Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 12 • Excision of Benign Breast Lesion |
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Incision site being sutured
FIGURE 12–5
Incision closed with subcuticular running suture
FIGURE 12–6
C H A P T E R 13
MAJOR DUCT EXCISION
Courtney M. Townsend, Jr.
STEP 1: SURGICAL ANATOMY
A comprehensive understanding of the location of the mammary gland in relation to the chest wall musculature, the fascial boundaries, the lymphatic drainage pathways, the vascular supply to the breast and the associated supporting structures, and the innervation of the breast and surrounding tissues is essential for appropriate surgical management.
STEP 2: PREOPERATIVE CONSIDERATIONS
Bilateral nipple discharge, which is usually seen in postmenopausal patients, is sometimes sufficiently voluminous to cause problems with soiling.
Bilateral nipple discharge is rarely due to neoplastic lesions and almost always due to duct ectasia. As noted, the lobes of the breast are drained by ducts that coalesce in the subareolar area into 5 to 10 lactiferous ducts, each of which opens independently in the nipple.
Diagnosis of duct ectasia is made when single-digit compression is carried out and discharge from multiple ducts in the nipple is noted, usually bilaterally.
Preoperative mammography is required for all patients.
General anesthesia is used.
STEP 3: OPERATIVE STEPS
1.INCISION
When resection is required, it is performed through an areolar margin incision. The areola is elevated from the intramammary fat and all of the ducts together can be identified and dissected free from the undersurface of the nipple (Figures 13-1 and 13-2).
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C H A P T E R 13 • Major Duct Excision |
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Incision line
FIGURE 13–1
Incising through lower portion of areola
FIGURE 13–2
1 5 2 S E C T I O N I I • TH E B R E A S T
2. DISSECTION
The ducts are ligated and divided, as a group, in the subareolar area, and an inverted cone excision removing the lactiferous ducts is carried out in a circumferential fashion
(Figures 13-3 and 13-4).
Dissection and hemostasis are carried out with cautery.
C H A P T E R 13 • Major Duct Excision |
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Removing abnormal ductal tissue
FIGURE 13–3
Conical space
FIGURE 13–4
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3. CLOSURE
The breast tissue is not closed.
The wound is irrigated with hydrogen peroxide and, after hemostasis is secured, the wound is closed with running subcuticular absorbable sutures (Figure 13-5).
STEP 4: POSTOPERATIVE CARE
I recommend that all patients who are going to have partial mastectomy for benign or malignant conditions wear a new sport or jogging bra after the procedure, because it gives good nonrigid support to the breast.
An ice pack is often helpful to relieve localized pain, and one or two doses of nonopioid analgesic is usually all that is required. The dressing can be removed in the bath 24 to 36 hours after the operation and no further dressing needs to be used.
STEP 5: PEARLS AND PITFALLS
I do not close the breast tissue because of the distortion that would occur.
The extent of breast tissue excised is different from when resecting an area of pathologic nipple discharge. This is a method to ablate the ducts; therefore, less extensive breast tissue resection is required.
Incision closed with subcuticular running suture 
FIGURE 13–5
C H A P T E R 14
INTRADUCTAL PAPILLOMA
Courtney M. Townsend, Jr.
STEP 1: SURGICAL ANATOMY
The ducts draining the 15 to 20 lobes of the breast tissue coalesce into 5 to 10 lactiferous ducts, each of which opens separately in the nipple.
Understanding that the subareolar ducts represent components from multiple glands, excision extends from the immediate area under the nipple in which the involved duct is identified to encompass the tissue drained. It is excised en bloc so that the specimen is much larger than simply a duct as shown in Figure 14-1.
Ductal tissue to be excised
Intraductal papilloma
FIGURE 14–1
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1 5 6 S E C T I O N I I • TH E B R E A S T
STEP 2: PREOPERATIVE CONSIDERATIONS
Pathologic nipple discharge is spontaneous, persistent, nonlactational, and unilateral. A single-duct opening in the nipple can be identified as the source of the discharge.
The color and consistency of the discharge play no role in determination for resection once the criteria for pathologic nipple discharge are met.
Everyone with a breast complaint, including nipple discharge, should have a bilateral mammogram. The object of the mammogram is not to determine whether operation for pathologic nipple discharge will be performed but to search for occult cancer in both breasts.
Ductography is not required to identify the segment of breast to be resected.
Cytologic examination of nipple discharge is not required.
Pathologic nipple discharge requires resection and pathologic examination of the tissue. The danger is that intraductal papillary cancer could be overlooked.
STEP 3: OPERATIVE STEPS
I prefer that the patient has general anesthesia, although local anesthesia may be used.
1. INCISION
The area of breast in which the lesion is located can be identified by single-digit compression from periphery toward the areola (Figure 14-2).
2. DISSECTION
The duct opening through which discharge flows can be identified; that identifies the area for the excision. An areolar margin incision is used, and the areola is elevated from underlying intramammary fat. The involved duct can usually be identified as distended and often containing a dark substance visible through the wall of the duct (Figure 14-3).
C H A P T E R 14 • Intraductal Papilloma |
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Milking duct
FIGURE 14–2
Dab of blood
FIGURE 14–3
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If the involved duct cannot be identified, single-digit compression in the area after the areola is raised can be carried out to elicit discharge from the nipple, which is noted so that the area of resection can be identified (Figure 14-4).
Once the duct is isolated below the nipple, it is dissected free from the surrounding tissue, ligated, and divided just below the nipple (Figures 14-5 and 14-6).
Involved duct
FIGURE 14–4
Duct is ligated and transected
FIGURE 14–5