Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg September 5, 2014
Jan 20, 2015
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgSeptember 5, 2014
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
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)
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)
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?
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
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 Planning• Good Execution
• Good Contingency Adjustment during
Execution
Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis
Incision
Flap Creation
Total Mastectomy
Axillary Dissection
Drain
Incision Repair
Risks
Local recurrence
Surgical complications
Unwanted side-effects
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis
Incision
Flap Creation
Total Mastectomy
Axillary Dissection
Drain
Incision Repair
Infection
Dehiscence
Local Recurrence
Flap Necrosis
Hematoma
Seroma
Major Axillary Vascular / Nerve Injury
Avoidance of
Others
Dog-ear Deformity
Ugly Scar
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Surgical Complications and Unwanted Side-effects
Key Strategies on Prevention
Flap necrosis Provide an adequate layer of subcutaneous tissue in the flap
Dehiscence Plan incision properly to avoid tension; close and repair wound securely
Seroma Provide adequate drainage
Bleeding and hematoma Ensure effective and adequate hemostasis
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do itSurgical Complications and
Unwanted Side-effectsKey Strategies on Prevention
Infection Maintain sterility of the operative field
Iatrogenic injuries Dissect carefully and preciselyDog ear Plan and close incision properly
(with trimming if needed to avoid dog ear)
Ugly scar Plan and close incision properly to promote a cosmetically acceptable scar
Local recurrence Provide adequate surgical margins around the breast cancer mass
Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis Infection
Key Strategies on Prevention
• Asepsis• Maintain sterility of
the operative field
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
Suturing of the Drape along the Posterior Axillary Line to Prevent Contamination in the Lateral Field
Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision
Tension-Dehiscence
Local Recurrence
Dog-ear Deformity
Key Strategies on Prevention
• Proper and accurate planning of incision before and during operation
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
Key Strategies on Prevention
• Proper and accurate planning of incision before and during operation
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
Key Strategies on Prevention
• Proper and accurate planning of incision before and during operation
Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
45
Avoid a scar that can be seen when patient wears a bra!
Planning the Incision
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.
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!
Key Strategies on Prevention
• Proper and accurate planning of incision before and during operation
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
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
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!
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
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 RecurrenceKey Strategies on Prevention
Flap Creation – How I Usually Do It
1-cm of subcutaneous tissue(subcutaneous tissues only –
pink-whitish tissues stay away)
Flap Creation – How I Usually Do It
Control thickness / thinness of flap
Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Local RecurrenceTotal Mastectomy
HematomaEnsure TOTAL mastectomy!
Ensure adequate and secure hemostasis!
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
Removing part of pectoralis major muscle in MRM
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
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
Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Local Recurrence
Hematoma
Axillary Dissection
Major Axillary Vascular / Nerve Injury
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
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 DissectionMajor Axillary Vascular
/ Nerve Injury
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
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
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
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
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
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
Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Incision Repair
Ugly Scar
Dog-ear Deformity
Dehiscence
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
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
How I usually repair mastectomy wound
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
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do it
Procedure MRM
OutcomesEvaluation
Planning Execution with contingency adjustment
Asepsis
Incision
Flap Creation
Total Mastectomy
Axillary Dissection
Drain
Incision Repair
Infection
Dehiscence
Local Recurrence
Flap Necrosis
Hematoma
Seroma
Major Axillary Vascular / Nerve Injury
Avoidance of
Others
Dog-ear Deformity
Ugly Scar
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)
Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes
How I Usually Do itReynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
September 5, 2014
For further reading and copies of my slides:http://www.slideshare.net/rjoson/mastectomy-morbidities-pghrj08sept11
http://www.slideshare.net/rjoson/preventing-complications
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