incision to avoid dog-ear deformities!
Dog-ear Deformity
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Not TOO thick to include breast tissue
Not TOO thin to cause flap necrosis
Flap Creation Flap Necrosis
Local Recurrence
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Flap Creation – How I Usually Do It
1-cm of subcutaneous tissue(subcutaneous tissues only –
pink-whitish tissues stay away)
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Flap Creation – How I Usually Do It
Control thickness / thinness of flap
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Local RecurrenceTotal MastectomyHematoma
Ensure TOTAL mastectomy!Ensure adequate and secure hemostasis!
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Flap not TOO thick to include breast tissue
Be guided by the usual boundaries of the breast (clavicle, latissimus dorsi,
parasternal, rectus sheath)
Remove part of the pect major if too near
Local RecurrenceTotal Mastectomy
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Removing part of pectoralis major muscle in MRM
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Ligate transected blood vessels ≥ 2 mm In diameter
Cauterize fully – transected vessels not to be ligated
Ligate and cauterize blood vessels right away
Check hemostasis prior to wound closure
Total Mastectomy Hematoma
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Promote a taut flap over the chest wall
Ensure ever-functional tube drain
Total Mastectomy Hematoma
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Local RecurrenceHematoma
Axillary Dissection
Major Axillary Vascular / Nerve
Injury
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Remove ALL grossly palpable masses / nodes
guided by the usual boundaries of the axilla
Local RecurrenceAxillary Dissection
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Avoid injuryCareful dissection when near the areas
Axillary Dissection Major Axillary Vascular / Nerve
Injury
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Adequate and secure hemostasis.
Axillary Dissection Hematoma
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Axillary Dissection Hematoma
Ligate transected blood vessels ≥ 2 mm In diameter
Cauterize fully – transected vessels not to be ligated
Ligate and cauterize blood vessels right away
Check hemostasis prior to wound closure
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Axillary Dissection Hematoma
Checking hemostasis prior to wound closure
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Axillary Dissection Hematoma
Promote a taut flap over the chest wall
Ensure ever-functional tube drain
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Drain lateralMedial as indicated
SeromaDrain
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Closed tube suction drain at axillary space
Medial drain indicated if there is a significant cavity
after laying down of flaps prior to wound repair
Drain removed if output is less than 50 cc
past 24 hours (assumption: tube functional)
SeromaDrain
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision RepairUgly Scar
Dog-ear Deformity
Dehiscence
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision Repair Dehiscence
Avoid tension Secure knots
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Avoid excessive stitch marksRailroad tracks
Avoid dog-ear deformity
Incision Repair Ugly Scar
Dog-ear Deformity
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How I usually repair mastectomy wound
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
For every intraoperative move made, there is a risk for surgical complications and
unwanted side effects!
Intraoperative Risk Management
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
AsepsisIncision
Flap CreationTotal MastectomyAxillary Dissection
DrainIncision Repair
Infection
DehiscenceLocal Recurrence
Flap NecrosisHematoma
SeromaMajor Axillary Vascular / Nerve Injury
Avoidance of
Others
Dog-ear Deformity
Ugly Scar
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrenceNO surgical complications
(dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injury)
NO unwanted side-effects (seroma, dog-ear, ugly scar)
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Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do itReynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
September 5, 2013
For further reading and copies of my slides:http://www.slideshare.net/rjoson/mastectomy-morbidities-pghrj08sept11
http://www.slideshare.net/rjoson/preventing-mrm-complications-pghrj13sept5
For feedback and queries:
[email protected] (text me if you like my lecture now)
Facebook / rjoson2001