новая папка / 450-550 operativ

wall by shaft of humerus, coracobrachialis, short head of biceps. It contains axillary artery with its branches, axillary vein with its tributaries, axillary groups of lymph nodes, and long thoracic nerve of Bell to serratus anterior, intercostobrachial nerve, fat and fascia. Subscapular vessels run along the lower border of the subscapularis with its nerve and thoracodorsal nerve. Medial wall is related to long thoracic nerve and intercostobrachial nerve. Anterior/pectoral group of lymph nodes lie along the lower border of pectoralis minor on lateral thoracic vessels. Lateral group of nodes lie posteromedial to axillary vein. Central group lies in the fat of the axilla towards medial side. Apical nodes lie behind, above the pectoralis minor, medial to axillary vein. Axillary sheath covers axillary artery and brachial plexus but not axillary vein.

Note: A communicating vein between cephalic vein and external jugular vein (neck) is present which runs across the clavicle. It is important in draining the upper limb in axillary vein removal (in carcinoma breast, segment may be removed)/blockage (Fig. 16-5).

Fig. 16-5: Surgical levels of lymph nodes (Berg’s) in the axilla draining from breast.

Levels of the axillary nodes (Berg’s)

•Level I—Below and lateral to the pectoralis minor muscle—anterior, lateral, posterior

•Level II—Behind the pectoralis minor muscle—central

•Level III—Above and medial to pectoralis minor muscle—apical – Halsted’s node

Note in carcinoma breast

•Spread restricted to Level I nodes carries better prognosis

•Spread to Level II has poor prognosis

•Spread to Level III indicatesworst prognosis

Nerves Related to Axillary Dissection

Long thoracic nerve arises from C5, 6, 7 nerve roots of brachial plexus, enters the axilla running on the lateral surface of the serratus anterior muscle invested by serratus fascia and supplies serratus anterior which on division during axillary dissection causes winged scapula with inability to x the shoulder.

oracodorsal nerve arises from posterior cord of brachial plexus runs posteriorly downwards to supply latissimus dorsi muscle. Its division may cause di cult in extending the shoulder but more importantly reconstruction with latissimus dorsi myocutaneous ap (LD ap) after mastectomy is not possible.

Intercostobrachial nerve is communicating nerve between lateral cutaneous branch of 2nd intercostal nerve and medial cutaneous nerve of arm, denervation of this nerve causes sensory loss of skin of upper medial and inner aspect of the arm, apex and lateral axilla. Second intercostobrachial nerve may be present occasionally arising from anterior branch of 3rd lateral cutaneous nerve.

Medial pectoral nerve arising from medial cord of the brachial plexus runs along the lateral margin of the pectoralis minor supplying pectoralis minor mainly and pectoralis major muscle partly. It often may pass through the bres of the pectoralis minor muscle at its lateral aspect. It should be preserved during axillary dissection otherwise atrophy of pectoral muscles occur.

Lateral pectoral nerve arises from lateral cord of the brachial plexus after running on the medial aspect, supplies the medial part of the pectoralis major muscle (Lateral pectoral nerve is medial; medial pectoral nerve is lateral. ey are not named on anatomical location but on their origin of cord).

Muscles Related to Breast/Breast Surgery

Pectoralis major muscle – It arises from medial half of clavicle (clavicular bers), anterior part of manubrium and sternum up to 6th costal cartilages (sternal bres), 2nd to 6th costal cartilages (costal bres). It is inserted as bilaminar tendon into lateral lip of bicipital groove of the upper end of humerus. It is supplied by lateral and medial pectoral nerves. Fibres are mainly placed as transverse and oblique. It is adductor and medial rotator of the shoulder; clavicular bres ex the arm also. Deeper relations are pectoralis minor, clavipectoral fascia which is pierced by cephalic vein, thoracoacromial artery and lateral pectoral nerve. Anterior axillary fold is formed by twisted bres of the

pectoralis major muscle (Fig. 16-6).

Pectoralis minor muscle – It arises from 3rd, 4th and 5th costal cartilages near costochondral junctions. It is inserted to medial upper part of the coracoid process (along with coracobrachialis). It is supplied by medial and lateral pectoral nerves (Fig. 16-7).

Serratus anterior muscle – It arises from 8 digitations from upper eight ribs and intervening intercostal fascia. It is inserted into the costal surface of the scapula; rst to superior angle; 2-4 to medial margin of the scapula; last 4 into inferior angle of the scapula. It is supplied by long thoracic nerve to serratus anterior (of Bell) – C5, 6 and 7. Muscle pulls the scapula forward in pushing and punching movement; it rotates the scapula forward; it helps in raising the arm above the head; it steadies the scapula during weight carrying. Its paralysis causes inferior angle and medial border of the scapula to become more prominent during the pushing movement causing ‘winging of the scapula’.

Latissimus dorsi muscle – It arises from posterior third of outer lip of iliac crest; lumbar fascia; T7 to T12 spines; lower four ribs; inferior angle of scapula. It forms posterior fold of the axilla, with twisted tendon inserted into the oor of the intertubercular sulcus of the upper end of the humerus. It is supplied by thoracodorsal nerve (C6, 7 and 8). It causes adduction, extension and medial rotation of the shoulder. It is a muscle of climbing, swimming and rowing. Muscle is important in mastectomy while creating the L D myocutaneous ap.

Fig. 16-6: Pectoralis major muscle.

FNAC (Fine Needle Aspiration Cytology)

Often, 22 gauge needle with 20 ml syringe with syringe holder (aspiration gun) is used. Two syringes are usually required. After cleaning the area, needle is passed into the required tissue/mass obliquely; - 40 cm of H2O suction is created into the syringe. Needle is manoeuvred at different angles at same site to allow cells to enter the needle. Cells should ll the needle not the syringe. Before removal of the needle from the tissue suction is released. Needle is withdrawn; contents are carefully expressed into glass slides. 5 mm drop of contents are placed over the slides, smear is created by rubbing another slide over it. One slide is air dried; other slides are

xed with 95% ethanol. Remaining cells in the needle can be used for culture, cytocentrifugation. Complications of FNAC of breast are rare. Rarely pneumothorax, haemothorax, haematoma and acute mastitis

Fig. 16-7: Pectoralis minor muscle.

can develop. Sensitivity is 98%. Speci city and positive predictive value is near 100%.

OPEN BIOPSY OF BREAST LESION

Indications – Lesions with atypia; LCIS; radial scar; atypical papillary lesions; high risk group with suspected lesions; radiologic-pathologic discordance; phylloides tumour; inadequate tissue harvesting; negative FNAC/core biopsy but doubtful lesion; failure of infection

to subside in spite of proper treatment plan; mammographically suspected lesion.

Anaesthesia – Xylocaine 1% local (plain) anaestheticagent is used (with adrenaline may cause epidermolysis). In ltration is done deep into retromammary space. General anaesthesia is used when mass is not palpable or deeply placed; apprehensive non-cooperative patient; if one stage procedure (biopsy – frozen section con rmation – de nitive surgical procedure) is planned.

Procedure –Incisionisplaced asperiareolaror circumferential along the Langerlines whichis cosmeticallyacceptable andshouldable toinclude the specimenof the eventual anticipated mastectomy. Sharp dissection is preferred method in biopsy. Bipolar cautery can be used (unipolar cautery should be avoided). Surrounding 1 cm marginof normal breast parenchyma is included with the lump. A ‘ gure of eight’ suture may be placed on the mass tofacilitate the dissection around.Holding the mass with crushing/damaging instruments should be avoided. Skin edge is retracted using hook retractor. After excision, haemostasis is achieved by bipolar cautery. Wound is irrigated with saline and drain is placed if required. Skin is sutured with subcuticular or interrupted sutures. Specimenshouldbeorientedwithmarker stitches(Figs16-8 and16-9).

Fig. 16-8: Circumferential incision is preferred in breast biopsy.

Fig. 16-9: Excision biopsy of the lump.

Incision biopsy instead of excision biopsy is done when tumour is more than 4 cm in size.

When there is nipple discharge suspicious of malignancy without any mass lesion, duct can be cannulated with a fine probe and circumferential excision of the duct with the lobe is done. Haematoma (10%), infection are the complications of breast biopsy.

De nitive surgery if done within 2 weeks of biopsy, it will not alter the recurrence rate or survival bene t.

EXCISION OF BENIGN BREAST LUMP

Palpable cyst can be aspirated. Recurrent cysts, solid benign masses need to be excised. Fibroadenoma, cysts, indicated brocystadenosis, traumatic fat necrosis are the common indications. Circumareolar, circumferential, lateral submammary incisions are commonly used. Smaller lesions are excised using circumareolar incision (Webster’s); larger lesion is excised using submammary incision (Gaillard

omas incision). Type of incision is decided on individual patient basis. Superomedial incision is usually avoided as scar may become hypertrophic (Figs 16-10 to 16-13).

Procedure

General anaesthesia is usuallyused.Patient isplaced in supine position, cleaning and draping is done. Both monopolar and bipolar cautery can be used. Incision is made depending on the location and size of the lump. In circumareolar incision, dissection under the nipple should be done in deeper plane otherwise areolar necrosis may occur. Fine scissor and cautery dissection is done around the lump. Freely mobile and encapsulated broadenoma will easily come out of the woundwith dissection around the capsule. Figure of eight traction suture on the swelling is bene cial to facilitate proper dissection around. It prevents destructionoftheswelling/tissuetoberemovedbymultipleapplications of forceps. When cautery is used for excision, it should be wider to prevent coagulation artifacts in the specimen surface. Haemostasis achieved using cautery. Suction drain is placed. Deeper subcutaneous tissue is apposed using absorbable sutures (3 zero vicryl). Skin is closed using mono lament nonabsorbable (3 zero polypropylene) or 3 zero monocryl.Compression dressingapplied.Drain is removedin48 hours. Specimen should sent for histology after making proper markings. Special sports bra is used in postoperative period until recovery occurs. Anicepackover the breastmay be useful torelievethe paininimmediate postoperative period (Fig. 16-14).

omplications

Subcutaneous Mastectomy

It is removal of entire breast with retaining skin over the breast, areola and nipple. It is done through a submammary Gaillard omas incision. Adequate skin ap is raised with ap containing subcutaneous fat which maintains the blood supply of the ap and prevents flap necrosis. Entire breast is removed using fine scissor dissection or cautery dissection. It is done in gynaecomastia, as a prophylactic mastectomy in high risk patients. After haemostasis drain is placed. Breast implant can be placed in subcutaneous/ submuscular plane either immediately or as delayed reconstruction.

DRAINAGE OF A BREAST ABSCESS

Both subareolar and intramammary breast abscess should be drained. Drainage is done under general anaesthesia. Subareolar abscess is drained with a subareolar incision. Intramammary abscess is drained with a deep incision. Once cavity is reached all loculi should be broken using a sinus forceps/ nger/scoop. Pus should be sent for culture. Counter incision is often needed to achieve complete drainage of the abscess cavity. Corrugated drain is placed for 72 hours or more or as required. Since intramammary abscess is common in lactating women, milk stula may be a sequelae. It is often very di cult to manage such case. Milk from opposite breast should be expressed at regular intervals either manually or using breast pump. Only occasionally suppression of milk is needed using bromocryptine 2.5 mg for 5 days (Figs 16-16 to 16-18).

Indications for drainage in mastitis/breast abscess

•Mastitis not resolving with antibiotics in 48 hours

•Persistent fever and progression of mastitis

•Brawny induration

Do not wait for abscess to form(fluctuationto develop)

Surgical Treatment of Mammary Fistula

Mammary stula develops in a chronic abscess cavity at the drainage site or where abscess has pointed and opened. A probe is passed through the stula towards the apex of the nipple. Track is laid open by cutting tissues along the probe. Opened wound is left to granulate. Often it requires major duct excision (Fig. 16-19).

Fig.16-16:Differenttypesofbreastabscesses–subareolar,intramammary and retromammary.

Fig. 16-17: Drainage of subareolar breast abscess.

MICRODOCHECTOMY

It is excision of the entire lactiferous duct (single duct disease). It is done for duct papilloma. In a duct papilloma when there is no palpable mass, duct is expressed to see the discharge. A ne probe/ sti nylon suture (as a probe) is passed gently into the duct. Probe is xed to nipple skin using silk sutures so that it will not displace during procedure. A triangular area is cut 1 mm away from the probe using ne scissor to raise the skin aps. e duct with the probe is excised

closed without a drain. Compression bandage is applied. It is ideal to rule out DCIS by frozen section biopsy.

MAJOR DUCT EXCISION ADAIR–

HADFIELD OPERATION

It is done mainly for duct ectasia with involvement of many ducts or multiple papillomas. A circumareolar incision is made usually along lower half of the areola not exceeding more than 3/5th of circumference. After incising the subcutaneous tissue, with blunt dissection terminal lactiferous ducts are circumferentially dissected. All dissected ducts are divided at thejunctionof nipple. A cone of tissue of 4 cm depth and 2 cm width is removed with base deep in the breast parenchyma. Excised entire lactiferous ducts are sent for histology. Cavity in the breast is obliterated with vicryl sutures. Wound is closed with a suction drain. Bruising, infection, haematoma and recurrence of the disease – 15% (duct ectasia) are the complications (Fig. 16-20).

Melhem Novel modi ed breast ductal system excision is also done for duct ectasia. Here only lactiferous ducts are excised after raising the areolar ap through circumareolar incision.

SENTINEL LYMPH NODE BIOPSY/

DISSECTION SLNB/SLND

e rst axillary (SLN) node draining the breast (by direct drainage) is designated as the sentinel node. SLN is rst node involved by tumour cells and presence or absence of its histological involvement, when assessed will give a predictive idea about the further spread of tumour to other nodes. e incidence of involvement of other nodes without SLN is less than 3% and so if SLNB is negative nodal dissection can be avoided but regular follow up is needed. SLNB is done in all cases of

480 SRB’s Surgical Operations

early breast cancers, T1 and T2without clinically palpable node. It is not done in clinically palpable axillary node as there is already distortion of lymphatic ow due to tumour. It is also not done in multifocal and multicentrictumours, as thereisinvolvement of manylymphatictrunks from di erent places of breast, and chances of false negative is high. Sentinel node is localised by preoperative (within 12 hours prior) or peroperative injection of patent blue (Isosulfan vital blue dye 2.5 – 7.5 ml) or 99m TC radio isotope labeled albumin (one mCi on previous day)/sulphur colloid (6 hours before) near the tumour (peritumour area) or over subdermal plexus around the nipple. Marker will pass through the sentinel node which can be detected visually as blue stainingorwithahandheld gammacamera; andisbiopsiedwithasmall incisiondirectly overit. Frozensection biopsy ortouchimprint cytology is done for presence of malignant cells. If there is no involvement of sentinel node by tumour then further axillary dissection is not required as skip lesions(skipping sentinel node) occur only in less than3% cases. Detection rate of sentinel node for blue dye and radioisotope is 90% and 98% respectively. Subdermal/subareolar injection of radioisotope has got better sentinel node localisation than peritumour injection. But better imaging is obtained by peritumour injection and so peritumour injection is usually practiced. Radioisotope tracer injection done in the early morning of the day of surgery into peritumour area and perioperative injection of patent blue dye in subareolar region – as a combinedmethod is oftenused in many centres. Afterinjectionofpatent blue, breast is massagedcontinuously toenhance the uptake. Incision is made after 5-7 minutes between pectoralis major and latissimus dorsi to identify blue stained lymphatics which are traced to 2-3 blue lymph nodes. Hand heldradioprobeis used toidentifythe sentinelnodewhich is later excised. Often 2-3 nodes are removed. Para n section histology is better than frozen section to identify positive sentinel lymph node. If report comes negative immunohistochemistry test is done to con rm that lymph node is negative for tumour. Sentinel lymph node biopsy should be done before wide local excision of the primary tumour.

Wide local excision of the primary tumour is done after SLNB in the same sitting.

SLNB is less invasive than axillary dissection. It is ideal in early invasive carcinoma. Positive SLNB is again classified as macrometastasis (> 2 mm) or micrometastasis (< 2 mm).

SLNB is contraindicated in patients who are allergic to vital blue dye orradio-colloid,inpregnancyand in in ammatorycarcinomaofbreast.

omplications

Axillary Sampling

It is done before wide local excision of primary tumour. Incision is made between pectoralis major and latissimus dorsi muscles. Deep fascia is opened. 10 – 15 nodes of level I are dissected and removed. Often this procedure is done along with sentinel lymph node biopsy. Occasionally when level I nodes are not found, level II or III nodes are removed to identify 3-5% skip metastases.

BREAST CONSERVATIVE SURGERY BCS

In early breast cancer, breast conservative surgeries like quadrantectomy, axillary dissection (level I and II) and postoperative

radiotherapy (tothe breast) are used which prevents the dis gurement and psychological trauma of mastectomy to the patient. It is very well acceptable cosmetically. When disease outcome is considered, it is equivalent to mastectomy if patient is carefully selected. Tumour is removed with a rim of 1 cm normal tissue (macroscopic margin). Wide

Principles and Technique of Conservative

Breast Surgery

Curvilinear non-radial incision (radial incision should not be placed, if there is a need to convert intototal mastectomy, and then incision plan may be di cult) is used to remove primary tumour. Separate incision is used for axillary dissection. Undermining of the skin ap must be avoided. Tumour clearance should be con rmed by frozen section. It may be often di cult and so tumour is cut and only margin which is close and doubtful is advocated for frozen section. Radiotherapy is a must to breast and chest wall region (locally). Consent for total mastectomy should be taken in case if need arises (Fig. 16-21).

Fig. 16-21: Curvilinear incision should be placed in conservative breast surgeries. Never place wrong radial incisions. If conversion to total mastectomy is needed, it will be dif cult in placing incision if radial incision is placed. In conservative breast surgery for axillary dissection separate incision in the axilla should be placed.

Ultrasound is good way of assessing the size of the tumour. If mammography shows calcification, this calcification should be localised using hook wires. Impalpable lesions are localised preoperatively by blue dye injection, hook wires, radioisotope markers. Intraoperative ultrasound also can be used. By mammography or ultrasound controlled injection of technetium labeled human serum albumin or sulphur colloid into the tumour and using hand held gamma probe intraoperatively lesion is located and excised.

Quadrantectomy and wide local excision are two types of BCS. Breast is distributed into segments with each segment draining into one major duct. Removal of one entire segment with ductal system with 2 cm clearance is quadrantectomy which is much wider and extensive removal than wide local excision. But presently quadrantectomy is not advocated as it is cosmetically poorer and there is no di erence in outcome between quadrantectomy and wide local excision.

Incision over the breast should be circumferential along the Langer’s line or parallel to the lines of maximum resting skin tension in the breast (dynamic lines of Kraisl) (Fig. 16-22).

Fig. 16-22: Langer lines and dynamic lines of Kraisl.

If there is previous open biopsy scar, it should be included in the specimen as ‘en bloc’. Mexican hat incision of the preexisting scar gives better scar. Otherwise routine skin excision is not done (Fig. 16-23).

Fig. 16-23: Mexican hat incision is used to include previous scar area.

Skin aps are deepened straight up to 1-2 cm beyond the lump margin. Only rising skin aps is not advised. Skin with subcutaneous tissue can be raised judiciously.

Dissection is done around the tumour with a volume of normal breast tissue all around. Pectoral fascia should notbe opened in deeper plane. Tumour with surrounding normal clearance tissue is lifted o the pectoralis fascia and breast tissue in deeper plane can be dissected off the fascia. Bipolar cautery is better than monopolar cautery. After removal of the specimen, it is properly marked using coloured markers or paints as superior, inferior, medial, lateral, anterior and posterior for identi cation of the clearance margins and orientation. Entire specimen is coated in India ink. Specimen should be inspected properly for tumour relation to margins. All marked surfaces and margin which is close to the tumour should undergo frozen section biopsy for con rmation of clearance. Doing specimen mammography is often better. Specimen may be kept in an orientation – grid and mammography of the specimen is taken. If few margins are close to the tumour, then re-resection at that particular margin is su cient which again should be confirmed by frozen biopsy. Achieving margin clearance all around the tumour is essential but width of cleared margin is not important. Once con rmed, specimen is sent for receptor/molecular/cellular/biochemical study. Wound is closed without a drain. Small defect in the breast tissue (tumour area) less than 10% of volume can be left alone; larger defect in breast more than 10% of breast volume should be apposed by proper sutures. If many margins are invaded or very close to tumour, then total mastectomy should be planned (Fig. 16-24).

Fig. 16-24: Technique of wide local excision.

Complications of wide local excision are – haematoma (2%); seroma; infection (5%); incomplete excision (15%); poor scar.

Recurrence after BCS is usually at primary site. Young age, family history, small volume breast are the patient related factors for recurrence. Grading ofthe tumour, lymphaticor vascular invasion (two times more), extensive in situ component (4 times more), multifocal tumours are the tumour factors for recurrence of the tumour. Delay in radiotherapy to breast area, further chemotherapy and hormone therapy also in uence the local recurrence rate. Radiotherapy to breast is a must after BCS. Recurrence is treated by total mastectomy.

Microscopic disease free margin is de ned as at least 1 mm rim of normal tissue around the tumour in all directions. Area lesser than 1 mm is considered as inadequate clearance and such area should